Nutritional counselling and risk factors for obesity: an observational study in toddlers.

BACKGROUND: Nutrition exerts a fundamental role in the prevention of obesity (OB). The aim of this study was to assess the extent to which well recognized risk factors for early OB can be associated to overweight (OW) or OB under a standardized nutritional approach and surveillance in toddlers. METHODS: The eligible population was represented by 676 toddlers aged 24-36 months, assigned to 18 primary care pediatricians trained on nutritional issues who shared a standardized nutritional approach. Six-hundred-twenty-nine children (333 boys), mean age 27.8 ± 4.2 months were effectively included in this observational study. Parents received nutritional advice with particular emphasis to proteins and sugar composition supported by leaflets and reinforced at each visit. Body mass index was assessed at the age of 24-36 months. The following individual and family risk factors were considered: gestational age, birth weight, eutocic/caesarean delivery, milk feeding history, household smoking or antibiotics exposure, parents' weight, height and educational level. Prevalence of OW/OB was compared to a group of 742 toddlers (373 boys) under usual care. RESULTS: Under a standardized nutritional counselling, 28.1% toddlers were classified as OW/OB compared to 36.9% toddlers under usual care (p = 0.005). In unadjusted models, parental OW/OB was significantly associated to OW/OB in toddlers (p < 0.01), while high birth weight did not reach statistical significance (p = 0.07). In adjusted models, including all the explanatory variables studied, only paternal OW/OB vs. normal weight was significantly associated to OW/OB in toddlers (OR 2.035, 95% confidence interval 1.206-3.436). No protective effect of exclusive breast feeding during the first 6 months of age was demonstrated. CONCLUSIONS: Toddlers under a standardized nutrition counselling focused to limit protein and simple sugars, showed lower prevalence of OW/OB compared to usual care. Healthy promotion activities should take into account the influence of paternal BMI on the offspring adiposity.

Flexor Tendon Pulley Injuries: A Systematic Review of the Literature and Current Treatment Options.

Closed injuries of the finger flexor pulley system are rare among the general population, and most of them occur during rock climbing. During the last few decades, scientific interest on this topic has increased. We conducted a systematic review of the literature according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The research was limited from January 2000 to March 2022. PubMed and Scopus databases were investigated for full-text articles published in English, French, and Italian using the following MeSH terms: ([pulley rupture] OR [finger pulley lesion]) AND ([injur*] OR [ruptur*] OR [damage] OR [trauma*]). Initial screening results identified 461 studies, among which 172 were included after including additional records identified through other sources and excluding repeated studies. Finally, four clinical studies were included in the analysis. The methodological quality of the articles was evaluated through the methodological index for nonrandomized studies (MINORS) score. Our search identified four studies that enrolled a total of 189 patients, of whom 164 were male and 25 were female. We finally examined 154 patients with a total of 208 pulleys damaged. Except for the thumb, all fingers were involved. Depending on the type of flexor pulley injury, graded with Schöffl classification, 69 patients underwent a surgical procedure, whereas 85 patients were treated conservatively. Closed finger pulleys injury occurred in rock climbers and non - rock climbers. All patients had excellent results on the Buck-Gramcko score regardless of the return to sports activity. Considering the overall outcomes of the reviewed articles, functional results were satisfactory in both conservative and surgical treatment. Moreover, in grade 3 and 4, surgical results were positive regardless of the specific technique used for finger pulley reconstruction. Only minor complications were reported. Closed flexor tendon pulley injuries require a careful clinical and imaging examination to confirm the diagnosis. In most cases, positive clinical results can be achieved with either conservative or surgical therapy.

Minimally Invasive ALPPS Procedure: A Review of Feasibility and Short-Term Outcomes.

BACKGROUND: Associated liver partition with portal vein ligation for staged hepatectomy (ALPPS) represents a recent strategy to improve resectability of extensive hepatic malignancies. Recent surgical advances, such as the application of technical variants and use of a mini-invasive approach (MI-ALPPS), have been proposed to improve clinical outcomes in terms of morbidity and mortality. METHODS: A total of 119 MI-ALPPS cases from 6 series were identified and discussed to evaluate the feasibility of the procedure and short-term clinical outcomes. RESULTS: Hepatocellular carcinoma were widely the most common indication for MI-ALPPS. The median estimated blood loss was 260 mL during Stage 1 and 1625 mL in Stage 2. The median length of the procedures was 230 min in Stage 1 and 184 in Stage 2. The median increase ratio of future liver remnant volume was 87.8%. The median major morbidity was 8.14% in Stage 1 and 23.39 in Stage 2. The mortality rate was 0.6%. CONCLUSIONS: MI-ALPPS appears to be a feasible and safe procedure, with potentially better short-term outcomes in terms of blood loss, morbidity, and mortality rate if compared with those of open series.

A post hoc analysis on the effects of a probiotic mixture on asthma exacerbation frequency in schoolchildren.

The present randomised, placebo-controlled, double-blind study showed that a probiotic mixture significantly reduced the number of asthma exacerbations in schoolchildren https://bit.ly/382LYKV.

The Probiotics in Pediatric Asthma Management (PROPAM) Study in the Primary Care Setting: A Randomized, Controlled, Double-Blind Trial with Ligilactobacillus salivarius LS01 (DSM 22775) and Bifidobacterium breve B632 (DSM 24706).

BACKGROUND: Type-2 inflammation commonly marks asthma in childhood. Also, gut and lung dysbiosis is detectable in patients with asthma. Strain-related probiotic supplementation may restore a physiological immune response, dampen airway inflammation, and repair dysbiosis. Therefore, the probiotics in pediatric asthma management (PROPAM) study is aimed at demonstrating that Ligilactobacillus salivarius LS01 (DSM 22775) and Bifidobacterium breve B632 (DSM 24706) mixture could reduce asthma exacerbations in children, followed in a primary care setting. METHODS: The study was randomized, placebo-controlled, and double-blind. It involved 11 Italian primary care pediatricians. The probiotic mixture (containing Ligilactobacillus salivarius LS01 1 × 109 live cells and Bifidobacterium breve B632 1 × 109 live cells) or placebo was taken twice daily (1 sachet in the morning and 1 in the evening) for eight weeks and subsequently once daily for a further eight weeks. Outcomes included number, severity, and duration of asthma exacerbations, intensity of maintenance and as need treatments, and safety. RESULTS: The per-protocol population included 422 children (mean age seven years, 240 males and 182 females). The probiotic mixture significantly reduced the number of asthmatic exacerbations (OR = 3.17). In addition, the number of children with two exacerbations was less than a third in the active group (OR = 3.65). CONCLUSIONS: This PROPAM study demonstrated that probiotic strains Ligilactobacillus salivarius LS01 (DSM 22775) and Bifidobacterium breve B632 (DSM 24706) were safe and significantly reduced by more than a third the frequency of asthma exacerbations. At present, the first-line treatment of asthma is still drug-based, but specific strains of probiotics may be auxiliary remedies.

Clinical audit in the pediatric primary care office and overweight prevention in toddlers.

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

Chronic Pain After Lung Resection: Risk Factors, Neuropathic Pain, and Quality of Life.

CONTEXT: Chronic postsurgical pain (CPSP) can occur frequently after thoracic surgery. OBJECTIVES: This retrospective study aimed to determine CPSP prevalence, risk factors, neuropathic pain (NP) occurrence, and its impact on quality of life. METHODS: About 200 patients who underwent lung resection via minithoracotomy or thoracoscopy between January 2017 and December 2017 were assessed 4-12 months postoperatively via phone interview for chronic pain by a 0-10 Numeric Rating Scale, for NP using the Douleur Neuropathique 4 test, and for quality of life using a Short Form-36 (SF-36) Health Survey (Italian version). RESULTS: CPSP incidence was 35% (n = 70 of 200; 95% CI 41-28) of which 31.5% (n = 22 of 70; 95% CI 41-21) was with NP. Only 10% of patients with CPSP reported severe chronic pain. According to univariate analysis, CPSP was associated to moderate and severe acute postoperative pain (P < 0.001), open surgery (P = 0.001), and female gender (P = 0.044). According to multivariable analysis, independent risk factors for CPSP development included moderate-to-severe acute postoperative pain occurrence (odds ratio 32.61; 95% CI 13.37-79.54; P < 0.001) and open surgery (odds ratio 6.78; 95% CI, 2.18-21.03; P = 0.001). NP incidence was higher in female patients (16% in women and 6% in men, respectively; P = 0.040). A significant decrease in all SF-36 Health Survey domain scores was recorded for patients with CPSP and NP (P < 0.001). CONCLUSION: More than one of three patients who underwent lung resection could develop CPSP, frequently showing neuropathic component. Female gender reported a higher CPSP and NP incidence. Moderate-to-severe acute postoperative pain occurrence and open surgery seem to be independent risk factors for CPSP. Chronic pain and NP have a negative impact on quality of life, decreasing the SF-36 scores of all domains.

The "TIP algorithm" for the accurate diagnosis of pediatric otitis media.

OBJECTIVES: The authors studied the correlation between the grading TIP which evaluates three otoendoscopic characteristics of the tympanic membrane (TM) (transparency, integrity and position) with the gold standard represented by the impedenzometry. METHODS AND MATERIALS: Cross-sectional studies with independent and blind comparison with the gold standard diagnostic. The setting was primary care and ambulatory. 115 TMs were examined (57 right and 58 left) of 60 children (36 males and 24 females) and classified according to the TIP grading (transparency, integrity, position). Each patient underwent otoendoscopy to obtain TIP grading and subsequently to tympanometry, which was considered the gold standard for diagnosis. The Transparency is the condition in which at least one or more structures behind the TM are visible: promontory, incudo-malleolar and incudo-stapedial articulations. The Integrity is such when no holes in the TM are visible. The TM must be displayed up to the anulus. The position of the TM is evaluated according to the handle and the short apophysis of the malleus. The correlation between TIP grade and tympanometry was measured by the "Chi Square" test. RESULTS: The method showed an average sensitivity and specificity of the three TIP parameters (TIP1 TIP2, TIP 4) versus tympanometry of 95.6% (I.C. 90.1-98.5); PPV and PPN 95.6 (I.C 90.3%-98.1%) Positive Likelihood Ratio 22,000 (I.C. 9.327 to 51.894) Negative Likelihood Ratio 0.045 0.019 to 0.107. CONCLUSION: Grading TIP is a valid method for accurate diagnosis of pediatric otitis media and can predict the tympanometry result with high statistical significance.

Clinical Improvement of Subacute and Chronic Otitis Media With Effusion Treated With Hyaluronic Acid Plus Hypertonic Solution via Nasal Lavage: A Randomized Controlled Trial.

Background. This study, a randomized controlled trial, aims to demonstrate a clinically significant improvement in subacute and chronic otitis media with effusion through the administration of hyaluronic acid associated with hypertonic solution compared with the administration of hypertonic solution alone. The setting was an outpatient clinic of 20 primary care pediatrician offices affiliated with the 3 Local Health Units (Azienda Sanitaria Locale) of Naples. Materials and Methods. The study was conducted for 6 months, from October 2014 to the end of March 2015. The study saw the participation of 20 pediatricians who were experts in pneumatic otoscopy, each of whom enrolled 15 children. Each investigator was randomized to carry out the treatment with 3% hypertonic solution or high-molecular-weight hyaluronic acid + 3% hypertonic solution. Results. A total of 275 children were enrolled, of whom 11(equal to 4% ) were lost to follow-up. A total of 264 children completed the trial according to the protocol, 120 in the hyaluronic acid + hypertonic solution group and 144 in the hypertonic solution group. Hyaluronic acid associated with hypertonic solution and hypertonic solution alone administered by nasal lavage have proven to be safe and effective in the treatment of prolonged otitis media with effusion (initial score of -0.5, final score of 0.9, P < 001, for the hypertonic + hyaluronic acid group; initial score of -0.3, final score of 0.2, P < .001, for the hypertonic solution group). Though starting from a less favorable initial clinical score (-0.5 vs -0.3, P < .016), hyaluronic acid associated with hypertonic solution resulted in a significant increase in clinical healing (0.9 vs 0.2, P < .001). One interesting outcome was the significant reduction in the consumption of drugs (cortisone and antibiotics) during the follow-up.

SGA Children in Pediatric Primary Care: What Is the Best Choice, Large or Small? A 10-Year Prospective Longitudinal Study.

BACKGROUND: Epidemiologic evidences suggest a strong association between low birth weight and some diseases in adult life ( hypertension, diabetes, cardiovascular diseases).Aim of this study was to evaluate the obesity/overweight prevalence in a population of children born small for gestation age, SGA children 400, 208 males and 192 females compared to a population of children born appropriate for gestational age 6818 AGA children, 3502 males and 3316 females, during childhood. Our intention was also to build the natural history of weight gain during prepubertal age in children born SGA and AGA. DESIGN AND METHODS: Observational prospective longitudinal study. We followed our patients from January2001 up to December 2010; weight, height and body mass index (BMI) were evaluated in all the SGA and AGA children. BMI z-score range for defining overweight and obesity was, respectively, 1.13 to 1.7 and >1.7 according to CDC growth charts. RESULTS: In transversal evaluation, we prove that 10-year-old SGA females are twice obese and more overweight compared to equal age AGA females. In longitudinal evaluation, we highlight different observations: SGA children obese at 2 years are still obese at 10 years; the number of obese SGA children increases gradually until the age of 10; AGA children, appear to be less obese than SGA children at 10 years. CONCLUSION: SGA males and females are more obese at 5 and 10 years compared to the AGA population. Primary care pediatricians, through early detection of the children at risk, can carry out an effective obesity prevention project in SGA children.

Decreased Antibiotic Prescription in an Italian Pediatric Population With Nonspecific and Persistent Upper Respiratory Tract Infections by Use of a Point-of-Care White Blood Cell Count, in Addition to Antibiotic Delayed Prescription Strategy.

The aim of this study was to test, in delayed antibiotic strategy, if the usages of a point-of-care leukocyte count would significantly decrease the prescription rate of antibiotics for children with nonspecific upper respiratory tract infections. A prospective clinical trial was performed in 23 primary care pediatric doctors' offices on children with nonspecific upper respiratory tract infection with fever for at least 48 hours. The children were randomized into 2 groups: one using a point-of-care white blood cell (WBC) count as guidance and the other prescribing antibiotics to all children, according to delayed antibiotics prescription strategy. A total of 792 patients participated. In the WBC group (n = 437), 56 patients had WBC >15 000/mm(3) and received antibiotics. At follow-up, an additional 44 children received antibiotics. In the control group (n = 355), antibiotics were prescribed to all children. The reduction of antibiotic usage was 77% between the groups. The decrease in antibiotic usage gave no influence on recovery, complications, or other medical outcome.

Laparoscopic surgical treatment of hepatic splenosis. A case report.

AIM: Isolated hepatic splenosis is a rare but possible condition in abdominal surgery. At radiological imaging liver splenosis mimics malignant or pathological condition of the liver; obtaining a certain diagnosis prior to surgery is difficult. For this reason, the patients undergo to unnecessary operation, with a laparotomy access. We report a case of suspicious liver mass removed laparoscopically and revealed as hepatic splenosis. CASE REPORT: A 31 years old man patient was admitted to our Institution because of upper chronic abdominal pain. Thirteen years before the recovery the patient was operated of splenectomy with laparotomic incision. Computerized Tomography and Magnetic Resonance demonstrated the presence of suspicious hepatic mass in the III segment. RESULTS: The mass has been radically excised with laparoscopic approach. Postoperative stay was good and patient was discharged seven day after the operation. At histological examination ectopic splenic tissue on liver surface was found (socalled splenosis). DISCUSSION AND CONCLUSION: Hepatic splenosis is not a rare condition and should be considered with the differential diagnosis especially in patients who had previous splenectomy and absence of liver cirrhosis. Laparoscopic exploration should always be preferred for the diagnosis of uncertain liver mass. Few works report laparoscopic excision for liver splenosis. For experience at our Institution laparoscopic procedure has an important role to get the diagnosis and it is also a feasible approach for minimally invasive resection. KEY WORDS: Laparoscopy, Liver, Splenosis.

Mils for HCC: the state of art.

After an initial skepticism, minimally invasive liver surgery (MILS) gained popularity and is nowadays a consolidated option in specialized centers for the surgical treatment of selected patients affected by both benign and malignant liver diseases. Nevertheless, the role of MILS in the surgical treatment of hepato-cellular carcinoma (HCC) developed on the background of chronic liver disease is still a matter of debate. The indications and the current evidences on MILS for HCC are discussed in this paper. MILS being less invasive and harmful for the patients proved to offer a reduction in post-operative morbidity and specific benefits have been highlighted in case of patients affected by HCC and chronic liver disease. In fact, by minimizing liver manipulation and mobilization and by preserving the collateral blood and lymphatic flow, MILS seems to reduce the incidence of post-operative ascites and post-operative liver failure without compromising the oncologic outcomes. This has been confirmed by an analysis of 21 comparative studies and 5 metanalyses comparing MILS and open surgery for HCC. With an adequate surgical training, MILS for HCC can be undertaken safely even in case of major hepatectomies and technically demanding operations such as resections of posteriorly located tumors proved to be feasible in specialized centers. Therefore, with an appropriate patients' selection, MILS for HCC is becoming the preferred option for the surgical treatment of HCC in cirrhotic patients.

Liver resection for hepatocellular carcinoma in patients with portal hypertension: the role of laparoscopy.

Liver resection (LR) for hepatocellular carcinoma (HCC) in patients with chronic liver disease (CLD) is a major issue since patients are at risk of serious intraoperative and postoperative complications. The current EASL/AASLD guidelines recommend LR only in case of patients with stage A HCC with well-preserved liver function and consider the presence of portal hypertension (PHT) as a contraindication to surgery. Nevertheless, the literature on this topic is conflicting. Recently several studies reported that favorable outcomes can be achieved with a careful patients' selection in high volume centers. Laparoscopic LR, when performed by well-trained surgeons and with appropriate indications, proved to be a valid option for the surgical treatment of HCC on cirrhosis offering similar oncologic outcomes but a reduction in surgical related morbidities. Laparoscopic LR thanks to a reduction in the incidence of post-operative liver failure and ascites development in comparison to standard open LR could, in selected cases challenge alternative treatments in the treatment of HCC patients with preserved liver function and clinical signs of mild PHT.

Laparoscopic Drainage as First Line Treatment for Complex Pyogenic Liver Abscesses.

UNLABELLED: Background/aims: Pyogenic liver abscess (PLA) is a rare but potentially fatal condition if untreated. In available retrospective series successful rate of per- cutaneous drainage (PD) on large multiloculated PLA, that has been definited "complex". In this observation- al study, we report the experience of our Institution in performing laparoscopic drainage of complex liver ab- scess over a 5-years period as first line treatment for selected cases of PLA. Methodology: All cases of large multiloculated liver abscesses admitted to the General and Hepatobiliary Surgery of "Loreto Nuovo" Hospital Naples, Italy over the last 5-years period were treated by laparoscopic drainage and his clinicopathological variables were retrospectively reviewed. RESULTS: Ten patients with large multiloculated liver abscess has been admitted and treated by only laparoscopic drainage without need of other perioperative procedures. Mean age was 51.5 years (range 41-75y); average hospital stay was 4.6 days (range 2-6 days) and major postoperative morbidity or deaths were not registered. Successful rate was 100% with no recurrence at 2-years follow up (range 12/38 months). CONCLUSIONS: Laparoscopic drainage seems to be a safe and reproducible mini-invasive treatment of complex liver abscesses and to offer advantages over percutaneous and surgical open approach.

Laparoscopic and open surgical treatment of left-sided pancreatic lesions: clinical outcomes and cost-effectiveness analysis.

BACKGROUND: Previous studies comparing open distal pancreatectomy (ODP) and laparoscopic distal pancreatectomy (LDP) have found advantages related to minimal-access surgery. Few studies have compared direct and associated costs after LDP versus ODP. The purpose of the current study was to compare perioperative outcomes of patients undergoing LDP and ODP and to assess whether LDP was a cost-effective procedure compared with the traditional ODP. METHODS: A retrospective analysis of a prospectively maintained database of 52 distal pancreatic resections that were performed during a 10-year period was performed. RESULTS: Patients included in the analysis were 16 in the LDP group and 29 in the ODP. Tumors operated laparoscopically were smaller than those removed at open operation, but the length of pancreatic resection was similar. The mean operating time for LDP was longer than ODP (204 ± 31 vs. 160 ± 35; P < 0.0001), whereas blood loss was higher in the open group (365 ± 215 vs. 160 ± 185, P < 0.0001). Morbidity (25 vs. 41; P = 0.373) and pancreatic fistula (18 vs. 20%; P = 0.6) rates were similar after LDP and ODP, as was 30-day mortality (0 vs. 2%; P = 0.565). LDP had a shorter mean length of hospital stay than ODP (6.4 (2.3) vs. 8.8 (1.7) days; P < 0.0001). Operative cost for LDP was higher than ODP (2889 vs. 1989; P < 0.0001). The entire cost of the associated hospital stay was higher in the ODP group (8955 vs. 6714; P < 0.043). The total cost was comparable in LDP and ODP groups (9603 vs. 10944; P = 0.204). CONCLUSIONS: Laparoscopic distal pancreatectomy for left-sided lesions can be performed safely and effectively in selected patients, with reduced hospital stay and operative blood loss. Major complications, including pancreatic leak, were not reduced, whereas total cost was comparable between LDP and ODP. A selective use of LDP seems to be an effective and cost-efficient alternative to ODP.

Single port laparoscopic cholecystectomy: a new evolving technique.

Although multiple groups have reported initial success with single port laparoscopy, no consensus exists concerning the technical aspect of this surgery. In this report, we describe in detail our technique to perform single port laparoscopic cholecystectomy. Twelve cases of single port laparoscopic cholecystectomy for gallbladder stones were performed in our surgical unit. There was only one conversion during the first operation of the series to standard laparoscopy, and never to open operation. No intraoperative adverse events or major perioperative complications were reported. All the patients have been discharged within 48 hours, with uneventful postoperative course, nearly painless, without any discomfort and no visible scar. Single port laparoscopic surgery is a promising option for the treatment of gallbladder stones providing that technical and oncological surgical principles are respected.