Bouveret's Syndrome with Severe Esophagitis and a Purulent Fistula

Bouveret's syndrome is a rare variant of gallstone ileus with an overall incidence of 1–3%. It is a rare cause of gastric outlet obstruction resulting from the passage and impaction of a large gallstone through a cholecysto-duodenal fistula. A combination of diagnostic modalities is often required for a diagnosis. Management options include endoscopy and surgery. The most commonly performed procedures are enterolithotomy or gastrostomy, either alone or with cholecystectomy and fistula repair. We describe a unique variant of chronic Bouveret's syndrome with the unusual associations of severe esophagitis and a purulent fistula

Imaging assessment and clinical significance of pneumatosis in adult patients.

Gas detection in the bowel wall and in portomesenteric venous vessels in adults has long been related to intestinal infarction and poor outcome; many case reports have shown that pneumatosis may be associated with a large variety of pathological situations, ranging from absolutely benign and asymptomatic forms to abdominal catastrophes. Several studies have been conducted on this topic with different conclusions, probably due to differences in population so that the clinical value of these signs is still questioned. Intestinal pneumatosis, especially if presenting with a band-like pattern and if associated with portomesenteric vein gas, when observed in an acute abdominal setting should raise the suspicion of mesenteric infarct and prompt a careful search for other signs of intestinal involvement, so as not to miss cases of life-threatening intestinal infarct or allow them to further evolve into extensive necrosis with worse prognosis. In this review we illustrate the most relevant aspects of these debated but significant radiological signs

Façade retrofitting: from energy efficiency to climate change mitigation

Abstract Since climate changes are now evident, it is not only important to achieve high level of energy efficiency, but also to think about retrofit actions in order to mitigate the natural hazard impacts and to make buildings resilient. The paper focuses on climate change effects in summer and investigates how it is possible to reduce them through facade retrofitting solutions (external insulation, PCM, green wall, cool materials) in Mediterranean climate. The goal is to develop a set of climatic resilience indicators for opaque envelopes in order to consider resilience ability against climate change, both inside and outside of buildings

CHILDHOOD OBESITY AND RELATED COMORBIDITIES:FROM UNHEALTHY DIET TO A FOOD-BASED APPROACH

The childhood obesity epidemic, that is rapidly increased in most high-income, low- and middle-income countries, is considered as one of the most serious global public health challenges for the 21st century. It may be associated with adverse health effects during childhood and an increased risk of premature morbidity and mortality later in life. Investigating possible therapeutic strategies able to counteract negative effects on child health and the risk of more severe comorbidities during adulthood is considered as a major priority. Intensive lifestyle modifications, involving diet, physical activity and behaviors are fundamental to achieve this goal. However, the characteristics of all intervention components as well as the length, the intensity, and the effectiveness of lifestyle interventions may vary largely among studies. Additionally, recently a great deal of attention has been focused on the gut microbiota as \u201cenvironmental factor\u201d playing an important role in the development of obesity and its complications and several mechanisms able to explain this association have been proposed. This evidence needs to be further elucidated because it may have a relevant role in prevention and treatment of childhood obesity. Lastly, diets high in fruits and vegetables are widely recommended for their health-promoting properties, as they are important sources of dietary fiber, vitamins, especially vitamins C and A, minerals and phytochemicals, especially antioxidants and polyphenols. It has been suggested that, among phytochemicals, salicylic acid may have an important role, being involved in the regulation of inflammation, oxidative stress and glucose metabolism. The present PhD thesis tried to further elucidate these topics through three different tasks. The primary aim of the present PhD thesis was to evaluate whether a 1-year lifestyle intervention, based on normocaloric diet, promotion of physical activity and behavior changes, may improve obesity, metabolic profile and obesity-related comorbidities, as glucose metabolism alterations, hyperlipidemia, prehypertension/hypertension, increased liver echogenicity and metabolic syndrome, in a cohort of obese children. Secondary aims were to evaluate qualitatively and quantitatively gut microbiota biodiversity in obese and normal-weight children and to compare gut microbiota profiles with SCFAs and BMI z-scores to gain insights into the structure and activity of the microbiota in pediatric obesity. The tertiary aim was to determine the concentrations of serum salicylic acid in a group of obese children, compared to normal-weight children, and to evaluate if an association may exist between serum salicylic acid and fruit and vegetable consumption. Our results confirmed that obesity is associated with detrimental effects on health already during pediatric age, thus children may show prehypertension/hypertension, insulin resistance, pre-diabetes, hyperlipidemia, liver steatosis and metabolic syndrome. Moreover, childhood obesity may be associated with changes of some core microbial species, preexisting or diet-induced, and these changes may be involved in the etiology of obesity. Among these, an alteration of the gut microbiota composition of obese children, characterized by an increased abundance of Firmicutes and a decreased abundance of Bacteroidetes, was observed. Although beneficial effects of fruit and vegetable consumption are well-known, results from our study showed that fruit and vegetable consumption in children was very low, about 50% lower of the minimum recommended value by WHO (400 g daily). Furthermore, obese children had lower levels of serum salicylic acid than normal-weight children. These results suggest that nutrition education towards an adequate fruit and vegetable consumption should be stressed in children. Moreover, although the relationship of serum salicylic acid with fruit and vegetables consumption did not reach statistical significance both in obese and normal-weight children, promotion of fruit and vegetables with higher content of salicylic acid might be considered as part of the nutrition counseling for obese children. Finally, findings from our longitudinal study clearly highlighted the importance of a 1-year lifestyle intervention, based on a normocaloric Mediterranean balanced diet for pediatric age, promotion of physical activity and behavior changes, in the improvement of cardio-metabolic risk factors and in the reduction of the prevalence of some obesity-related comorbidities, as insulin resistance, pre-diabetes, prehypertension/hypertension, hypertriglyceridemia, higher liver echogenicity and metabolic syndrome

Mitigation and Adaptation Strategies for Different Urban Fabrics to Face Increasingly Hot Summer Days Due to Climate Change

As global warming and heat waves are becoming more frequent and severe, cities, with their different morphological districts, must be at the forefront of environmental challenges. Notably, many Mediterranean towns maintain the original medieval urban fabric and the regular one. The research focuses on the development of a methodology with the application of high-resolution 3D modelling software ENVI-met V5.1 to analyze the microclimatic effects of mitigation and adaptation strategies derived from the study of medieval and regular urban fabric. The aim is to address contemporary challenges such as heat waves and urban heat island (UHI) effects in modern cities. By studying outdoor energy behavior in a southern Italian city (Bari), the research proposes scenarios for urban settlements in the face of climate change. This approach provides recommendations for creating more climate-resilient urban environments both in the historic and modern city. The use of trees with large crowns and tall shrubs and the inclusion of fountain jets are strategies to achieve sky view factor and air temperatures in the modern city similar to those in the historical fabric. Increasing albedo values and the use of green roofs prove to be further strategies for improving outdoor climatic conditions

Energy and seismic drawbacks of masonry: a unified retrofitting solution

All over the world, a large part of existing buildings is not adequate to satisfy the safety requirement and the thermal comfort criteria. For this reason, the interest in structural and energy retroftting systems has steadily grown in the last decades. In this scenario, an innovative thermal resistant geopolymer mortar has been developed and used for Inorganic Matrix Composite (IMC) systems aimed to a combined seismic and energy new retroftting technique. The geopolymer-based IMC is able to ensure competitive mechanical properties with respect to the traditional lime-based IMCs and, at the same time, a signifcant reduction in thermal conductivity. In this paper, an experimental program is reported considering small-scaled masonry panels with double-side IMC-retroftting and determining both the in-plane shear strength and the thermal resistance. The experimental shear tests are aimed to compare the mechanical performance of the geopolymer innovative systems with those of the traditional lime-based ones. Moreover, the thermal resistance gain of the innovative solutions was measured and compared with traditional systems. The results evidenced the efectiveness of the proposed technique that signifcantly improved the performances of masonry walls from both the thermal and the mechanical point of view

Rituximab Unveils Hypogammaglobulinemia and Immunodeficiency in Children with Autoimmune Cytopenia

BACKGROUND: Rituximab (RTX; anti-CD20 mAb) is a treatment option in children with refractory immune thrombocytopenia, autoimmune hemolytic anemia (AHA), and Evans syndrome (ES). Prevalence and clinical course of RTX-induced hypogammaglobulinemia in these patients are poorly known. OBJECTIVE: To evaluate the prevalence and risk factors for persistent hypogammaglobulinemia (PH) after RTX use. METHODS: Clinical and immunologic data from children treated with RTX for immune thrombocytopenia, AHA, and ES were collected from 16 Italian centers and 1 UK center at pre-RTX time point (0), +6 months, and yearly, up to 4 years post-RTX. Patients with previously diagnosed malignancy or primary immune deficiency (PID) were excluded. RESULTS: We analyzed 53 children treated with RTX for immune thrombocytopenia (n = 36), AHA (n = 13), and ES (n = 4). Median follow-up was 30 months (range, 12-48). Thirty-two percent of patients (17 of 53) experienced PH, defined as IgG levels less than 2 SD for age at last follow-up (>12 months after RTX). Significantly delayed B-cell recovery was observed in children experiencing PH (hazard ratio, 0.55; P < .05), and 6 of 17 (35%) patients had unresolved B-cell lymphopenia at last follow-up. PH was associated with IgA and IgM deficiency, younger age at RTX use (51 vs 116 months; P < .01), a diagnosis of AHA/ES, and better response to RTX. Nine patients with PH (9 of 17 [53%]) were eventually diagnosed with a PID. CONCLUSIONS: Post-RTX PH is a frequent condition in children with autoimmune cytopenia; a sizable proportion of patients with post-RTX PH were eventually diagnosed with a PID. In-depth investigation for PID is therefore recommended in these patients

Gallstone ileus following endoscopic retrograde cholangiopancreatography and sphincterotomy: a case report

<p>Abstract</p> <p>Introduction</p> <p>Gallstone ileus is a mechanical obstruction caused by the impaction of one or more gallstones within the lumen of any part of the gastrointestinal tract. Although the disorder is a rare cause of small bowel obstruction (1% to 2%), it has been reported to cause up to 25% of cases of non-strangulated small bowel obstruction in patients over 65 years of age.</p> <p>Case presentation</p> <p>We report a case of a 67-year-old woman who presented with gallstone ileus following endoscopic retrograde cholangiopancreatography and sphincterotomy for choledocholithiasis. She had a history of terminal ileum resection with ileocolic anastomosis for Crohn's disease. A 3 cm gallstone was found to be impacted just proximal to the previous ileocolic anastomosis. A second gallstone was found on digital examination of the proximal small bowel.</p> <p>Conclusion</p> <p>A gallstone may enter the gastrointestinal tract following endoscopic retrograde cholangiopancreatography and sphincterotomy and impact proximal to an anastomotic stricture as demonstrated here. The radiographic image of small bowel obstruction plus air in the biliary tree is a classic diagnostic finding. After stone extraction, the entire small bowel and colon should be digitally examined for further stones.</p