Adjunctive use of locally delivered host-modulators in intra-bony defects as part of step 2 periodontal therapy: systematic review, meta-analysis and trial sequential analysis

BACKGROUND

This systematic review and meta-analysis aimed at investigate the role of locally delivered host-modulators in combination with step 2 of periodontal therapy in reducing probing pocket depth, improving clinical attachment level and reducing bone defect depth in intra-bony defects.

HIGHLIGHT

RCT with at least 6 months follow-up were included in this study. Risk of bias assessment was performed with Cochrane collaboration tool and Grade GRADEpro. In addition, meta-analysis and trial sequential analysis were used to aggregate the available evidence. 22 studies met the inclusion criteria and were included in this systematic review. At 6 months locally delivered host-modulators significantly improved PD and CAL and bone defect depth.

CONCLUSION

Considering the emerging role of host-inflammatory response in the treatment of periodontitis, several studies are exploring the role of locally delivered host modulators as an adjunct to step 2 of periodontal therapy.

Multitraits evaluation of a Solanum pennellii introgression tomato line challenged by combined abiotic stress

Rising daily temperatures and water shortage are two of the major concerns in agriculture. In this work, we analysed the tolerance traits in a tomato line carrying a small region of the Solanum pennellii wild genome (IL12-4-SL) when grown under prolonged conditions of single and combined high temperature and water stress. When exposed to stress, IL12-4-SL showed higher heat tolerance than the cultivated line M82 at morphological, physiological, and biochemical levels. Moreover, under stress IL12-4-SL produced more flowers than M82, also characterized by higher pollen viability. In both lines, water stress negatively affected photosynthesis more than heat alone, whereas the combined stress did not further exacerbate the negative impacts of drought on this trait. Despite an observed decrease in carbon fixation, the quantum yield of PSII linear electron transport in IL12-4-SL was not affected by stress, thereby indicating that photochemical processes other than CO₂ fixation acted to maintain the electron chain in oxidized state and prevent photodamage. The ability of IL12-4-SL to tolerate abiotic stress was also related to the intrinsic ability of this line to accumulate ascorbic acid. The data collected in this study clearly indicate improved tolerance to single and combined abiotic stress for IL12-4-SL, making this line a promising one for cultivation in a climate scenario characterized by frequent and long-lasting heatwaves and low rainfall.

Rapid quasi-periodic oscillations in the relativistic jet of BL Lacertae

Blazars are active galactic nuclei (AGN) with relativistic jets whose non-thermal radiation is extremely variable on various timescales^1-3. This variability seems mostly random, although some quasi-periodic oscillations (QPOs), implying systematic processes, have been reported in blazars and other AGN. QPOs with timescales of days or hours are especially rare⁴ in AGN and their nature is highly debated, explained by emitting plasma moving helically inside the jet⁵, plasma instabilities^6,7 or orbital motion in an accretion disc^7,8. Here we report results of intense optical and γ-ray flux monitoring of BL Lacertae (BL Lac) during a dramatic outburst in 2020 (ref. ⁹). BL Lac, the prototype of a subclass of blazars¹⁰, is powered by a 1.7 × 10⁸ M_Sun (ref. ¹¹) black hole in an elliptical galaxy (distance = 313 megaparsecs (ref. ¹²)). Our observations show QPOs of optical flux and linear polarization, and γ-ray flux, with cycles as short as approximately 13 h during the highest state of the outburst. The QPO properties match the expectations of current-driven kink instabilities⁶ near a recollimation shock about 5 parsecs (pc) from the black hole in the wake of an apparent superluminal feature moving down the jet. Such a kink is apparent in a microwave Very Long Baseline Array (VLBA) image.

Antibiotic prophylaxis at the time of dental implant placement: a cost-effectiveness analysis

Background

Antibiotic prophylaxis during implant placement may improve implant short term survival. Nevertheless, use of antibiotics carries risks of adverse effects and antibiotic resistance. The aim of the present study is to compare the use of antibiotics in dental implant procedures in terms of costs and effectiveness.

Methods

A decision-tree model was developed using TreeAge Pro Healthcare software. Two strategies were compared: Antibiotics and No antibiotics in implant placement procedures. The costs were calculated considering direct costs for implant placement, antibiotic costs, and costs for implant replacement in case of failure. Effectiveness was defined in terms of General Oral Health Assessment Index. Outcomes were evaluated as Incremental Cost Effectiveness Ratio (ICER). One-way sensitivity analysis and Probabilistic Sensitivity Analysis were performed for the most influential variables to test parameter uncertainty. Patient and healthcare perspectives were considered.

Results

Antibiotic prophylaxis resulted to be cost-effective compared to no use of antibiotics (ICER = 14,692,64 and ICER = 3841,18, respectively for patient’s and healthcare perspective). The cost of antibiotics, cost of implant replacement in case of failure and probability of adverse effects significantly influenced the results.

Conclusions

From an individual patient perspective, antibiotic strategy can be considered cost-effective, even when the cost of antibiotic therapy increases. We can conclude that the administration of antibiotics in association with implant placement is recommended in clinical practice, as it increases the success rate and makes the treatment more effective. However, attention should be placed when healthcare perspective is considered, particularly in terms of antibiotic resistance that may impact public health and associated costs.

The role of keratinized mucosa width as a risk factor for peri-implant disease: A systematic review, meta-analysis, and trial sequential analysis

Background

Studies have examined the benefit of having keratinized peri‐implant mucosa width with mixed results.

Purpose

This study examines whether the lack of a prespecified (2 mm) amount of keratinized mucosa width (KMW) is a risk factor for peri‐implant diseases.

Methods

A systematic electronic and manual search of randomized or nonrandomized controlled or noncontrolled clinical trials was conducted. Qualitative review, quantitative meta‐analysis, and trial sequence analysis (TSA) of implants inserted at sites with <2 mm or ≥2 mm of KMW were analyzed to compare all the predetermined outcome variables. The level of evidence concerning the role of KMW in peri‐implant health was evaluated via the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system guide.

Results

Nine studies were included in the qualitative analysis and four in the meta‐analysis and TSA. No significant inter‐group difference (p > 0.05) and a low power of evidence were found for probing depth, soft‐tissue recession, and marginal bone loss. A significant difference favoring ≥2 mm KMW had a lower mean plaque index (MD = 0.37, 95% CI: [0.16, 0.58], p = 0.002) (3 studies, 430 implants, low‐quality evidence). GRADE system showed very low and low quality of evidence for all other outcome measures.

Conclusion

Based on the available studies, the impact of amount of KMW (either <2 mm or ≥ 2 mm) as a risk factor for developing peri‐implant disease remains low. Future control studies with proper sample size and longer follow‐up are needed to further validate current findings.

The efficient physiological strategy of a novel tomato genotype to adapt to chronic combined water and heat stress

Climate change is increasing the frequency of high temperature shocks and water shortages, pointing to the need to develop novel tolerant varieties and to understand the mechanisms employed to withstand combined abiotic stresses. Two tomato genotypes, a heat-tolerant Solanum lycopersicum accession (LA3120) and a novel genotype (E42), previously selected as a stable yielding genotype under high temperatures, were exposed to single and combined water and heat stress. Plant functional traits, pollen viability and physiological (leaf gas exchange and chlorophyll a fluorescence emission measurements) and biochemical (antioxidant content and antioxidant enzyme activity) measurements were carried out. A Reduced Representation Sequencing approach allowed exploration of the genetic variability of both genotypes to identify candidate genes that could regulate stress responses. Both abiotic stresses had a severe impact on plant growth parameters and on the reproductive phase of development. Growth parameters and leaf gas exchange measurements revealed that the two genotypes used different physiological strategies to overcome individual and combined stresses, with E42 having a more efficient capacity to utilize the limiting water resources. Activation of antioxidant defence mechanisms seemed to be critical for both genotypes to counteract combined abiotic stresses. Candidate genes were identified that could explain the different physiological responses to stress observed in E42 compared with LA3120. Results here obtained have shown how new tomato genetic resources can be a valuable source of traits for adaptation to combined abiotic stresses and should be used in breeding programmes to improve stress tolerance in commercial varieties.

Influence of sterilization procedures on the physical and mechanical properties of rotating endodontic instruments: a systematic review and network meta-analysis

The fracture of endodontic instruments inside the canal represents a problem that is not always easy to solve. The reutilization of endodontic instruments after sterilization procedures raises the question of how these processes affect their physical and mechanical properties. Alterations can involve the surface of the instruments, as well as their cutting effectiveness, shape and resistance to torsional and cyclic fatigue. The methodology adopted for this systematic review followed the PRISMA guidelines for systematic reviews. The following search terms were used in PubMed and Scopus: "endodontic sterilization", "endodontic autoclave", "cyclic fatigue", "torsional", "cutting efficiency", "sterilization", "surface characteristics" and "corrosion". After the screening phase, the application of exclusion criteria and the removal of duplicates, 51 studies were identified and divided into four outcomes: cyclic fatigue; deformation and torsional fatigue; corrosion or surface alterations; and cutting efficiency. Our study of the scientific literature highlights disagreements between studies on these effects. After autoclaving, instruments exhibit a reduction in the cutting efficiency, but NiTi alloy instruments have an improved resistance to cyclic and torsional fatigue.

Prognostic assessment of different methods for eosinophils detection in oral tongue cancer

BACKGROUND

TATE has been proposed as a prognostic factor in oral cancer staging; however, the controversial literature data limit its application in the routine diagnosis. The aim of this study was to evaluate the prognostic value of TATE in patients with oral tongue cancer. The second aim was to identify any difference in the methods of eosinophil quantification or in the cutoff values reported in literature.

METHODS

Clinic-pathological data of 204 patients treated at "Ospedali Riuniti" Hospital, Ancona, Italy, were collected. Evaluation of TATE was performed on hematoxylin-and-eosin-stained slides and correlation with survival outcomes was evaluated. The number of eosinophils per square millimeter was evaluated by using two methods, namely density (TATE-1) and classical (TATE-2) methods. For each of the 2 methods tested, patients were stratified into two or three groups, according to the most used cutoff values reported in literature.

RESULTS

Regardless of the method of eosinophil quantification or the cutoff values used, patients with high TATE had a significantly better disease-specific survival. The density method (TATE-1) showed a better predictive performance, in particular when applying a single cutoff of 67 eosinophils/mm² , two cutoffs of 10 and 100 eosinophils/mm² , or two cutoffs of 50 and 120 eosinophils/mm² .

CONCLUSION

The evaluation of TATE is simple, cost-effective, and easy to implement in daily practice with the aim of improving risk stratification of patients affected by oral tongue cancer. Results of prognostic performance analysis suggest using density (TATE-1) method as the standard approach to evaluate TATE in future studies, enhancing replicability.

Innate Immunity in Children and the Role of ACE2 Expression in SARS-CoV-2 Infection

COVID-19 (Coronavirus Disease 2019) is an emerging viral disease caused by the coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), which leads to severe respiratory infections in humans. The first reports came in December 2019 from the city of Wuhan in the province of Hubei in China. It was immediately clear that children developed a milder disease than adults. The reasons for the milder course of the disease were attributed to several factors: innate immunity, difference in ACE2 (angiotensin-converting enzyme II) receptor expression, and previous infections with other common coronaviruses (CovH). This literature review aims to summarize aspects of innate immunity by focusing on the role of ACE2 expression and viral infections in children in modulating the antibody response to SARS-CoV-2 infection. This review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles deemed potentially eligible were considered, including those dealing with COVID-19 in children and providing more up-to-date and significant data in terms of epidemiology, prognosis, course, and symptoms, focusing on the etiopathogenesis of SARS-CoV-2 disease in children. The bibliographic search was conducted using the search engines PubMed and Scopus. The following search terms were entered in PubMed and Scopus: COVID-19 AND ACE2 AND Children; COVID-19 AND Immunity innate AND children. The search identified 857 records, and 18 studies were applicable based on inclusion and exclusion criteria that addressed the issues of COVID-19 concerning the role of ACE2 expression in children. The scientific literature agrees that children develop milder COVID-19 disease than adults. Milder symptomatology could be attributed to innate immunity or previous CovH virus infections, while it is not yet fully understood how the differential expression of ACE2 in children could contribute to milder disease.

Everolimus therapy and side‑effects: A systematic review and meta‑analysis

Recent studies have focused on identifying novel targeted agents in order to reduce the undesired side‑effects of conventional chemotherapeutic agents on normal cells. However, even targeted therapies may exert certain negative effects on healthy tissues. The present systematic review was performed in order to evaluate the type and the incidence of side‑effects in patients treated with everolimus. The PubMed and Scopus databases were searched using the following free words and MESH terms: 'everolimus' AND 'side‑effects' OR 'toxicities' OR 'adverse events'. A total of 912 potentially relevant studies that were screened based on the title and abstracts were identified. A total of 731 were excluded as they did not fulfil the inclusion criteria. Of the 181 remaining studies included, the adverse events reported were obtained. The primary adverse events reported were stomatitis, leukopenia, anorexia, anaemia and fatigue. The majority of the patients reported adverse events limited to grade 1 or 2. On the whole, the data presented herein confirm the findings of previous studies on the relative safety of everolimus, a targeted therapeutic agent, which differs from that of conventional chemotherapy, and highlight the potential adverse events associated with the therapeutic use of everolimus.

Biology and crop production in Space environments: Challenges and opportunities

Long-term manned space-exploration missions and the permanence of human colonies on orbital stations or planetary habitats will require the regeneration of resources onboard or in-situ. Bioregenerative Life Support Systems (BLSSs) are artificial environments where different compartments, involving both living organisms and physical-chemical processes, are integrated to achieve a safe, self-regulating, and chemically balanced Earth-like environment to support human life. Higher plants are key elements of such systems and Space greenhouses represent the producers' compartment. Growing plants in Space requires the knowledge of their growth responses not only to all environmental factors acting on Earth, but also to specific Space constraints such as altered gravity, ionizing radiations and confined volume. Moreover, cultivation techniques need to be adjusted considering such limitations. The type and intensity of environmental factors to be taken into account depend on the mission scenarios. Here, we summarize constraints and opportunities of cultivating higher plants in Space to regenerate resources and produce fresh food onboard. Both biological and agro-technological issues are considered briefly going through experiments both ground-based on Earth and in Space.

Periodontal infrabony defects: Systematic review of healing by defect morphology following regenerative surgery

BACKGROUND

It is thought that infrabony defect morphology affects the outcome of periodontal regenerative surgery. However, this has not been systematically investigated.

AIMS

To investigate how well defect morphology is described in papers reporting regenerative therapy of periodontal infrabony defects and to investigate its effect on clinical and radiographic outcomes.

MATERIALS AND METHODS

A search was conducted in 3 electronic databases for publications reporting clinical and radiographic outcomes of periodontal intra-bony defects after regenerative therapy, divided by defect morphology.

RESULTS

The initial search resulted in 4487 papers, reduced to 143 after first and second screening. Fifteen of these publications were suitable for a fixed-effects meta-analysis. Initial defect depth was found to influence radiographic bone gain 12 months post-surgery, while narrower angles and increased number of walls influenced both radiographic bone gain and clinical attachment level (CAL) gain at 12 months. These associations seemed to occur irrespective of biomaterials used. Risk of bias ranged from low to high.

CONCLUSION

Deeper defects with narrower angles and increased number of walls exhibit improved CAL and radiographic bone gain at 12 months post-regenerative surgery. More data are needed about other aspects of defect morphology such as extension to buccal/lingual surfaces.

Reading-writing disorder in children with idiopathic epilepsy

Several studies have documented learning disabilities (LDs) in subjects with epilepsy, who have been shown to be at greater risk of mild neuropsychological damage, with the consequent risk of academic failure. This retrospective study aimed to investigate the peculiarities of reading and writing disorders in subjects with idiopathic epilepsy. The reading and writing performance of 35 children affected by reading and writing disorders and idiopathic epilepsy (R/WD + E group) has been compared with the performance of 37 children with only reading and writing disorders (R/WD group). A comparison group of 22 typical developing healthy children (TDC group) was also included in the study. As expected, the TDC group reached better performances in the reading and writing tests administered. Between R/WD + E and R/WD groups, there was a substantial analogy in reading and writing disabilities. The differences between the two clinical groups concern writing ability in sentences dictation and verbal and visuospatial short-term memory in digit span and memory-for-location (MFL) tests.

Dust accumulation due to anthropogenic impact induces anatomical and photochemical changes in leaves of Centranthus ruber growing on the slope of the Vesuvius volcano

In Mediterranean ecosystems, some natural areas are exposed to severe anthropogenic impact. Especially in summer, the considerable number of tourists visiting such areas, often with vehicles, causes deposition of dust over the vegetation due to formation of powder clouds, also favoured by wind erosion, high temperature, low precipitation and incoherent soil structure. The main aim of this study was to analyse whether the deposition of dust can induce changes in leaf anatomical functional traits and in the efficiency of photosynthetic apparatus in Centranthus ruber, a species widespread in Mediterranean ecosystems. Leaf morpho-functional traits were quantified in plants growing at sites characterised by high (HD) and low (LD) dust deposition, in periods with high anthropogenic impact. Analyses included quantification of chlorophyll fluorescence emission parameters, photosynthetic pigment concentration as well as stomatal size and frequency, leaf lamina thickness, quantification of intercellular spaces and phenolics in the mesophyll through microscopy. The overall analysis suggested that the different conditions of dust deposition induced different adjustment of morpho-functional traits in leaves of C. ruber. High dust deposition shielded the leaf lamina, protecting the photosynthetic apparatus from excess light and favoured plant photochemical efficiency. Leaves exposed to low dust deposition showed higher accumulation of phenolic compounds, protecting chloroplast membranes and characterised by high thermal dissipation of excess light. Such adaptive phenomena can affect vegetation dynamics due to possible different species-specific plant responses, resulting in different plant competitiveness under the limiting conditions of Mediterranean environments.

Stomatitis And Everolimus: A Review Of Current Literature On 8,201 Patients

Background

Oral toxicities, such as mucositis and stomatitis, are some of the most significant and unavoidable side effects associated with anticancer therapies. In past decades, research has focused on newer targeted agents with the aim of decreasing the rates of side effects on healthy cells. Unfortunately, even targeted anticancer therapies show significant rates of toxicity on healthy tissue. mTOR inhibitors display some adverse events, such as hyperglycemia, hyperlipidemia, hypophosphatemia, hematologic toxicities, and mucocutaneous eruption, but the most important are still stomatitis and skin rash, which are often dose-limiting side effects.

Aim

This review was performed to answer the question “What is the incidence of stomatitis in patients treated with everolimus?”

Methods

We conducted a systematic search on the PubMed and Medline online databases using a combination of MESH terms and free text: “everolimus” (MESH) AND “side effects” OR “toxicities” OR “adverse events”. Only studies fulfilling the following inclusion criteria were considered eligible for inclusion in this study: performed on human subjects, reporting on the use of everolimus (even if in combination with other drugs or ionizing radiation), written in the English language, and reporting the incidence of side effects.

Results

The analysis of literature revealed that the overall incidence of stomatitis after treatment with everolimus was 42.6% (3,493) and that of stomatitis grade G1/2 84.02% (2,935), while G3/4 was 15.97% (558).

Conclusion

Results of the analysis showed that the incidence of stomatitis of grade 1 or 2 is higher than grade 3 or 4. However, it must be taken into account that it is not possible to say if side effects are entirely due to everolimus therapy or combinations with other drugs.

Possible Uses of Plants of the Genus Asphodelus in Oral Medicine

Among the many plants used in traditional medicine we have the plants of the genus Asphodelus, which are present in the Mediterranean area in North Africa and South East Asia, and have been used by indigenous peoples until recently for various pathologies, including: Psoriasis, alopecia areata, acne, burns, nephrolithiasis, toothache, and local inflammation. The scientific literature over the last five years has investigated the various effects of the metabolites extracted from plants of the genus Asphodelus, paying attention to the diuretic, antihypertensive, antimicrobial, anti-inflammatory, and antioxidant effects, and it also has begun to investigate the antitumor properties on tumor cell lines. Studies have been identified through bibliographic research on electronic databases. A total of 574 records were identified on the PubMed, Scopus, Web of Science, and EBSCO databases. After having proceeded to the screening of the articles with the application of the eligibility criteria (all the articles pertaining to the issue Asphodelus), we arrived at a number of 163 articles, and then after the elimination of overlaps, to 82 articles. There are 11 articles which investigate the possible uses of plants of the genus Asphodelus in oral medicine. In oral medicine, the possible uses investigated by the scientific literature are for the treatment of neoplastic (melanoma and oral cancer), viral (herpetic viruses), and microbial diseases (candida, bacteriosis, leishmaniasis), and in the affection of the skin.

Suitability of Solanum lycopersicum L. 'Microtom' for growth in Bioregenerative Life Support Systems: exploring the effect of high-LET ionising radiation on photosynthesis, leaf structure and fruit traits

The realisation of manned space exploration requires the development of Bioregenerative Life Support Systems (BLSS). In such self-sufficient closed habitats, higher plants have a fundamental role in air regeneration, water recovery, food production and waste recycling. In the space environment, ionising radiation represents one of the main constraints to plant growth. In this study, we explore whether low doses of heavy ions, namely Ca 25 Gy, delivered at the seed stage, may induce positive outcomes on growth and functional traits in plants of Solanum lycopersicum L. 'Microtom'. After irradiation of seed, plant growth was monitored during the whole plant life cycle, from germination to fruit ripening. Morphological parameters, photosynthetic efficiency, leaf anatomical functional traits and antioxidant production in leaves and fruits were analysed. Our data demonstrate that irradiation of seeds with 25 Gy Ca ions does not prevent achievement of the seed-to-seed cycle in 'Microtom', and induces a more compact plant size compared to the control. Plants germinated from irradiated seeds show better photochemical efficiency than controls, likely due to the higher amount of D1 protein and photosynthetic pigment content. Leaves of these plants also had smaller cells with a lower number of chloroplasts. The dose of 25 Gy Ca ions is also responsible for positive outcomes in fruits: although developing a lower number of berries, plants germinated from irradiated seeds produce larger berries, richer in carotenoids, ascorbic acid and anthocyanins than controls. These specific traits may be useful for 'Microtom' cultivation in BLSS in space, in so far as the crew members could benefit from fresh food richer in functional compounds that can be directly produced on board.

Necrotizing sialometaplasia can hide the presence of salivary gland tumors: A case series

OBJECTIVE

Necrotizing sialometaplasia (NS) is an uncommon benign process which affects minor and, more rarely, major salivary glands. While self-limiting, the condition might be clinically and histologically mistaken for malignancy. Furthermore, NS may accompany neoplasms. The aim of this paper was to report a series of Italian patients affected by NS associated with an unusual high presence of neoplasms of minor and major salivary glands.

STUDY DESIGN

Clinical and histological features of twelve patients with NS were retrospectively evaluated.

RESULTS

Eight patients presented NS of the minor salivary glands of the palate, and two of them had associated neoplasms (pleomorphic adenoma and adenoid cystic carcinoma) at the same site. Four patients had NS of the parotid gland associated with a history of fine-needle aspiration biopsy performed to diagnose parotid neoplasms. These were epithelial-myoepithelial carcinoma, adenoid cystic carcinoma, Warthin's tumor, and oncocytoma, respectively.

CONCLUSION

Tumors of minor and major salivary glands might be associated with NS more frequently than previously reported. While NS of the parotid is generally the result of invasive diagnostic procedure and is detected after the excision of the tumor, NS of the minor salivary glands may obscure an underlying neoplasm, resulting in delays in referral or treatment.

High PD-L1 expression in the tumour cells did not correlate with poor prognosis of patients suffering for oral squamous cells carcinoma: A meta-analysis of the literature

OBJECTIVES

Oral cancer represents one of the most common malignancies in humans. Its prognosis is still poor, despite the most recent improvements in therapies. An increasing attention is placed on the role of programmed death ligand 1 (PD-L1) in the tumour immunity and its potential function as a marker for tumour prognosis. Whether PD-L1 expression is a prognostic factor for the poor outcomes in oral squamous cell carcinoma is still controversial. This study aimed to investigate, through a meta-analysis, a potential correlation between PD-L1 expression and the prognostic outcomes in patients with oral squamous cell carcinoma.

MATERIALS AND METHODS

The studies were identified by searching PubMed, SCOPUS, Web of Science and were assessed by two of the authors. After the selection process, 11 articles met eligibility criteria and were included in the meta-analysis. Quality assessment of studies was performed according to the REMARK guidelines, and the risk of biases across studies was investigated through Q and I² tests. Meta-analysis was performed to investigate the association between the PD-L1 expression either overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), gender and lymph node metastasis.

RESULTS

A total of 1060 patients were analysed in the 11 studies included in the meta-analysis. Pooled analysis revealed that the expression of PD-L1 did not correlate with poor OS (HR, 0.60; 95% CI: [0.33, 1.10]; P = 0.10), DFS (HR, 0.62; 95% CI: [0.21, 1.88]; P = 0.40), DSS (HR, 2.05; 95% CI: [0.53, 7.86]; P = 0.29 and lymph node metastasis (HR, 1.15; 95% CI: [0.74, 1.81]; P = 0.53). Furthermore, results of the meta-analysis showed that high expression of PD-L1 is two times more frequent in female patients (OR, 0.5; 95% CI: [0.36, 0.69]; P < 0.0001) compared to males. For all the three outcomes analysed, a high rate of heterogeneity was detected (I²  > 50%).

DISCUSSION

High PD-L1 expression did not correlate with poor prognosis of patients suffering for oral squamous cell carcinoma. Studies published on the topic showed a significant variation in results, limiting the use of PD-L1 expression by immunohistochemistry as prognostic biomarker in clinical practice.

Physiological, biochemical and molecular responses to water stress and rehydration in Mediterranean adapted tomato landraces

Mediterranean tomato landraces adapted to arid environments represent an option to counteract drought, and to address the complexity of responses to water deficit and recovery, which is a crucial component of plant adaptation mechanisms. We investigated physiological, biochemical and molecular responses of two Mediterranean tomato landraces, 'Locale di Salina' (Lc) and 'Pizzutello di Sciacca' (Pz) under two dehydration periods and intermediate rehydration in greenhouse pot experiments. Relationship between CO₂ assimilation (A) and stomatal conductance under severe water stress (g_s  < 0.05 mol·m^-2 ·s^-1 ) indicated the occurrence of stomatal and non-stomatal limitations of photosynthesis. Gas exchange promptly recovered within 2-3 days of rehydration. ABA and g_s showed a strict exponential relationship. Both leaf ABA and proline peaked under severe water stress. Lc showed higher accumulation of ABA and higher induction of the expression of both NCED and P5CS genes than Pz. Poly(ADP-ribose) polymerase increased during imposition of stress, mainly in Lc, and decreased under severe water stress. The two landraces hardly differed in their physiological performance. Under severe water stress, g_s showed low sensitivity to ABA, which instead controlled stomatal closure under moderate water stress (g_s  > 0.15 mol·m^-2 ·s^-1 ). The prompt recovery after rehydration of both landraces confirmed their drought-tolerant behaviour. Differences between the two landraces were instead observed at biochemical and molecular levels.

The Effects of Adjuvant Fermented Wheat Germ Extract on Cancer Cell Lines: A Systematic Review

Fermented wheat germ extract (FWGE; trade name AVEMAR) is a natural compound derived from industrial fermentation of wheat germ. Its potential anticancer properties has emerged from recent studies. The aim of this systematic review is to summarize the data available in the scientific literature concerning the in vitro activity of FWGE on malignant cells. A systematic review of English articles in electronic databases has been performed. The primary outcomes of the review regarded types of cancer cell lines subjected to the investigation and the main results concerning cell viability, proliferation, and apoptosis observed within the studies. Sixteen articles were included in the final qualitative analysis. Various types of cancer cells treated with FWGE have been analyzed, showing mainly cytotoxic effects, alteration of the cell cycle, antiproliferative effects, and induction of apoptosis. FWGE can be a promising drug component in cancer treatment; however, further in vitro and in vivo studies are necessary to prove its effectiveness and safety in humans.

Oral stomatitis and mTOR inhibitors: A review of current evidence in 20,915 patients

BACKGROUND

Traditional treatment of malignancies with chemotherapeutic agents is often affected by the damage inflicted on non-cancerous cells. Toxicities of the oral cavity, such as mucositis and stomatitis, are some of the most significant and unavoidable toxicities associated with anti-cancer therapies. For such reason, in the last decades, newer targeted agents have been developed aiming to decrease the rates of side effects on healthy cells. Unfortunately, targeted anti-cancer therapies also showed significant rate of toxicity on healthy tissues. mTOR inhibitors showed some adverse events, such as hyperglycemia, hyperlipidemia, hypophosphatemia, hematologic toxicities, and mucocutaneous eruption, but the most important are still stomatitis and skin rash, often reported as dose-limiting side effects.

PATIENTS AND METHODS

A search of the literature was performed by authors on the PubMed online database using the following key words: "sirolimus" OR "everolimus" OR "temsirolimus" OR "deforolimus" OR "ridaforolimus" combined with the Boolean operator AND with the terms: "stomatitis" OR "mucositis" OR "oral pain." Titles and abstracts of 382 potentially relevant studies were screened; of these, 114 studies were excluded because they did not report the inclusion criteria. In the second round, 268 studies were read full-text, but only 135 reported the inclusion criteria and were included for data extraction. Of the included studies, 95 referred to everolimus use, 16 to ridaforolimus, and 26 to temsirolimus (two studies referred to both everolimus and temsirolimus).

RESULTS

The incidence rate of stomatitis according to the agent used was 25.07% (3,959/15,787) for everolimus, 27.02% (724/2,679) for temsirolimus, and 54.76% (598/1,092) for ridaforolimus. All the three agents analyzed showed high rates of low-grade stomatitis (G1-G2), while the onset of severe stomatitis (G3-G4) was rare.

CONCLUSIONS

Analysis of the reports with patients treated with everolimus, temsirolimus, and ridaforolimus showed a clear prevalence of stomatitis grade 1 or 2. These data differ from that of patients treated with conventional chemotherapy in which mucositis is predominantly of grade 3 or 4.

Performance of three cardoon cultivars in an industrial heavy metal-contaminated soil: Effects on morphology, cytology and photosynthesis

In the present work the cytomorphological and physiological effects on three cardoon cultivars - Sardo, Siciliano, Spagnolo - grown in a metal-polluted soil, were investigated, to assess the traits concurring to the high tolerance to metal stress observed in cv. Spagnolo compared to the other two cultivars. The plants were grown for one month on a real polluted soil collected at a dismantling battery plant, highly enriched by heavy metals, especially Cd and Pb, and their leaves were analyzed by a multidisciplinary approach. TEM observations highlighted severe ultrastructural damage in Sardo and Siciliano, and preserved cytological traits in Spagnolo. Both pigment content and photochemistry indicated a decline in photosynthesis in Sardo and Sicilano and a substantial stability of the same parameters in Spagnolo. Protein analysis indicated a decrease in D1 level in all cultivars; in Spagnolo the D1 decrease was more pronounced and associated to a significant increase in Rubisco, a pattern likely preserving photosynthetic efficiency and high biomass production. In conclusion, Spagnolo cardoon was able to face metal stress through a prompt, multiple response balancing structural and functional traits.

Ultrastructural, protein and photosynthetic alterations induced by Pb and Cd in Cynara cardunculus L., and its potential for phytoremediation

The effects of cadmium and lead were investigated in Cynara cardunculus L. Plant uptake by root and shoot, changes in cell ultrastructure and photosynthetic efficiency, photosynthetic key protein levels, as well as regulation of stress-induced Hsp70 were examined. Cynara cardunculus accumulated Cd and Pb in their tissue, with a different trend for the two metals. The prompt translocation of Cd to the shoot may justify the ultrastructural injuries, especially observed in chloroplasts. However, Cd- treated plants did not show any decline in photochemistry; it is likely that Cd in shoot tissue triggers defense mechanisms, increasing the level of proteins involved in photosynthesis (i.e., Rubisco and D1 increased 7 and 4.5 fold respectively) as a compensatory response to neutralize chloroplast damage. The accumulation of Pb mainly in root, can explain the increase in Hsp70 level (23 folds) in this tissue. Pb reached the shoots, even at low amounts, causing an overall significant change in some photochemical parameters (QY and NPQ decreases and increases of 25%, respectively). The results suggest a higher sensitivity of C. cardunculus to Pb than Cd, although maximal photochemical efficiency suggests that this species seems to tolerate Pb and Cd and hence, it is a suitable candidate for phytoremediation.

Age-related changes of bone mineral density in mandible by quantitative computed tomography

Quantitative Computed Tomography (QCT) was used to investigate age-related changes in trabecular bones of the mandible. The volumetric Bone Mineral Density (vBMD) of mandibles was found to be increasing with aging in the 20-29, 30-39, 40-49 age groups, while resulted decreasing in the 50~ years age group in a Chinese population. The aim of this study was to validate QCT as a reliable method to measure the vBMD of the mandible and to assess vBMD of the mandible in a Chinese population. A total of seven hundred and eighteen volunteers (299 males, 419 females), ranging from 20 to 63 years of age, previously enrolled in another study, were included for vBMD measurements by QCT. A total of 50 subjects were enrolled for the validation of QCT measurement. Basic information (age, height and weight), and vBMD of the mandible (middle, body and angle) were recorded. Comparisons among age and sex groups were analyzed using the Mann-Whitney test. Linear correlation analysis between vBMD and age was performed. The mandibular vBMD was twice measured with QCT by one operator and resulted highly repeatable (ICC 0. 97, P 0. 05). The vBMD in the middle of the mandible was the highest, followed by that in the body and at the angle of mandible. In each age group, the mean vBMD increased with aging except for the 50~ years age group (P less than 0.05) in which it decreased. The mean mandibular vBMD was higher in females than males in each age group (P less than 0.05). Correlation between vBMD and age was statistically significant (r=0.15, P less than 0.01). QCT shows high precision for the measurement of BMD in the mandible. The present study provides normative data of the mandible in an age- and sex-stratified manner, which can be helpful in clinical practice.

Balanced performance measurement in research hospitals: the participative case study of a haematology department

Background

The paper aims to review, design and implement a multidimensional performance measurement system for a public research hospital in order to address the complexity of its multifaceted stakeholder requirements and its double institutional aim of care and research.

Method

The methodology relies on a participative case study performed by external researchers in close collaboration with the staff of an Italian research hospital.

Results

The paper develops and applies a customized version of balanced scorecard based on a new set of performance measures. Our findings suggest that it can be considered an effective framework for measuring the research hospital performance, thanks to a combination of generalizable and context-specific factors.

Conclusions

By showing how the balanced scorecard framework can be customized to research hospitals, the paper is especially of interest for complex healthcare organizations that are implementing management accounting practices. The paper contributes to the body of literature on the application of the balanced scorecard in healthcare through an examination of the challenges in designing and implementing this multidimensional performance tool. This is one of the first papers that show how the balanced scorecard model can be adapted to fit the specific requirements of public research hospitals.

Performance implications of public–private partnerships in research hospitals: Lessons from the involvement of a charity

The paper examines the financial and non-financial performance effects of the third sector involvement in public research hospitals. By relying on multiple data sources, the study compares the performance of an Italian public research hospital before and after the establishment of a partnership with a charity institution. The results reveal that the involvement of the charity is beneficial for both care and research activities, thus supporting the research hospital in achieving its twofold mission. Beside the advancement of the literature, the paper offers a successful example of collaboration between public and not-for-profit organizations that can be replicated to improve public health.

Simultaneous Overexpression of Functional Human HO-1, E5NT and ENTPD1 Protects Murine Fibroblasts against TNF-α-Induced Injury In Vitro

Several biomedical applications, such as xenotransplantation, require multiple genes simultaneously expressed in eukaryotic cells. Advances in genetic engineering technologies have led to the development of efficient polycistronic vectors based on the use of the 2A self-processing oligopeptide. The aim of this work was to evaluate the protective effects of the simultaneous expression of a novel combination of anti-inflammatory human genes, ENTPD1, E5NT and HO-1, in eukaryotic cells. We produced an F2A system-based multicistronic construct to express three human proteins in NIH3T3 cells exposed to an inflammatory stimulus represented by tumor necrosis factor alpha (TNF-α), a pro-inflammatory cytokine which plays an important role during inflammation, cell proliferation, differentiation and apoptosis and in the inflammatory response during ischemia/reperfusion injury in several organ transplantation settings. The protective effects against TNF-α-induced cytotoxicity and cell death, mediated by HO-1, ENTPD1 and E5NT genes were better observed in cells expressing the combination of genes as compared to cells expressing each single gene and the effect was further improved by administrating enzymatic substrates of the human genes to the cells. Moreover, a gene expression analyses demonstrated that the expression of the three genes has a role in modulating key regulators of TNF-α signalling pathway, namely Nemo and Tnfaip3, that promoted pro-survival phenotype in TNF-α injured cells. These results could provide new insights in the research of protective mechanisms in transplantation settings.

Incidence and hospitalisation rates of Lyme borreliosis, France, 2004 to 2012

Binary file ES_Abstracts_Final_ECDC.txt matches

Anatomical alterations of Phaseolus vulgaris L. mature leaves irradiated with X-rays

The cultivation of higher plants in Space involves not only the development of new agro-technologies for the design of ecologically closed Space greenhouses, but also understanding of the effects of Space factors on biological systems. Among Space factors, ionising radiation is one of the main constraints to the growth of organisms. In this paper, we analyse the effect of low-LET radiation on leaf histology and cytology in Phaseolus vulgaris L. plants subjected to increasing doses of X-rays (0.3, 10, 50, 100 Gy). Leaves irradiated at tissue maturity were compared with not-irradiated controls. Semi-thin sections of leaves were analysed through light and epi-fluorescence microscopy. Digital image analysis was applied to quantify anatomical parameters, with a specific focus on the occurrence of signs of structural damage as well as alterations at subcellular level, such as the accumulation of phenolic compounds and chloroplast size. Results showed that even at high levels of radiation, general anatomical structure was not severely perturbed. Slight changes in mesophyll density and cell enlargement were detected at the highest level of radiation. However, at 100 Gy, higher levels of phenolic compounds accumulated along chloroplast membranes: this accompanied an increase in number of chloroplasts. The reduced content of chlorophylls at high levels of radiation was associated with reduced size of the chloroplasts. All data are discussed in terms of the possible role of cellular modifications in the maintenance of high radioresistance and photosynthetic efficiency.

Growth alteration and leaf biochemical responses in Phaseolus vulgaris exposed to different doses of ionising radiation

Ionising radiation may have different effects on plant metabolism, growth and reproduction, depending on radiation dose, plant species, developmental stage and physiological traits. In this study, exposure of dwarf bean plants to different doses of X-rays (0.3, 10, 50, 100 Gy) was investigated with a multidisciplinary approach consisting of morphological, ecophysiological and biochemical analysis. Both mature and young leaves still growing during the X-rays exposure were compared with non-irradiated control leaves. In particular, leaf expansion, leaf anatomy and functional traits, as well as photosynthetic pigment content and Rubisco expression were analysed. Moreover, the activity of poly(ADP-ribose) polymerase (PARP) was also measured as an indicator of radiation-induced DNA damage. Our data showed that leaf growth is affected by high levels of radiation and demonstrate that mature leaves are more radio-resistant than young leaves, which experience severe dose-dependent changes in leaf functional traits. In particular, young leaves exhibited a reduction of area and an increase in specific mass and dry matter content, as well as a decline in Rubisco activity. Moreover, they showed elevated PARP activity and an increase in phenolic compounds in wall cells if compared with mature leaves. Both of these strategies have been interpreted as a way to help developing leaves withstand irradiation.

Mumps: burden of disease in France

This article provides a review of the epidemiological data on mumps in France since 1986. The results of 26 years of monitoring in general practice by the Sentinel network are analysed, such as hospitalisation data between 2004 and 2010, as well as mortality data between 2000 and 2009. The annual incidence rate has plummeted between 1986 and 2011, from 859 cases per 100,000 inhabitants [95% CI: 798-920] to 9 cases per 100,000 inhabitants [95% CI: 4-14]. A change in the age distribution is significant with an increase of Relative Illness Ratio (RIR) for patients over 20 years. Since 2000, vaccine status has also changed, and the majority of recent mumps cases occur among previously vaccinated patients. The average annual hospitalisation rate is 3.2 per 1 million inhabitants. Mumps was identified as the initial cause of death in 1 case every 5 years. This study estimates the burden of mumps disease in France.

[Orientation of patients referred by their general practionner to the public or private hospital sector in France: A prospective epidemiologic study]

PURPOSE

In-patients characteristics generate cost differences between hospitals. In France, there are few data on the characteristics on the patients referred to hospitals by their general practitioners (GPs) and none on the predictors of referral to the public or for-profit hospitals. The aim of this study was to analyze those characteristics and the predictors of referral to the public or for-profit hospitals.

METHODS

We collected, prospectively, the request for hospitalizations made by the GPs of the Sentinelles network in France, from 2007 to 2009. Patients' characteristics and also the reasons for that request were analyzed. A logistic regression was used to compare the population between local hospitals.

RESULTS

Ten thousand seven hundred and eighteen statements were collected. The median age was 73 years. Patients were women in 51% of the cases, and only 14% of the hospitalizations had been planned. Hospitalization in the public sector was preferred for young children and the elderly (P<0.001). When compared to the patients referred to the private sector, patients addressed to the public sector were more often seen for emergencies (OR: 2.3 [2.0-2.8]), by a doctor different from their referring GP (OR: 1.7 [1.4-2.1]) and out of the GP's office. The reasons for hospital admission were different depending on the sector of hospitalization (P<0.001), patients addressed to the public sector hospitals presented with greater comorbidity or more complex diagnosis (for example: feeling ill, fainting or syncope and fever) or a greater disability (for example: stroke, neurological and psychiatric diseases).

CONCLUSION

This study suggests that GPs send their patients to the public or for-profit hospitals according to criteria of severity, comorbidity and disability.

[Patients' beliefs about long-term glucocorticoid therapy and their association to treatment adherence]

BACKGROUND

In patients treated with systemic glucocorticoids (GCs), it is unknown if beliefs about the treatment are associated with level of reported adherence.

PATIENTS AND METHODS

Cross-sectional study conducted in two departments of internal medicine during a six-month period. All patients receiving long-term GCs therapy were asked to fill in a questionnaire regarding their beliefs about (specific scale of the Beliefs about Medicines Questionnaire) and their adherence to (four-item Morisky-Green scale) GCs. Logistic regression analysis was used to assess association between beliefs about GCs and adherence to treatment.

RESULTS

One hundred and eighty one questionnaires were analysed (women: 79%, median age [IQR]: 47 [33-61] years, median duration of treatment: 18 [7-72] months, median daily dosage of prednisone equivalent: 10 [6-20] mg). Among these 181 patients, 83 (46%) reported a "concern" score equal to or higher than the "necessity" score. Nineteen percent of patients reported a low adherence level. In multivariate analysis, these patients were significantly younger (OR: 0.96 [0.93-0.98] per increasing year of age, P=0.002) and reported more frequently a "concern" score higher than a "necessity" score (OR: 3.08 [1.27-7.46], P=0.01) as compared to patients reporting a high adherence level.

CONCLUSION

Informing patients about the "necessity" of GCs and taking into account their "concerns" about adverse events or their fear of becoming dependent on the medication may improve their adherence to treatment.

Impact of glucocorticoid-induced adverse events on adherence in patients receiving long-term systemic glucocorticoid therapy

BACKGROUND

Factors influencing adherence to long-term (i.e. ≥ 3 months) systemic glucocorticoid therapy are poorly understood.

OBJECTIVE

To evaluate the relationship between glucocorticoid-induced adverse events and therapeutic adherence in patients on long-term glucocorticoid treatment.

METHODS

A cross-sectional survey was conducted in three departments of dermatology/internal medicine between April and September 2008. Patients were asked to provide data regarding symptoms they attributed to glucocorticoids, and adherence to treatment was measured using the four-item Morisky-Green adherence scale. Logistic regression analyses were used to assess the association between reported adverse events and adherence to glucocorticoids.

RESULTS

A total of 255 questionnaires were completed and analysed [women 78%; median age 48 years (interquartile range (IQR) 34-65); connective tissue diseases 59%; median duration of treatment 24 months (IQR 8-72); median daily dose 10 mg (IQR 6-20)]. Among these 255 patients, 199 (78%) reported themselves as 'good adherents' and 56 (22%) as 'poor adherents' to treatment. Poor adherence was associated with younger age [odds ratio (OR) 0·97, 95% confidence interval (CI) 0·95-0·99, per increasing year; P < 0·01], presence of glucocorticoid-induced epigastralgia (OR 4·02, 95% CI 2·00-8·09; P < 0·01) and presence of glucocorticoid-induced morphological changes (OR 2·49, 95% CI 1·19-5·21; P = 0·02). Moreover, patients with poor adherence were likely to report concomitantly poor adherence to dietary advice associated with glucocorticoid therapy (OR 2·44, 95% CI 1·12-5·26; P = 0·02).

CONCLUSIONS

As with other chronic therapies, the presence of glucocorticoid-induced adverse events is associated with an altered self-reported adherence to glucocorticoids. Patients who report epigastric pain or morphological changes that they associate with glucocorticoid therapy are particularly at risk of poor adherence. Adherence to dietary advice associated with glucocorticoid therapy may be an indirect measure of treatment adherence.

Suitability of two types of organic wastes for the growth of sclerophyllous shrubs on limestone debris: a mesocosm trial

This study investigated whether overlaying organic wastes directly on limestone debris allowed the growth of sclerophyllous shrubs; the aim was to explore the feasibility of rehabilitation of sites destroyed by quarrying activity. In an open air mesocosm experiment two types of organic material were compared: compost from municipal wastes (C) and a mixture of compost and poultry manure added with wheat husk (C-PW). Mesocosms were pots (1m diameter, 60cm height) containing limestone debris covered by the organic material. Seven mesocosms with C and seven mesocosms with C-PW were planted with sclerophyllous shrubs (Laurus nobilis L., Phillyrea angustifolia L. and Quercus ilex L.). The substrates were characterised in terms of chemical and physical parameters, microbial activity and biomass, and total and active fungal biomass. Shrub photosynthetic performance and growth were evaluated. Over the whole experimental period, organic matter mineralization was higher in C-PW. Microbial biomass and respiration were higher in C-PW than in C but after one year no statistically significant difference between the two substrates occurred. Fungal mycelium was a minor fraction of the microbial community in both types of substrates and decreased dramatically after setting up the mesocosms. The metabolic quotient was higher in C suggesting more stressful conditions as compared to C-PW. Both substrates allowed shrub growth; however photosynthetic rates and the increase of plant size were higher on C-PW than on C. The results demonstrated that, as compared to only compost, the mixture of compost and poultry manure added with wheat husk is a substrate more suitable to both microbial processes and plant growth. Therefore a plan to revegetate quarries based on the use of organic wastes as a substrate for sclerophyllous shrubs could be feasible and, what is more, helpful to mitigate the environmental impact of organic wastes disposal.

Paraheliotropism in Robinia pseudoacacia L.: an efficient strategy to optimise photosynthetic performance under natural environmental conditions

We assessed the contribution of leaf movements to PSII photoprotection against high light and temperature in Robinia pseudoacacia. Gas exchange and chlorophyll a fluorescence measurements were performed during the day at 10:00, 12:00, 15:00 and 18:00 hours on leaves where paraheliotropic movements were restrained (restrained leaves, RL) and on control unrestrained leaves (UL). RL showed a strong decrease of net photosynthesis (A(n)), stomatal conductance (g(sH2O)), quantum yield of electron transport (PhiPSII), percentage of photosynthesis inhibited by O2 (IPO) and photochemical quenching (q(P)) in the course of the day, whereas, a significant increase in C(i)/C(a) and NPQ was observed. Contrary to RL, UL had higher photosynthetic performance that was maintained at elevated levels throughout the day. In the late afternoon, A(n), g(sH2O), PhiPSII and q(P) of RL showed a tendency to recovery, as compared to 15:00 hours, even if the values remained lower than those measured at 10:00 hours and in UL. In addition, contrary to UL, no recovery was found in F(v)/F(m) at the end of the study period in RL. Data presented suggest that in R. pseudoacacia, leaf movements, by reducing light interception, represent an efficient, fast and reversible strategy to overcome environmental stresses such as high light and temperature. Moreover, paraheliotropism was able to protect photosystems, avoiding photoinhibitory damage, leading to a carbon gain for the plant.

The Color Doppler with contrast agent US in the study of post Cholecistectomy Syndrome

PURPOSE

The aim of this study was to evaluate the study of intra- and extra-biliary ducts by contrast-enhanced colour-Doppler in patients who have undergone laparoscopic cholecystectomy.

MATERIALS AND METHODS

Contrast-enhanced colour-Doppler US was performed in 15 patients who had undegone laparoscopic cholecystectomy. The US contrast agent was introducted into the Kehr or Pedinelli tube to allow visualisation of the bile ducts and duodenum.

RESULTS

The colour-Doppler study enabled visualisation of the contrat agent in the intra- and extra-hepatic bile ducts and in the duodenum in all patients, thereby permitting the accurate study of the post-operative course. The data obtained were confirmed by conventional radiology.

CONCLUSIONS

The advantages of this US ultrasound technique are the complete absence of ionising radiation and no intolerance to the US contrast agent. This technique could therefore be used in selected patients as an alternative to trans-Kehr and trans-Pedinelli cholangyography.