Search

Issue/problem AGENAS supports the implementation of health policies in direct collaboration with Italian Regions and Autonomous Provinces. To improve public reporting, we aimed to complement the production of technical reports with new forms of timely communication, using National Portals. Description of the problem Between October-December 2020, we designed and implemented the Covid-19 National Portal, including a suite of targeted indicators, fully automated via ad hoc scripts written in php and R on top of a relational database using internal and external data sources. Targeted information was widely communicated and continuously updated. Dedicated sections on forecasting and resilience were delivered in collaboration with specialised academic institutions. In 2021, we deployed the Portal for the Transparency of Health Services, broadly oriented towards health issues, the location of services and performance indicators. Results Pre-post comparisons of web analytics for Jan-Apr 2020-2022 showed clear advantages of Covid-19 Portal. By Apr 2020, Italy had introduced national lockdown, while AGENAS covered the topic traditionally, recording 48,122 users overall, with daily peaks below 5,000 sessions. In 2021-2022, the number of users skyrocketed at 436,280, with daily peaks of 100,000 sessions, and 421,123 respectively, with daily peaks of 150,000 sessions. Visits to the Transparency Portal were considerably more limited. Lessons To be widely used, public health information needs to be relevant (responding to personal need close to home), understandable, accurate and timely. National Portals can gain efficiency through the mediation of search engines, enhanced by: targeted naming (url), coherent semantic perimeter (third level domain in a highly referenced institutional website), continuous updating, and impact factor (linked by authoritative websites). The Transparency Portal will take stock of these lessons to succeed in a new funded program of NextGenerationEU. Key messages • Relevant, understandable, accurate and timely dissemination for different types of audience may be effectively organised through National Portals. • Productive collaboration between health specialists and communication experts can enhance usability and actionability of National Portals for public health.

Background We assessed the difference in survival rates for people with diabetes experiencing LEA in England and Scotland, using large databases held by the Royal College of General Practitioners (RCGP) and the Scottish Diabetes Register (SCI-DC). Methods Observational retrospective study of T2D adults 18+ years with LEA between 1/1/2008-1/1/2018 from 1,800 general practices in England (7.4%) and all primary, secondary care units in Scotland. Significance tests were carried out using univariate odds ratios within each database. Results On 1/1/2018, N = 127,100 people with T2D were registered alive in RCGP, with N = 1,052 (832 per 100,000) experiencing prior LEA, vs N = 2,200 (783 per 100,000) out of 280,908 in SCI-DC. Among them, England recorded N = 405 patients (72.5%) with prior DFU diagnosis vs N = 993 in Scotland (74.3%), with a median time DFU to LEA of 2.0 vs 2.4 years. The median time spent with LEA was 3.4 years in England vs 3.9 years in Scotland. After including those dying earlier, different univariate patterns were found for England and Scotland. In both networks, increased risk was found for those aged 50+ at first LEA, with prior history of acute myocardial infarction, peripheral arterial disease, ischemic heart disease, cerebrovascular event, higher glomerular filtration rate and major LEA first. In England, reduced risks were found for males (OR = 0.77, 95%CI: 0.64-0.93) and people with retinopathy (0.69; 0.57-0.82), while higher risk were found for hypertension (1.29; 1.09-1.54). In Scotland, lower risks were found for obese (0.59; 0.52-0.66) and those with DFU after LEA (0.74; 0.62-0.89), vs higher rates among those of non-white ethnicity (1.63; 1.19-2.23) and dyalisis (2.31; 1.75-3.07). Conclusions Notable differences were found between England and Scotland in terms of characteristics associated with different outcomes following LEA among T2D adults. Multivariate analyses of aggregate patterns are currently ongoing to adjust for potential confounding. Key messages • Routine datasets from England and Scotland showed a differential impact of case-mix characteristics on lower extremity amputations among adults with Type 2 diabetes. • Information available from different clinical networks can be mapped against the available standard sets to compare health care outcomes of people with different complex conditions.

Background Previous studies allowed defining a novel checklist for the participatory evaluation of person-centredness in hospital care using 243 items, grouped in 4 main areas, 12 sub-areas and 29 criteria. We aimed to validate a reduced set of core items that could be continuously used for service improvement in Italy. Methods Validation was performed using data collected during the last national survey carried out in 2017-2018 in N = 387 acute care hospitals from 16 out of 21 Italian regions. Descriptive measures for each item were used to assess eligibility for factor analysis, applied separately on each of the 4 main areas originally identified. Varimax rotation with eigenvalues>1 was used to optimise factor structure. Items with an item-total correlation>0.30 and factor loadings>0.4 were attributed to individual factors. Items with inter-item correlation coefficient>0.70 were included in a list of candidate mergers, submitted to expert opinion. Cronbach's alpha was used to assess overall internal consistency. Results A total of 183 out of 243 items included in the original checklist were submitted to factor analysis. Overall values of Cronbach's alpha ranged between 0.77-0.90, indicating a high consistency. A total of 67 items were finally attributed to 4 main areas, allocated as follows: 16 items in 4 sub-areas for ‘Person-oriented organisational and care processes’, 16 items in 4 sub-areas for ‘Physical accessibility, livability and comfort of the facilities’, 15 items in 3 sub-areas for ‘Access to information, streamlining and transparency’, and 20 items in 4 sub-areas for ‘Taking care of the relationship with patients and citizens’. Conclusions A simplified checklist including a manageable number of items that can be easily managed to evaluate hospital services was identified through an objective validation process. The national experience can provide valuable lessons for the application of participatory approaches of person-centred care. Key messages • A standardised checklist has been validated using survey data collected through a participatory process in Italian regions. • The checklist can be used to evaluate and improve person-centered hospital services through a manageable number of items and factors.

Background The SCORE2 risk model has been recommended for cardiovascular risk assessment in individuals aged over 40 years without diabetes in 4 defined risk regions of Europe. We aimed to validate a novel SCORE2-DM model in Type 2 diabetes with additional risk factors mainly based on UK datasets, using federated databases from the EUBIROD network. Methods We defined a full operational protocol to implement a standard procedure for validation across contributing sources in Europe. The manual described inclusion/exclusion criteria (aged 40+, diagnosis of T2 diabetes at 30+, no prior CVD), risk factors measured over a baseline interval (1/2013-62015), target/competing events at follow-up (2015-2019). We specified a common data model with 9 steps required to process longitudinal records and deliver summary cohort data (one record per person). All rules were implemented in R and NeuBIRO, an original tool written in Java/Groovy and H2 SQL (https://github.com/eubirodnetwork/neubiro). Results Software was able to produce the following outputs at each source: distribution of risk factors by sex and 5-year age groups; Harrell's C-index and standard error of SCORE2 and SCORE2-DM by sex and 10-year age groups, C-index differences; average 5-year predictive vs observed risk by risk deciles; adjusted cumulative incidence of 5-year competing risk by sex and 5-year age groups. Code was packaged into a stand-alone bundle, with test data and coefficients ofthe SCORE2-DM model. The procedures allowed either creating cohort data autonomously to run the supplied R code, or let NeuBIRO complete all steps foreseen to deliver. Tests have been successfully completed in the derivation data, with results from federated databases expected to contribute to the final external validation of SCORE2-DM by midyear. Conclusions We defined a collaborative method to validate risk prediction models in high risk subgroups using international pooling of cohort data with privacy protection. Key messages • Collaborative methods to validate risk prediction models can enhance access to real world data for researchers across chronic diseases. • Implementation of flexible and reusable source code can increase opportunities to use prediction models for robust clinical decision making in multimorbidity.

Background During the pandemic, restrictions set by the Italian Government were primarily based on the regional level of key parameters including hospitalization and incidence rates. We aimed to build a specific plot to monitor trends and trigger early alerts, with daily updates publicly available on a National Portal. Methods A multidisciplinary team conceived and implemented a new composite plot, developing ad hoc R scripts on top of a specialised database, built in collaboration with the Ministry of Health. We calculated the doubling time Td as log(2)/log(1+r/100), where r is the daily change of target parameters and Td ranges between (0,+-infinity), and not determined for constant or missing values. We calculated Td daily, as either doubling (growth) or halving (decrease) time. To visualize trends, we assembled two different types of graphs: a bivariate plot showing the path of each point (Td, target parameter) over time, and a line plot of Td over time. The Y axis was inverted for doubling times, as lower Td indicate higher alert in this case. The two graphs were arranged in lines, using cutoffs for excessive high values for doubling times and low values for halving times. A third line was included to display trends of the target parameter over time. Results The plot was successfully realized and published on the Portal for all regions in February 2021 (https://www.agenas.gov.it/covid19/web/index.php?r=english%2Fdoubling&q=ITA&t=0). Since July 2021, we used the doubling plot to monitor the three main parameters adopted to set restrictions for Covid-19: a) occupancy rates in intensive care; b) occupancy rates in medical wards; c) weekly incidence rates. The plot highlighted growth trends and early alerts, particularly in the initial phases of growth. Conclusions The doubling plot can provide useful information to trigger early responses for pandemic control in decentralised governance. R code is available open source from AGENAS for free use. Key messages • The doubling plot was conceived and implemented on a National Portal to trigger early alerts of Covid-19 progression in Italian Regions and Autonomous Provinces. • The plot could be rapidly adapted to legislative parameters and can be useful in different situations to monitor epidemic growth and support public health policies.

Periodontal diseases are among the most common infectious diseases in the world, caused by pathogenic bacteria that trigger innate, inflammatory, and adaptive immune responses, leading to the destruction of supporting periodontal tissues and, if untreated, tooth loss. The objective of this study was to explore the efficacy of medical device that produced ozonized water (Medica S.r.l. Bologna, Italy) in the treatment of chronic periodontitis of adult patients. A randomized controlled split-mouth study was carried out in ten patients (5 men and 5 women age 42-73 mean 55 ± 7) with a diagnosis of chronic periodontitis. None of these patients received any surgical or non-surgical periodontal therapy and demonstrated radiographic evidence of moderate bone loss. The mouth has been divided into upper right and left quadrants. The upper and lower right quadrants were treated with ultrasonic scaler, the left quadrants with ultrasonic scaler with ozonated water. Ten microbiological samples were collected from upper left quadrants and 10 from upper right quadrants from each patient. Microbiological samples were collected from the sites of the patients at baseline and at the 7th day. Twenty localized chronic periodontitis sites were selected (10 in left quadrants and 10 in right quadrants). After the treatment with ozonized water, a remarkable decrease in bacteria amount, both for some species and for the total count was observed in the left quadrants respect to right ones. Our study demonstrated the efficacy of the ozonized water in the management of moderate to severe chronic periodontitis.

The aim of the multicentre study promoted by Nuova FIO is to evaluate the beneficial effects of the systemic Oxygen-Ozone (O2O3) therapy in patients suffering from SARS COV-2 disease in the early phases of the disease, before worsening, up to the need of tracheal intubation. The study is based on the rationale on that the systemic oxygen-ozone treatment could be effective, positively influencing the disease evolution and/or being able to mitigate the onset of the cytokine storm syndrome at least partially.

CBCT combined to intra-oral scansion are the means to build an endodontic surgical guide to perform an easier and safer access to the apex in endodontic micro-surgery. .A 38-year-old woman presented chronic apical periodontitis, which involved the three roots of 16 that was treated by endodontic therapy several years ago elsewhere. The palatine channel was retreated, the mesio- and disto- buccal roots were instead treated with apicoectomy. A surgical template was printed by a 3D printer to obtain greater precision in the surgical access.Endodontic microsurgery has evolved over the years. New tools have been introduced to improve therapy, even if the basic principles have not changed. In fact, according to the literature, it is necessary to cut at least 3 mm of root to be sure of eliminating the anatomical variations and the accessory channels. Several Authors have devoted themselves to creating an endodontic surgical template, some in vitro and others in vivo. The present paper introduces a new method that allows a more conservative osteotomy and greater precision the surgical access. Further investigation are needed to test and improve the effectiveness of the treatment but this technique seems very promising because it is less invasive for the patient and simplifies the work for the dentist who can perform micro-surgery in an easier and faster way.

The aim of this study was to evaluate the progression of the light through a series of translucent posts available on the market (D.T. Light-post, R.T.D.).nine D.T. Light-posts (DTLPs) were analyzed, 3 for each available measure. Each post was trans-illuminated both in vertical trans-ilumination (VTI) and oblique trans-illumination (OTI), via a light curing unit (LCU) (V.I.P., Bisco), in complete darkness conditions, and the resulting image of the post, was digitally acquired with a 1:1 ratio. The images were then analyzed using digital image analysis software (Image Pro plus 4.1, Media Cybernetics) previously performing the light intensity calibration, of the LCU, by means a radiometer (Curing Radiometer model 100, Demetron Corp.). The evaluation of the progression of the light through the posts was conducted for each post along its longitudinal axis.no significant differences concerning VTI vs OTI for DTLP n.1 (p = 0.341) and DTLP n. 3 (p = 0.115), while for DTLP n.2 a significant difference was observed (p = 0.041); Conclusion: The results demonstrate that the greater the section of the post, the greater its ability to transmit light at a distance; also the vertical Trans-illumination of the post is to be preferred to the oblique one.

Background In recent literature, different approaches have been proposed to improve the long-lasting treatment of age-related alterations on the human face with decreased invasiveness and side effects such as scar tissue. Voltaic arc dermabrasion is a minimally painful procedure that does not create discomfort to the patient and requires no anaesthesia. Aims The aim of this investigation was to evaluate the voltaic arc technique for the treatment of skin wrinkles in the periauricular area. Methods A total of 80 patients were treated in this study, 56 females and 24 males. The population was visited at 1 week, 1 month, and 2 months postoperative follow-ups to evaluate the healing of the treated regions. Results All subjects showed evidence of tissue contraction related to the skin of the periauricular region with a cosmetic reduction of wrinkles in the treated area. No scars, complications, or pigmentary alterations were reported. At 1 month, all treated areas showed complete healing. Conclusions The voltaic arc dermabrasion can be considered a useful tool for a noninvasive treatment of wrinkles related to the periauricular skin, with no discomfort for the patient or complications related to the procedure.

Background The EU-funded Marie Curie project HEALTHPROS aims to foster a new generation of “Healthcare Performance Intelligence Professionals” through a cohesive stream of 13 doctoral projects (www.healthpros-h2020.eu). Over 48 months, researchers will investigate key levers of healthcare improvement in 7 different countries, using methods drawn from the diverse fields of biostatistics, medical informatics and health services research. Objectives To describe barriers and enablers in the conduction of two doctoral projects aimed at exploring the impact of personal risk factors and organizational arrangements on lower extremity amputations in diabetes, through the use of large-scale databases from England, Scotland, Denmark and Germany. Results The research plan included a systematic review, structured comparison of data sources, predictive modelling and software development for automated international comparisons. Barriers encountered by researchers were: knowledge and access to data sources from different countries, dealing with data protection rules and the ability to carry out international comparisons when individual records are not easily allowed to leave national boundaries. Enabling factors included: a targeted educational process for risk modelling in diabetes and a multidisciplinary support team to help doctoral students overcoming the above barriers across different sites. Further clinical insight and contextual knowledge of data systems in place at different locations were needed in addition to the statistical, epidemiological and technical skills initially foreseen by the program. Conclusions The success of studies within a general educational program on health systems performance may depend from the continued support of a multidisciplinary team helping students in their educational process as well as with the practicalities of their research. International comparisons using routine data may require prioritisation to meet the tight timelines of doctoral theses. Key messages Academic programs for international comparisons in health care may be hampered by different type of barriers including technical aspects, legal regulations and a range of contextual factors. The establishment of multidisciplinary support teams may be essential for training doctoral students aiming to conduct international comparisons using routine data.

The indication for using chemical devices as an adjunct of domestic oral hygiene has gained increased attention in last decades. The efficacy of chemical devices for oral biofilm control is proven by evidence from clinical studies. The purpose of this study was to assess the effect of a new oral gel named ADC to reduce oral bacterial loading investigated by means of Polymerase Chain Reaction (PCR). Materials and methods A total of 20 patients with a diagnosis of chronic periodontitis in the age group >25 years, were selected. None of these patients had received any surgical or non-surgical periodontal therapy and demonstrated radiographic evidence of moderate bone loss. The study sample was divided into two groups of 10 patients each, homogeneous by age and sex. The study group was given a little bottle containing ADC gel, while the control group was given an identical pack-containing placebo, a gel similar to ADC for consistence, colour, taste and odour. Four sites in separate quadrants were selected in each patient for testing the efficacy of the new medical device. Microbial analysis (MA) was performed at baseline and at day 15. Paired T-Test was used to detect statistical significant reduction of total bacterial loading and specific bacteria. Results Specimens of subgingival plaque from patients were investigated for the presence of six bacterial species and for total bacterial loading by quantitative PCR. There was a statistically significant reduction total bacterial loading detected pre and post treatment (p= 0.029) in the study group. In the control group the reduction of total bacterial loading was not significant (p= 0,279). The ADC gel did not show any side effects and was not observed to cause discomfort or to produce adverse reactions in time. No patient reported pain, burning, tingling sensation or numbness. Conclusion The aim of our study was to test the efficacy of a new chemical formulation with antibacterial properties to use for domestic oral hygiene with a preliminary study. Although the reported data show a statistically significant drop in total bacterial loading after treatment our limited results do not allow us to draw final conclusions about the clinical efficiency of the ADC gel. There is currently a trend in the increased use of antimicrobial agents. The effectiveness of antimicrobial therapies depends on host defence mechanisms and virulence factors. Further research, with relatively larger sample size and longer follow-up period, will be performed to better validate the efficacy of ADC gel as an effective local drug delivery agent in daily oral hygiene.

Among complications in orthognathic surgery, the insurgence of pneumothorax is very rare. Pneumothorax is the presence of air or gas in the pleural cavity and it is rare complications in the postoperative oral and maxillofacial surgery patient. The clinical results are dependent on the degree of collapse of the lung on the affected side. Pneumothorax can impair oxygenation and/or ventilation. If the pneumothorax is significant, it can cause a shift of the mediastinum and compromise haemodynamic stability. While 10% of pneumothoraces are asymptomatic, patients often complain of acute chest pain and difficulty breathing. There is a reduction in vital capacity, tachycardia, tachypnoea and a decrease in partial pressure of oxygen with an inability to maintain oxygen saturations. We observed this unusual surgical consequence in a 28-year-old female with negative clinical history and instrumental evaluation after Le Fort I osteotomy and bilateral sagittal split osteotomy (BSSO). No further consequences, no neurological sequelae, no infections and no other osteotomies sequelae were seen. Sudden post-surgical dispnea associated to sub-cutaneous emphysema of the neck and of the thorax must be adequately observed with the aim of monitoring further severe sequelae. The anaesthetic management of the emergency difficult airway in any post-surgical orthognatic treatment can be extremely difficult requiring a multi-disciplinary approach.

Background: Titanium is the gold standard among materials used for prosthetic devices because of its good mechanical and chemical properties. When exposed to oxygen, titanium becomes an oxide, anatase that is biocompatible and able to induce osseointegration. Materials and Methods: In this study we compared the expression profiling of stem cells cultivated on two types of surface: Pure titanium disk and nanotube titanium disk in order to detect if nanotube titanium instead (NTD) surface stimulates stem cells towards osteoblast differentiation. Results: Stem cells cultivated on nanotube titanium disks showed the upregulation of bone-related genes RUNX2, FOSL1 and SPP1. Conclusions: Results demonstrated that nanotube titanium disk surface is more osteo-induced surface compared to titanium disk, promoting the differentiation of mesenchymal stem cells in osteoblasts.

Mast cells (MCs) are mediators of allergy and inflammation and participate in the growth of cancer cells. MCs can promote both neoangiogenesis and tumor growth. They increase in the stroma of certain tumors where they can be recruited by tumor-derived chemoattractants, such as monocyte chemotactic protein-1 (MCP-1), RANTES and stem cell factor (SCF) to selectively secrete inflammatory molecules including chemical mediators and cytokines (TNF, IL-6 and IL-1). However, MC differentiation pathways and heterogeneity in cancer are still poorly understood. Human interleukin 1 (IL-1) plays a pivotal role in the pathogenesis of many diseases and functions, including host response to microbial invasion, injury inflammatory processes, immunologic challenges and cancer. Inflammation around the tumor includes the infiltration of mast cells and facilitates cancer growth. MCs are activated by IL-1 which can be produced by certain cancer cells and stimulate the stromal cells to selectively release IL-6, contributing to the development of Th-17 cells and increasing inflammation. IL-37, mainly generated by macrophage cell line, is an IL-1 family member which binds IL-18 receptor α (IL-18Rα) chain, and acts as a natural inhibitor of immune responses. IL-37 down-regulates cJun induced by IL-1, pro-inflammatory signals and reduces the expression of the mitogen-activated protein kinase (MAPK) p38α, STAT transcription factors and p53, affecting cellular differentiation and proliferation. In the present study we report the relationship between inflammatory mast cells, cancer and the beneficial effect of IL-37.

The aim of our study is to value the microbial contamination in the implant-abutment connections (IAC) of a Nobel Replace Conical Connection implant system [Nobel Biocare®, Vimercate (MB), Italy].To identify the capability of the implant to protect the internal space from the external environment, the passage of genetically modified bacteria across IAC was evaluated. Four Nobel Replace Conical Connection implants (Nobel Biocare®, Vimercate (MB), Italy) were immerged in a bacterial culture for twenty-four hours and then bacteria amount was measured inside and outside IAC with Real-time PCR. Bacterial quantification was performed by Real-Time Polymerase Chain Reaction using the absolute quantification with the standard curve method.In all tested implants, bacteria were found in the inner side, with a median percentage of 10.9%. The analysis revealed that in both cases (internally and externally), bacteria grew for the first 48 hours but subsequently they started to dye, probably as a consequence of nutrient consumption. Moreover, the difference between outer and inner bacteria concentration was statistically significant at each time point.Implant's internal contamination shows that IAC is not sealing. The reported results are similar to those of previous studies carried out on different implant systems. Until now, no IAC has been proven to seal the gap between implant and abutment.

Contour enhancements of the midface make up a dominant aspect of aesthetic surgery. The goal of midface rejuvenation is to decrease the prominence of grooves and creases as well as to provide volume to atrophied tissue. There are various options, including autologous tissue grafts, allogenic tissue grafts and alloplastic materials. In turn, patients’ needs have led to an increasing trend of less invasive treatments. In the present study, 82 implants were used for midface augmentation in 41 patients (38 women, 3 men) between January 2014 and January 2016. Twenty-five patients were treated with Hyaluronic acid implants while the remaining 16 patients were treated with lipofilling. For both groups and in all cases, good integration of the filled material was observed in the malar region, with no significant treatment complications and the last follow-up visit demonstrated good results and overall satisfaction. Hyaluronic acid fillers and lipofilling are therefore the ideal answer to patients who aim for a natural and immediate result with manageable complications, but, unlike Hyaluronic acid, autologous fat allows us to obtain a long-lasting effect over time, resulting the closest thing to an ideal facial filler.

The final outcome of dental treatment needs to be not only clinically sufficient, but also esthetically pleasing. Bilateral symmetry in the maxillary incisor teeth is of significant importance in esthetic dentistry. In restorative dentistry, symmetry refers to the appearance of balance around the dental midline. The purpose of this study was to measure and compare the maxillary incisor teeth dimensions from both sides of the dental midline, in order to asses if this symmetry occurs naturally. From the student community population at Tel Aviv University, 66 students between the ages of 20-35 (35 males, 31 females) were enrolled and gave consent. The inclusion criteria for this study were: upper maxillary incisors that have never undergone restorative or rehabilitative treatment, and no history of orthodontic treatment. Standardized digital photographs were taken, and the length and width of the maxillary central and lateral incisors were measured and proportions were calculated. SPSS was used to compare the measured differences between teeth on the left versus right of the midline. Tooth proportions were not significantly different between the left and right sides. Asymmetry was found only between the lengths of the maxillary lateral incisors (p=0.009); the width for these teeth was symmetrical. A significant statistical difference was not found on most parameters when evaluating symmetry of the upper incisors. Therefore, when treating the esthetically important anterior of the mouth, care must be taken to ensure bilateral symmetry to mirror the natural symmetry found in most patients.

Radiofrequency machines for medical use are known to produce moderate clinical improvement of skin laxity without invasive procedures. Numerous equipment with different characteristics have been proposed after the introduction in 2002 of the first FDA approved device. This report is aimed to test if RF treatment is effective when performed at low frequency and low energy level. Two RF treatments were performed unilaterally 7 and 2 days before a planned eyebrow lifting surgery, with a radiofrequency device with 0.52 to 0.7 MHz frequencies, maximum energy of 200 W, used at 40% of its power. A bipolar handpiece with a diameter of 30 mm and a maximum power of 9-9.5 W was massaged along the temporal area for 10 min. Skin samples of treated and untreated sides were collected during surgery and processed for histologic examination and RT-PCR analysis, to test differences in gene activation in a panel of proteins that are relevant in extracellular matrix of dermal connective tissue. The histological examination of the samples showed that the treatment induced a loss of the typical oriented structure in the reticular dermis. The study through RT-PCR evidenced that ELN, the gene codifying for Elastine was strongly enhanced. Some collagen-tested genes (COL1A1, COL3A1 and COL9A1) were inhibited by the treatment, whereas COL2A1 and COL11 were activated. The genes responsible for Metallo-proteases (MMP) 2, 3 and 13 were depressed, while the MMP9 was stimulated. Gene codifying for Hyaluronic synthase 1 (HAS1), Hyluronidase 1 (HYAL1), Neutrophyl elastase (Elane), Desmoplakin (DSP) and GDF6 were inhibited. Insulin like growth factor (IGF1) gene activity was enhanced. RF treatment, with the tested non-ablative equipment, produced histological effects and change in DNA expression of some extracellular matrix related genes, confirming the biostimulatory role of this procedure.

Some graft materials such as a heterologous porcine cortical lamina have an excellent capacity in creating recipient sites that can be filled with cortico-spongious collagenated bone paste that reabsorbs, allowing for the reformation of good-quality bone. In this work a technique is proposed which makes use of resorbable cortical lamina in order to create a new sinus floor that can be filled with cortico-spongious bone paste. The adequate vascularisation of the graft combined with the integration of the lamina, which does not need to be removed, makes it possible to propose this technique as a potential alternative to those used so far.

Among non-ablative procedures in aesthetic medicine, the radiofrequency (RF) is one of the most popular for the treatment of face and body skin laxity. It can be classified as a physical bio-stimulation that produces a temperature increase on biological structures, using electromagnetic waves. The term encompasses devices having substantial differences in energy, wavelengths, handpieces dimension and structure. Moreover, for some of these, the protocols are only partially defined. The aim of this short review is to clarify some aspecst of the RF therapy starting from the physics, passing through the mechanism of action and finally, with the most suitable protocols. Contrary to mechanic waves, electromagnetic waves, physics are always transversal to the impulse and this leads to the different energy distribution in capacitive (monopolar) or resistive (bi- or multi-polar) applications. The thermal damage as therapeutic effect is a postulate that needs to be discussed and the same is true for the terms “non-surgical” and “non-ablative”, often recurrent in the scientific literature. Protocols must be optimized according to the machine and the patient, keeping in mind the possibilities of biostimulation in terms of immediate improvement and of long lasting investment in skin rejuvenation. It is mandatory to understand the possibilities and limitations of each device to perform useful, safe and correct medical treatments.

The aim of this case report was to evaluate the potential of preformed titanium foil (PTF) as membrane, used together with a mouldable allograft paste, for guided bone regeneration in a case of severe mandibular posterior atrophy involving the alveolar nerve. In order to create a rigid barrier to the competitive growth of soft tissues and a stable volume for the colonization of the osteoprogenitor cells, a foil of pure titanium was pre-shaped by means of a stereolithographic model, obtained from a CT-scan of the patient. This procedure showed promising results, allowing to maximize the outcome and simplifying the surgical phase.

Surface modifications of commercially pure titanium (Cp-Ti), a material widely used to produce dental implants, can induce specific responses on osteoblastic cells after implantation. This work aims to investigate the influence of chemically modified surfaces of Cp-Ti by acid etching or acid etching plus alkaline treatment on the gene expression of human osteoblastic (Hob) cells. Roughness and contact angle measurements were carried out to evaluate the surface properties of the samples. The surface morphology was investigated with scanning electron microscopy. Chemical composition was analyzed by energy dispersive X-ray spectroscopy (EDS). The expression levels of some bone-related genes (ALPL, COL1A1, COL3A1, SPP1, RUNX2, and SPARC) were analyzed using real time Reverse Transcription-Polymerase Chain Reaction (real time RT-PCR). The results showed that all the chemical modifications studied in this work influenced the surface morphology, wettability, roughness and induced an osteoconductive behavior. The samples that were acid etched and alkaline treated showed a more pronounced effect. © 2013 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2013.

Background: Rehabilitation of partially or totally edentulous posterior mandible with implant-supported prosthesis has become a common practice in the last few decades, with reliable long-term results. The use of miniscrews and miniplates have been reported to increase the risk of fracture of the osteotomy segments. The purpose of this case series was to use an inlay technique, without the use of miniscrews and miniplates for stabilization of the transported bone fragments. Materials and methods: Nine consecutive patients (six men and three women) aged between 26 and 51 years (mean 44 years) were enrolled in this study. A horizontal osteotomy was performed 2–3 mm above the mandibular canal, and two oblique cuts were made using a piezosurgery device. The final phase of the osteotomy was performed with chisels. The osteotomized segment was then raised in the coronal direction, sparing the lingual periosteum. Two miniblocks of xenograft without miniscrews and miniplates were inserted mesially and distally between the cranial osteotomized segment and the mandibular basal bone. The residual space was filled with particles of cortico-cancellous porcine bone. Four months after surgery, a panoramic X-ray was taken before implant insertion. A bone trephine with an internal diameter of 2 mm was used as the second dental drill to take a bone core biopsy during preparation of the #35 and #37 or #45 and #47 implant sites. Results: The postoperative course was uneventful in seven of the nine patients. No dehiscence of the mucosa was observed at the marginal ridge of the mobilized fragment. Newly formed bone was present near the osteotomized segments, and was observed in the bottom half of the specimens and was identified by its higher affinity toward the staining. Newly formed bone was observed to be in close contact with the particles of biomaterials. No gaps or connective tissue were present at the bone–biomaterial interface. Histomorphometry demonstrated that 44±2.1% of the specimens was composed by newly formed bone, 18±0.8% by marrow spaces, and 33±2.4% by the residual grafted biomaterial. Conclusion: The rigidity of the equine collagenated block allowed to eliminate the use of miniscrews and miniplates and simplified the technique. Moreover, the rigidity of the block allowed maintenance of the space. To cite this article: Scarano A, Carinci F, Assenza B, Piattelli M, Murmura G, Piattelli A. Vertical ridge augmentation of atrophic posterior mandible using an inlay technique with a xenograft without miniscrews and miniplates: case series. Clin. Oral Impl. Res. 22, 2011; 1125–1130 doi: 10.1111/j.1600-0501.2010.02083.x

The repair of complex craniofacial bone defects is challenging and a successful result depends on the defect size, the quality of the soft tissue covering the defect and the choice of reconstructive method. Autologous bone grafts are the gold standard for bone replacement. Tissue engineered constructs are temporary substitutes developed to treat damaged or lost tissue. Recent advances in materials science have provided an abundance of innovations, underlining the increasing importance of polymer in this field. The Galeazzi Orthopedical institute of Milan received a Serbian soldier who reported a deep wound, due to the explosion of a grenade, during former-Yugoslavia’s war. His left cheekbone was completely lost, together with the floor of the left eye. SmartBone® technology allowed the realization of custom-made grafts which perfectly fitted the bone defect thanks to mechanical strength, also at small thicknesses, and the ability to be shaped without powder formation or unpredicted fractures. Tissue engineering approaches to regeneration utilize 3-dimensional (3D) biomaterial matrices that interact favorably with cells. The potential benefits of using a tissue engineering approach include reduced donor site morbidity, shortened operative time, decreased technical difficulty of the repair, ability to closely mimic the in vivo microenvironment in an attempt to recapitulate normal craniofacial development: this 36-month case study allowed to prove that SmartBone® custom-made bone grafts are an effective solution, gathering such benefits and being available now for daily routine.

One of the most frequent reasons for failure during the maxillary sinus floor lift operation is connected to the possibility of a rupture of the Schneiderian membrane which, if lacerated, cannot perform the function of graft containment. In order to reduce the incidence of complications it is necessary to cut the hard tissue with extreme accuracy and as little trauma as possible, while saving the soft tissue. The precision of pre-operation measures obtained through endoral x-rays, dental-scans and cone-beam CT allows us to approach and cut with delicacy the sinus cortical floor. The recent development of computer guided surgery gives the possibility of planning the operation, which reduces the risk of failure. The cortical of the maxillary sinus is reduced through the use of calibrated burs and a profiler to obtain a hole that enables both access to the maxillary sinus and, subsequently, the lifting of the Schneiderian membrane. Each stage of the operation is monitored and all the devices used pass through a custom-made template, which acts as a surgical guide. The sinus was filled using fluid biomaterial distributed through a dispenser, which had been created specifically for this technique. Due to the reduction in trauma and the fact that the process is much less invasive, this technique could be a valid alternative to the techniques known and carried out to date. Work time is reduced to less than 3 minutes in the cortical thinning operation and percussive trauma is avoided.

Bovine bone xenografts, made of hydroxyapatite (HA), were coated with poly(L-lactide-co-ε- caprolactone) (PLCL) and RGD-containing collagen fragments in order to increase mechanical properties, hydrophilicity, cell adhesion and osteogenicity. In vitro the scaffold microstructure was investigated with Environmental Scanning Electronic Microscopy (ESEM) analysis and micro tomography, while mechanical properties were investigated by means compression tests. In addition, cell attachment and growth within the three-dimensional scaffold inner structure were validated using human osteosarcoma cell lines (SAOS-2 and MG-63). Standard ISO in vivo biocompatibility studies were carried out on model animals, while bone regenerations in humans were performed to assess the efficacy of the product. All results from in vitro to in vivo investigations are here reported, underlining that this scaffold promotes bone regeneration and has good clinical outcome.

Several techniques have been proposed to increase the mandibular bone base, both horizontally and vertically, for implant purposes in atrophic distal ridges. Block graft and titanium grids are frequently used for this purpose. The former need to be fixed, in the case of an autologous bone block require a donor site graft, and if not kept sufficiently vascularized could result in necrosis. The latter are manageable with difficulties in the event of exposure and are removed with difficulty. In this work a technique is proposed which makes use of resorbable cortical lamina in order to create recipient sites which can be filled with prehydrated and collagenated granules covered by mesenchymal resorbable membranes. We demonstrated with this technique the good vascularization of the graft combined with the integration of the lamina, which do not need to be removed. Our results allow us to propose this technique as a potential alternative to those used to date.

This manuscript is a short review on the theories of aging, focusing mainly on the balance between the nutrient and the oxygen intake necessary for energy metabolism and the processes for neutralizing the negative consequences of energy production. The first section entitled “Why” provides brief historical details regarding the main group of aging theories, firstly the evolutionary theories and secondly the theories of aging related to humans, cells and biomolecules are discussed. The second section entitled ‘Where’ includes brief summaries of the many cellular levels at which aging damage can occur: replicative senescence with its genetic and epigenetic implications, cytoplasmic accumulation, mitochondrial respiratory chain dysfunction, peroxisome and membrane activity. In the third section entitled ‘How’ the linking mechanisms between the caloric restriction and the antioxidant intake on lifespan and aging in experimental models are discussed. The role of ROS is evaluated in relation to the mitochondria, the AMPK activated sirtuins, the hormesis, the target of rapamicin and the balance autophagy/apoptosis.

Objective: To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work. Design: A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development. Setting: International group of countries participating to OECD projects. Participants: Members of the OECD HCQI expert group. Results: A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions. Conclusions: The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

The mucocele, a mucus accumulation from the salivary gland, represents a common lesion of the oral cavity. From 44 % to 79 % of mucoceles occur on the lower lip. There is no gender predilection and it can arise at any age. Mucoceles do not cause direct obstruction of salivary flow, and the amount of secretion that can be extravasated is limited by the elasticity of the surround tissues. In the period between January 2001 December 2010, 21 patients underwent to ulcer treatments at the Pediatric Surgery Unit, S Anna Hospital, Ferrara, Italy. Patients included 9 females and 12 males. Age ranged from 5 months to 13 years with a mean value of 7 years. All were located in the lower lip. Mucocele were treated with surgical excision, 13 under general anesthesia and the remaining under local anesthesia. Several techniques have been proposed: initial cryosurgical approach, CO2 laser, marsupialization and complete resection: this last is in most cases the best option.

The aim of this clinical study was to evaluate the treatment skeletal effects induced by Twin Block in the therapy of Class II malocclusion during or slightly after the onset of the puberal peak in the growth. The study sample was obtained from the records of the author’s private practice and consisted of a parent sample of 70 Class II division 1 subjects treated consecutively with the Twin-block appliance, from which good quality lateral cephalograms were available. From this sample, 23 subjects (Study Sample) 8 males and 15 females, were selected according to the following inclusion criteria: ANB greater than or equal to 4°, full Class II or end-to-end molar relationships, no history of previous orthodontic treatment or surgery treatment, absence of congenital anomalies, same Caucasian race. All patients received active treatment with Twin-block before or during their pubertal growth spurt, as assessed by the cervical vertebral maturation (CVM) method. Lateral cephalograms for each subject was digitized by a single author (AL) respectively at time 1 (T1), immediately before treatment, (mean age 10.0± 1.1years) and at time 2 (T2) immediately after treatment (mean age 12.0 ± 1.1 years). The error of the method was calculated with the formula described by Dahlberg (1940). In addition systematic error and the coefficient of reliability were determined as suggested by Houston. The Control Group consisted of untreated Class II subjects. A modification of the Twin-block appliance, originally developed by Clark, was used in this study. In the present study the mean duration of the Twin -block treatment was 1.2 ± 0.5 years. Results of the statistical comparisons between Study Sample (treated subjects) and Control Group (untreated subjects) on the changes for all cephalometric variables during the T1–T2 observation showed significantly favorable changes: the total mandibular length (Co-Me) and ramus height (Co-Go) and corpus length (Go-Me) increased more in cases than in controls. Our results show a significantly higher average answer in the Study Sample, both in the paired t- test, comparing pre and post treatment, and in the unpaired t- test, comparing the Study Sample and the Control Group. Paired t- test data for the variables Co-Me, Co- Go, Go- Me, with a P=.05 significance level, lead us to reject the null hypothesis (differences average = 0) in favor of the alternative of a positive differences average, meaning that the average of the values is higher after the treatment.

Osteoplant, an equine flexible cortical and spongy bone tissue, is a promising material for bone grafting in orthopedic, maxillofacial and dental surgery. Osteoplant is completely resorbable, inducing oteoclast activation and promoting the substitution of the scaffold with new bone. To study how Osteoplant can induce osteoblast differentiation in mesenchymal stem cells, the expression levels of bone related genes and mesenchymal stem cells marker were analyzed, using real time Reverse Transcription-Polymerase Chain Reaction. Osteoplant is an inducer of osteogenesis on human stem cells, as showed by the activation of bone related genes ALPL, SPP1 and RUNX2, and by the down-regulation of the mesenchymal stem cells marker ENG.

Xanthelasma palpebrarum is a benign condition and almost never limits functioning; its appearance is often seen as cosmetically disturbing. Surgical excision has been the treatment of choice for decades. However, this normally effective measure bears a considerable risk of side effects, especially an ectropion, which could lead to additional procedures, e.g., full thickness skin graft. 13 patients with bilateral 26 xanthelasma with an voltaic arc dermoabrasion device (EL-Abras, TECNOSER s.r.l., Roma, Italy). Photographs were taken before and after treatment and were then evaluated by an independent observer. The evaluation of the results was made 2 months after this single treatment. The final evaluation assessed the presence or absence of hypochromic or achromic scars. The patients were given a single sessions to remove the lesions. Two months after treatment, the result was scored as 4 (i.e. with a clearing of lesions evaluated as being > 75% and in fact assessed by the independent observer as complete resolution) in six patients for a total of 12 lesions; scored as 3 in four patients for a total of 8 lesions, and as 2 in three patients for a total of 6 lesions. No patient presented a result scored as 0, 1 or 2. Eight lesions showed slight erythema in the treated areas and this persisted for 1 month. The visible and unsightly nature of xanthelasma has led to the proposal of numerous treatments. Reconstruction by a flap or full-thickness skin graft may be necessary in the presence of excessively large lesions or lesions involving the medial canthus. The possibilities of surgical resection appear to be more limited in the lower eyelid, as the more limited skin laxity rapidly induces a risk of ectropion. On the basis of our results, we would like to recommend xanthelasma treatment with the voltaic arc dermoabrasion as an excellent therapeutic alternative to the hitherto described approaches.

Peptide-15 (P-15) is. P-15 an analog of the cell binding domain of collagen, has been shown to facilitate physiological process in a way similar to collagen, to serve as anchorage for cells, and to promote the binding, migration and differentiation of cells. However, how P-15 alters osteoblast activity to promote bone formation is poorly understood. In this study we investigated the osteo-inductives properties of P15 on stem cells derived from bone marrow. In Real Time Reverse Transcription-Polymerase Chain Reaction (real time RT-PCR) we quantified the mRNA expression of specific genes, like transcriptional factors (RUNX2 and SP7), bone related genes (SPP1, COL1A1, COL3A1, ALPL, and FOSL1) and mesenchymal stem cells marker (ENG). Gene expression in BMSC was then compared with the gene expression in Human Osteoblasts (HOb) treated with P15, to evaluate the potential effect of this biomaterial in osteoblasts differentiation.