Burning Mouth Syndrome (BMS) is a chronic pain syndrome that mainly affects middle-aged/old women with hormonal changes or psychological disorders. This condition is probably of multifactorial origin, often idiopathic, and its etiopathogenesis remains largely enigmatic. The present paper discusses several aspects of BMS, updates current knowledge, and provides guidelines for patient management. There is no consensus on the diagnosis and classification of BMS. The etiopathogenesis seems to be complex and in a large number of patients probably involves interactions among local, systemic, and/or psychogenic factors. In the remaining cases, new interesting associations have recently emerged between BMS and either peripheral nerve damage or dopaminergic system disorders, emphasizing the neuropathic background in BMS. Based on these recent data, we have introduced the concepts of "primary" (idiopathic) and "secondary" (resulting from identified precipitating factors) BMS, since this allows for a more systematic approach to patient management. The latter starts with a differential diagnosis based on the exclusion of both other orofacial chronic pain conditions and painful oral diseases exhibiting muco-sal lesions. However, the occurrence of overlapping/overwhelming oral mucosal pathologies, such as infections, may cause difficulties in the diagnosis ("complicated BMS"). BMS treatment is still unsatisfactory, and there is no definitive cure. As a result, a multidisciplinary approach is required to bring the condition under better control. Importantly, BMS patients should be offered regular follow-up during the symptomatic periods and psychological support for alleviating the psychogenic component of the pain. More research is necessary to confirm the association between BMS and systemic disorders, as well as to investigate possible pathogenic mechanisms involving potential nerve damage. If this goal is to be achieved, a uniform definition of BMS and strict criteria for its classification are mandatory.

Background: Preclinical data have shown that proton pump inhibitors (PPI) can modulate the microbiome, and singlearm studies suggested that antibiotics (ATB) may decrease the efficacy of immune checkpoint inhibitors (ICI), but randomized controlled trial data are lacking. This pooled analysis evaluated the effect of ATB and PPI on outcome in patients randomized between ICI and chemotherapy. Patients and methods: This retrospective analysis used pooled data from the phase II POPLAR (NCT01903993) and phase III OAK (NCT02008227) trials, which included 1512 patients with previously treated non-small-cell lung cancer (NSCLC) randomly assigned to receive atezolizumab (n ¼ 757) or docetaxel (n ¼ 755). The main objective of this analysis was to assess the impact of ATB and PPI use on overall survival (OS) and progression-free survival (PFS). Results: A total of 169 (22.3%) patients in the atezolizumab group and 202 (26.8%) in the docetaxel group received ATB, and 234 (30.9%) and 260 (34.4%), respectively, received PPI. Multivariate analysis in all patients revealed that ATB were associated with shorter OS [hazard ratio (HR) 1.20, 95% confidence interval (CI) 1.04e1.39], as was PPI (HR 1.26, 95% CI 1.10e1.44). Within the atezolizumab population, OS was significantly shorter in patients who received ATB (8.5 versus 14.1 months, HR 1.32, 95% CI 1.06e1.63, P ¼ 0.01) or PPI (9.6 versus 14.5 months, HR 1.45, 95% CI 1.20e1.75, P ¼ 0.0001). PPI use was associated with shorter PFS in the atezolizumab population (1.9 versus 2.8 months, HR 1.30, 95% CI 1.10À1.53, P ¼ 0.001). There was no association between ATB and PPI use and PFS or OS within the docetaxel population. Conclusion:In this unplanned analysis from two randomized trials, data suggest that ATB or PPI use in patients with metastatic NSCLC is associated with poor outcome and may influence the efficacy of ICI.

Through the retrospective study of 1103 reconstructions of the anterior cruciate ligament (ACL) performed between 1984 and 1993, we try to outline the natural history of meniscal tears in acute lesions and in chronic insufficiency of the ACL. According to a more accurate evaluation of the clinical evolution, ACL-deficient knees can be classified into four different stages: acute, subacute, subchronic and properly chronic laxities. While acute injuries show a higher rate of lateral meniscus tears, chronic laxities are very frequently associated with severe medial meniscus lesions. Subacute and subchronic stages seem therefore to be the most favourable phases for ACL reconstruction, because of the lower percentage of severe associated meniscus tears and the minor risk of arthrofibrosis.

Ann R Coll Surg Engl 2010; 92:1 Intussusception of the vermiform appendix is a rare condition, with an approximate incidence of 0.01%. It can mimic several clinical conditions including acute appendicitis or be mistaken as a caecal polypoid lesion on radiological imaging and endoscopy. Correct diagnosis is paramount in order to prevent unnecessary and potentially catastrophic interventions such as endoscopic excision. Despite the availability of various investigative modalities including barium enema, transabdominal ultrasound, computed tomography (CT) colonogram and colonoscopy, 1,2 the diagnostic accuracy remains poor. We report a case of appendiceal intussusception which was erroneously labelled as a 10-mm polypoid caecal lesion on colonoscopy and, therefore, followed up over an 11-year period before the correct diagnosis was made. We present the radiological and endoscopic appearance of appendiceal intussusception and a review of the literature. Case historyA 49-year-old Caucasian woman with a strong family history of colon cancer presented to the colorectal clinic in 1997 with a several year history of constipation and mild abdominal pain. A barium enema showed a long and tortuous colon with a polypoid lesion in the caecum. A subsequent colonoscopy was technically challenging but successful and confirmed the presence of a 10-mm 'polypoid lesion' in the caecum. Multiple biopsies were taken and showed normal colonic mucosa.Because of doubt about its nature and in view of the difficulties met on previous colonoscopy, this lesion was followed up with serial barium enemas. It remained unchanged until 2008, when a fourth barium enema showed an increment in size and in fact a subsequent CT colonogram confirmed the lesion to be 18.2 mm at its base and 11.1 mm in anteroposterior depth (Fig. 1). A second colonoscopy was, therefore, performed with a view to endoscopic excision. However, on this occasion, the lesion was recognised as an intussuscepted appendix and multiple biopsies confirmed normal colonic mucosa (Fig. 2). The diagnosis become more obvious as the We report a case of appendiceal intussusception which was erroneously labelled as a 10-mm polypoid caecal lesion on colonoscopy and, therefore, followed up over an 11-year period before the correct diagnosis was made. We present the radiological and endoscopic appearance of appendiceal intussusception and a review of the literature. ON-LINE CASE REPORT

Surgical intervention within 48 h of hospital admission is the gold standard procedure for the management of elderly patients with femur fractures, since the increase in preoperative waiting time is correlated with the onset of complications and longer overall length of stay (LOS) in the hospital. However, national evidence demonstrates that there is still the need to provide timely intervention for this type of patient, especially in some regions of central southern Italy. Here we discuss the introduction of a diagnostic–therapeutic assistance pathway (DTAP) to reduce the preoperative LOS for patients undergoing femur fracture surgery in a university hospital. A Lean Six Sigma methodology, based on the DMAIC cycle (Define, Measure, Analyze, Improve, Control), is implemented to evaluate the effectiveness of the DTAP. Data were retrospectively collected and analyzed from two groups of patients before and after the implementation of DTAP over a period of 10 years. The statistics of the process measured before the DTAP showed an average preoperative LOS of 5.6 days (standard deviation of 3.2), thus confirming the need for corrective actions to reduce the LOS in compliance with the national guidelines. The influence of demographic and anamnestic variables on the LOS was evaluated, and the impact of the DTAP was measured and discussed, demonstrating the effectiveness of the improvement actions implemented over the years and leading to a significant reduction in the preoperative LOS, which decreased to an average of 3.5 days (standard deviation of 3.60). The obtained reduction of 39% in the average LOS proved to be in good agreement with previously developed DTAPs for femur fracture available in the literature.

Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.

Background Laparoscopic surgery has well-established benefits for patients; however, laparoscopic procedures have a long and difficult learning curve, in large part due to the lack of stereoscopic depth perception. Developments in high-definition and stereoscopic imaging have attempted to overcome this. Three-dimensional high-definition (3D HD) systems are thought to improve operating times compared to two-dimensional high-definition systems. However their performance against new, ultra-high-definition ('4K') systems is not known. Methods Patients undergoing laparoscopic cholecystectomy were randomised to 3D HD or 4K laparoscopy. Operative videos were recorded, and the time from gallbladder exposure to separation from the liver (minus on table cholangiogram) was calculated. Blinded video assessment was performed to calculate intraoperative error scores. Results One hundred and twenty patients were randomised, of which 109 were analysed (3D HD n = 54; 4K n = 55). No reduction in operative time was detected with 3D HD compared to 4K laparoscopy (median [IQR]; 23.41 min [17.00-37.98] vs 20.90 min [17.67-33.03]; p = 0.91); nor was there any decrease observed in error scores (60 [56-62] vs 58 [56][57][58][59][60]; p = 0.27), complications or reattendance. Stone spillage occurred more frequently with 3D HD, but there were no other differences in individual error rates. Gallbladder grade and operating surgeon had significant effects on time to complete the operation. Gallbladder grade also had a significant effect on the error score. Conclusions A 3D HD laparoscopic system did not reduce operative time or error scores during laparoscopic cholecystectomy compared with a new 4K imaging system.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The aim of the study was to assess the safety and efficacy of laparoscopic treatment of distal infiltrative ureteral endometriosis with segmental ureteral resection, ureteroneocystostomy, and vesicopsoas hitch. We performed a retrospective analysis of perioperative data and looked at follow-up outcomes of patients with deep endometriosis with ureteral involvement treated by laparoscopic vesicopsoas hitch. Six patients were treated for left ureteral endometriosis in the study period. Four of those were diagnosed during previous laparoscopies. A ureteroneocystostomy (Lich-Gregoir reimplantation procedure) with vesicopsoas hitch was fashioned laparoscopically in all cases, and a double-J stent was applied intraoperatively. There were no intraoperative or postoperative complications and no cases of extravasation of contrast at cystogram one week after surgery. The median follow-up time was 38 months (range 12-56). All patients had normal renal ultrasound or intravenous pyelogram results at one year follow-up. This study confirmed that laparoscopic ureteroneocystostomy and vesicopsoas hitch is a safe and effective option in the management of distal ureteral endometriosis. In view of the small size of this series, multicenter studies are needed to confirm these conclusions.