Background & Aims: There is a growing interest for the use of probiotics for chronic constipation. A recent randomized controlled trial (RCT) showed a positive effect of Lactobacillus reuteri (L. reuteri) on bowel movement frequency in infants with chronic constipation. The aim of the present study was to evaluate the effects of L. reuteri in adult patients with functional constipation.Methods: A double-blind, placebo RCT was conducted in 40 adults (18M/22F, 35±15 years) affected by functional constipation according to the Rome III criteria. Patients were randomly assigned to receive a supplementation of L. reuteri (DSM 17938), or matching placebo for 4 weeks. The increase of bowel movements/week was the primary outcome, while the improvement of stool consistency was the secondary outcome.Results: At week 4, the mean increase in bowel movements/week was 2.6 (SD±1.14, 95% CI:1.6-3.6) in the L. reuteri group and 1.0 (SD±1. 95% CI:0.12-1.88) in the placebo group (p=0.046). At the end of the treatment, the mean bowel movements/week was 5.28±1.93 in the L. reuteri group and 3.89±1.79 in the placebo group. There was a not significant difference in the stool consistency between the two groups.Conclusions: L. reuteri is more effective than the placebo in improving bowel movement frequency in adult patients with functional constipation as previously demonstrated in children, even if it seems to have no effect on stool consistency.

Since the human pathogen Helicobacter pylori was recognized as the most important aetiologic agent of chronic gastritis and as a major factor for peptic ulcer pathogenesis, the therapeutic approach to these common diseases has completely changed. 1 It has been well documented that H. pylori eradication not only heals duodenal ulcers, but also results in a marked decrease of peptic ulcer recurrence. 2 Despite the importance of H. pylori eradication in the management of a variety of upper gastrointestinal tract diseases and the many advances in eradication therapy over the last few years, treatment failure remains a signi®cant problem, eradication rates still being roughly 70±80%. The suggested ®rst line therapies for H. pylori eradication are based on an antisecretory agent (a proton pump inhibitor or ranitidine bismuth citrate) and two antibiotics in association for 7 days, while as far as second line therapies are concerned, i.e. in the case of treatment failure, a variety of agents have been employed, but large scale trials have not been conducted to establish the optimal regimen. 3±7 Major causes of failure may be poor patient compliance (many tablets have to be taken per day and/or side-effects may occur), inappropriate treatment prescription, and ®nally, the presence of a primary, or the development of a secondary, resistance to strains. 8 Because the development of antibiotic resistant strains is one of the major SUMMARY Background: Helicobacter pylori eradication therapies do not achieve 100% success rates. Antibiotic resistant strains are among the major causes of failure. Current recommendations concerning the management of treatment failures are not fully clear. Aim: To evaluate the ef®cacy of a multi-step therapeutic strategy in a large group of infected patients. Methods: A total of 2606 H. pylori-positive patients were administered tinidazole, clarithromycin and a proton pump inhibitor for 1 week. Patients with continuing infection were then given a second 1-week course of amoxycillin, clarithromycin and ranitidine bismuth citrate. Patients still infected after the second course underwent upper gastrointestinal endoscopy with H. pylori culture, and then received a 1-week

H. pylori infection has recently been associated with various vascular disorders. The aim of this study was to investigate its role in primary headache, a pathology strictly associated with vascular alterations. A total of 200 subjects affected by primary headache were evaluated. H. pylori infection was diagnosed by the 13C urea breath test. Headache was classified in tension-type headache, cluster headache, and migraine with or without aura. Prevalence of H. pylori infection and gastrointestinal (GI) symptoms were evaluated. H. pylori infection was found in 40% of the patients; prevalence of migraine without aura was found to be significantly greater in infected patients. The positive group showed no significant differences in the prevalence of the GI symptoms evaluated. In 30 infected patients, it was assessed whether the eradication of the bacterium was able to reduce frequency, intensity, and duration of clinical attacks of headache. After eradication, clinical attacks of headache completely disappeared in 17% of patients. Moreover, intensity, duration, and frequency of headache attacks were reduced in 69% of the remaining subjects. In conclusion, H. pylori infection is common in primary headache; bacterium eradication appears to be related to a significant reduction in clinical attacks of the disease.

Study design: Prospective study. Objectives: The objective of this study was to assess the prevalence of small intestinal bacterial overgrowth (SIBO), methane (CH 4 ) production and orocecal transit time (OCTT) in children affected by myelomeningocele. Setting: This study was conducted at the Catholic University in Rome, Italy. Methods: Eighteen (6M/12F; 16.4±7.6 years) children affected by myelomeningocele were enrolled. All subjects underwent H 2 /CH 4 lactulose breath tests to assess SIBO and OCTT. All patients performed a visual analog scale to investigate abdominal pain, bloating and flatulence, and maintained a diary of the frequency and consistency of the stool during the previous 7 days. A nephrourological clinical evaluation of the number of urinary tract infections (UTIs) and neurogenic bowel disease score were also performed. Results: Thirty-nine percent (7/18) of the children showed SIBO and 61% (11/18) presented a delayed OCTT. Moreover 44.4% (8/18) produced high levels of CH 4 . Interestingly, all myelomeningocele children who produced CH 4 showed a delayed OCTT and a higher incidence of UTI, with a lower frequency of evacuation, compared with those with a normal or accelerated OCTT. Conclusion: The association between CH 4 and constipation suggests that CH 4 has an active role in the development of constipation. One of the most interesting features of our study is to identify a correlation between myelomeningocele, CH 4 , delayed OCTT and UTI. INTRODUCTIONThe term spina bifida (SB) refers to a group of congenital neural tube defects with a variety of clinical manifestations, resulting from the lack of vertebral arches in the median line during the third and fourth week of gestational age. 1 The incidence of SB is around 0.1-0.3% and the risk for parents with SB of having an affected baby is estimated to be about 4%. 2 The multifactorial etiology of SB involves both genetic and environmental factors, for example, socioeconomic status, geographic area, maternal obesity, epilepsy or diabetes, maternal exposure to drugs, alcohol or radiations. 3 The open SB, called myelomeningocele (MMC), is characterized by a visible protrusion of spinal cord and/or meninges through the defect in the vertebral arch. MMC is a frequent form of SB with lifelong disabilities, characterized by the extrusion of spinal cord and by the development of Arnold-Chiari type II malformations and hydrocephalus in the central nervous system. 2 The level of neurological impairment influences muscle innervations, motor development, sensory and sphincter dysfunction. 3 The injury in the lumbosacral spine compromises the sensory and motor functions of the perianal region, leading to a delayed colonic motility and anorectal dysfunction, which result in functional obstruction and severe constipation. 4

Objectives To assess recent trends in susceptibility to antibiotics among urinary isolates isolated in European emergency departments (EDs) and to identify isolates with a high (90% or more) predicted probability of susceptibility to fluoroquinolones or third-generation cephalosporins (3GCs). Methods In this cross-sectional study, we included urine cultures obtained from adult patients between 2010 and 2016 in 24 European EDs. Temporal trends were assessed using time-series analysis and multivariate logistic models. Multivariate logistic models were also used to predict susceptibility to fluoroquinolones or 3GCs from patient age and sex, year, month and ED. Results We included 88242 isolates. Time-series analysis found a significant increase in susceptibility to fluoroquinolones and no significant trend for susceptibility to 3GCs. Adjusting for patient age and sex, ED and organism, multivariate models showed that susceptibility to 3GCs decreased from 2014 to 2016, while susceptibility to fluoroquinolones increased in 2015 and 2016. Among isolates from 2016, multivariate models predicted high probability of susceptibility to fluoroquinolones in 11% of isolates (positive predictive value 91%) and a high probability of susceptibility to 3GCs in 35% of isolates (positive predictive value 94%). Conclusions Susceptibility of ED urinary isolates to fluoroquinolones increased from 2014, while susceptibility to 3GCs decreased from 2015. Predictive models identified isolates with a high probability of susceptibility to fluoroquinolones or 3GCs. The ability of such models to guide the empirical treatment of pyelonephritis in the ED remains to be determined.

Raynaud's phenomenon is defined by an intermittent vasospasm of the arterioles of the distal limbs. Helicobacter pylori infection has been recently associated with Raynaud's phenomenon. The aim of this study was to assess the effects of H. pylori eradication on Raynaud's attacks. Forty-six patients affected by primary Raynaud's phenomenon were evaluated. H. pylori infection was assessed by [13C]urea breath test. Eradication therapy was given to infected patients for seven days. Discomfort and the duration and frequency of attacks of Raynaud's phenomenon per week were assessed. Thirty-six subjects were infected with H. pylori; the bacterium was eradicated in 83% of these after therapy. Attacks of Raynaud's phenomenon completely disappeared in 17% of the patients with H. pylori eradication. Discomfort and the duration and frequency of attacks of Raynaud's phenomenon were significantly reduced in 72% of the remaining patients. Conversely, attacks of Raynaud's disease did not change significantly during the 12-week follow-up period either in the H. pylori-negative patients or in the infected subjects in whom the bacterium was not eradicated by therapy. The study shows that H. pylori eradication causes a significant decrease in clinical attacks of Raynaud's disease. The reduction of vasoactive substances determined by the eradication of the bacterium may be the pathogenetic mechanism underlying the phenomenon.

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