psalari

Nato a Milano nel 1964, dove si è laureato a pieni voti in Medicina e Chirurgia nel 1989, si è occupato di ricerca sperimentale in Immunologia dei trapianti d’organo e ha in seguito conseguito, nel 1993, la specializzazione in Pediatria, dedicandosi in particolare alla fisiologia della nutrizione e allo studio degli acidi grassi in malattie metaboliche congenite. Parallelamente ha collaborato con numerose case editrici e testate scientifiche e divulgative, pubblicando articoli, libri, guide, saggi e partecipando a campagne stampa e iniziative sociali. Tuttora pratica attività clinica in regime libero professionale ed è componente di società scientifiche, comitati editoriali e board scientifici nell’ambito dell’alimentazione e dell’aggiornamento medico.

Beware of simple sugars, especially during the holidays

22 February 20246 January 2024 by psalari

It is estimated that during the Christmas season, food consumption (as well as body weight) in general increases by about 30 percent. But for many Italians, not much changes when it comes to the consumption of simple sugars, which consistently remains in excess of the recommendations of the World Health Organization and Italian and Population Reference Intake Levels of Nutrients and Energy (LARNs): the energy intake of simple sugars should not exceed 10 percent and 15 percent of total daily calories, respectively.

In this regard, data from a survey on eating habits, conducted among 5400 adults (58% female, 42% male) by the Grana Padano Nutritional Observatory: daily energy intake derived from simple sugars (between those naturally present in food and those added in preparations and beverages) corresponds to about 20 percent, registering a slight increase from surveys in previous years.

Preference for sweets does not differ between males and females: 57 percent of respondents consume snacks, brioche, and croissants (10 percent of the sample consumes them almost every day). Spoon desserts are among the most popular: 77 percent of respondents consume tiramisu, puddings, as well as cakes filled with cream, cream and chocolate. Ice cream is the favorite dessert (only 13% of the sample does not consume it!), while chocolate is by frequency the most consumed dessert: 7% of respondents every day, 16% 2 to 4 times a week; 15%, on the other hand, consume it only once a week. 22% of the sample surveyed never eat chocolate, half of the respondents never consume candy, and only 17% do not eat cookies.

“It’s important not to run out of blood sugar, but at the same time, it’s also important not to overdo it with quantities, ” says Dr. Michela Barichella of the Grana Padano Nutrition Observatory Scientific Committee and President of Brain and Malnutrition. particularly with simple sugars and especially those added in drinks and preparations. This recommendation is critical so that we do not get to the opposite situation, namely hyperglycemia, a condition that can decrease attention and memory capacity, as well as increase the risk of serious cardiovascular disease and diabetes.”
It is certainly not the occasional dessert or the teaspoon of sugar in coffee that needs to be avoided, but rather the excessive consumption of daily sugar protracted throughout the year, particularly added (free) sugars not only in industrial beverages and preparations, but also in everyday domestic gastronomy.

The harms of alcohol

22 February 20246 January 2024 by psalari

Worldwide, 1 in 3 people consume alcoholic beverages regularly (equivalent to 2.4 billion people, of whom 1.5 billion are men and 900 million are women): this is the result of a recent study, published in August in the scientific journal Lancet, which reviewed 694 studies on alcohol consumption worldwide and assessed the health risks associated with drinking alcoholic beverages in 195 nations. The study shows that consuming 10 grams of alcohol per day increases the risk of developing health problems by 0.5 percent and by 7 percent in those who consume twice that amount.

Alcohol use is a risk factor for numerous diseases and can impair brain maturation, especially in those areas involved in impulse control. In adolescence the maturation of the brain is not complete; there are areas such as the limbic area that mature after the age of 20. That is why in some countries, for example in the United States, there is a ban on alcohol use under the age of 21. Alcohol’s damage not only affects the brain, but many other organs: in fact, it is a risk factor for many cancers (liver, oral cavity, throat). The organ most affected is the liver, but the cardiovascular and gastrointestinal systems are also affected by the toxic effect of alcohol. In addition, alcohol abusers are more prone to hypertension, stroke, and heart disease. Alcoholism causes malnutrition, but also impaired sexuality, decreased libido, infertility and impotence, and obesity. Bottom line:

Alcohol abuse is addictive and comparable to drugs;
Alcohol is carcinogenic and creates organ damage such as cirrhosis of the liver;
Weakens the immune system and gives increased susceptibility to infection;
It reduces the absorption of vitamins A, D and E;
It causes malnutrition and alterations in body weight;
It modifies hormone production, has a negative effect on fertility, and is not conducive to sexual performance;
In pregnancy it can create problems for the fetus and the unborn child;
May interfere with ongoing drug therapies;
It alters cognitive function and is a risk factor for cognitive impairment;
It alters attention, reduces reaction time and causes drowsiness, which is why alcohol should not be taken if you are driving.

Renal failure: a widespread and very insidious chronic disease

22 February 20246 January 2024 by psalari

About 10 percent of the world’s adult population suffers from chronic renal failure (CRI), a condition, that is, characterized by reduced kidney function. Even more worrying is the increasing trend of this condition, especially due to the aging of the population: the functional decline of the kidney, in fact, is the physiological consequence of the deterioration of the organ over time, as well as dietary errors (excess salt and/or protein), the toxic effect of substances or drugs, or the impact of infectious or neoplastic events. Its epidemic dimensions, the associated high cardiovascular risk, and the high social and economic costs of dialysis and transplantation make CRI a priority area in prevention and health care planning.

The development of CRI is often asymptomatic, making early diagnosis difficult, for which periodic urine testing and determination of creatinine clearance would be advisable for all. Two simple tests costing only a few euros that would allow early interception of alterations in renal function and early introduction of therapies and, above all, changes in the patient’s lifestyle, starting with proper dietary-nutritional therapy (DNT), to slow the progression of kidney damage.

On the subject of CRI, then, one cannot overlook its psychological impact, which is related to the various factors that lead to a reduction in quality of life. To support all patients, starting with newly diagnosed patients, the “You are not alone” campaign was launched by Dr. Schär with the aim of telling, through the real experience of real patient couples, how even with chronic renal failure one can still maintain an active life and relationships, thanks to conservative therapy that combines nutritional and drug therapy, with the goal of reducing the progression of the disease.

About proper dietary nutrition therapy for patients with CRI, the guidelines of the Italian Society of Nephrology (SIN), indicate:

Reduce protein (no more than 0.7 g per day per kg of ideal body weight) and phosphorus intake.
Limit intake of potassium and sodium (table salt: no more than 2 g of salt per day added to meals).
Take in the right amount of calories each day. For adequate caloric intake, the dietitian might recommend specific supplements and low-protein foods

The approach to pain in the child

25 February 20246 January 2024 by psalari

How should we react when our little one complains of some kind of physical pain? The wise and recommended thing to do is to consult your pediatrician before giving your little one any kind of medicine. First, the pediatrician needs to acquire some information to understand the type and extent of the pain, and it is therefore good for parents (if the child is not yet able to express himself) to prepare to respond. He himself will recommend the most appropriate medications for each situation and type of pain.

The use of drugs

The drug of first choice in mild-to-moderate pain without inflammation, such as In the case of teething, growing pains and migraines, it is acetaminophen administered orally, which pmay be administered from day one due to the excellent relationship in terms of effectiveness and safety. Paracetamol acts within 30 minutes or so, and its analgesic effect lingers for 4-6 hours. Il paracetamol can also be employed even on an empty stomach, to a dosage higher than that indicated for fever, as directed by the pediatrician, but always In relation to the child’s weight e without exceeding over the course of one day the threshold of 60 mg/Kg In children younger than 3 months of age e di 80 mg/Kg In larger ones. Rectal administration of the drug is to be left
always as an alternative, for example in case thechild is unable to take anything by mouth because of vomiting. For pain associated with inflammation after the third month of life and over 5.6 kg in weight, the ibuprofen, to be administered on a full stomach, based on weight and with an interval of at least 6-8 hours (as opposed to 4-6 hours for acetaminophen) and without exceeding the maximum dosage of 30 mg/Kg in a day.

In any case, it should be remembered that i treatment of pain, in order for it to be effective, must take place according to a fixed schedule and not on an as-needed basis

. Finally, if the pain is associated with local manifestations, such as discharge from the ear or redness or swelling after a fall, or if it should increase in intensity, it is always advisable to consult the pediatrician.

Among all disorders, pain is the one that most undermines the child’s physical and psychological integrity and in addition distresses and worries his or her family members, with a significant impact on quality of life and care. For this reason, it should not be underestimated, nor should it be trivialized: even in cases where there are reasons to suspect that a child may be feigning sickness, for example as an excuse for shirking a school commitment, it is always advisable to proceed with the appropriate checks rather than risk not caring or treating him or her roughly.

Teenagers with tattoos and piercings: first recommendations from US pediatricians

25 February 20246 January 2024 by psalari

Birds of prey, fierce animals, butterflies, names, quotes from stanzas of songs or poems ’embroidered’ on the skin. All kinds of them are seen in every part of the body. The passion for tattoos and piercings has grown in recent years, and these practices have been joined by scarification, or skin deformation for decorative purposes. These are modes of expression that are also chosen by the very young today. However, not without some risks that it is good to know and make known.

U.S. pediatricians’ recommendations

U.S. pediatricians have presented the first recommendations on tattoos and piercings for adolescents and young adults. In many American states, as indeed in Italy, you have to be at least 18 years old to get a tattoo, but the rules vary widely. The first piece of advice to teens is first to do their research and think hard about why they want a tattoo and where they want it. Second, they need to be aware of the possible repercussions: for example, in a 2014 study of 2,700 people, 76 percent of respondents expressed the belief that a piercing or tattoo reduced their chances of finding a job. Then there is the rate of possible skin complications, which is not known but is considered rare: the most serious danger, in any case, is related to infections.

Due precautions

Before undergoing a tattoo or piercing, U.S. pediatricians recommend, be sure that the salon you choose is sterile, clean and has a good reputation. Managers should explain to clients, and in some cases their parents, how to care for the treated area after piercing or tattooing. In addition, the place should meet the same hygienic requirements as a medical office. Scarification, a kind of extreme tattooing that may involve cutting (etching), branding (branding), and ice kissing (ice branding) to “relief draw” images on the skin in the United States is prohibited.

Anyone thinking of getting a tattoo should be sure that they have had their vaccination booster shots and are not taking any immune-compromising drugs. Finally, very young tattoo wannabes “may not realize how expensive it is to get rid of a tattoo or the fact that tongue piercing can damage teeth,” the U.S. paper says. Ultimately, tattoos and piercings are equated with minor outpatient surgeries, but instead of helping to solve problems they can themselves become the cause of them.

Acne: what it is and how to fight it

25 February 20246 January 2024 by psalari

The term acne comes from the Greek word acmé or acné, meaning foam or summit. It is one of the most common skin diseases in the juvenile population; in fact, it is present in about 95%. The frequency is much higher certainly among adolescents, but acne can persist or appear in adulthood as well.

Types of acne

It typically makes its onset on the face, back, chest, and shoulders and affects both sexes in almost similar percentages. It typically manifests as closed and open comedones, so-called blackheads, papules, or whiteheads, pustules, better known as pimples, nodules i.e., furuncles, cysts, and unfortunately can also result in scarring in some cases. There are many causes of acne: increased activity of sebaceous glands, thickening of the wall of follicular ostium, bacterial colonization, in pjoint by Propionibacterium Acnes, and inflammation. In addition, various factors contribute to its occurrence such as family predisposition, stress, and smoking.

Especially in adolescence, it is important to be able to frame the degree of acne early, that is, whether it is mild, moderate, or severe, or, depending on the type of lesion, it can be classified into comedonic, papulo-pustular, nodular, and, in severe cases, conglobate. This avoids the development of scarring. In fact, this condition is often underestimated, which can therefore lead to psychological distress on the part of young patients and delay the benefits of treatment. It is known from studies conducted on patients’ quality of life that the acne-prone adolescent often suffers from low self-esteem, embarrassment, shyness, and in extreme cases even depression, emotional turmoil, shame about one’s appearance, resulting in difficulty relating to the opposite sex and a decline in school performance.

Therapies

Regarding treatment, the European Guidelines, published in 2012 recommend which drugs, topical and systemic, to use according to the degree of acne. Topical retinoids, derived from vitamin A, are the first choice in comedonic acne. An important role is also played by benzoylperoxide a keratolytic agent with antibacterial action but not inducing antibiotic resistance, which is recommended in acne vulgaris and comedo- or papulo-pustular-predominant forms.

The use of topical antibiotics is useful in inflammatory forms, but is limited by resistance, which unfortunately is increasing in Europe. therefore, as far as acne is concerned, their local use in combination with other topical drugs is advisable, avoiding the concomitant administration of oral antibiotics and limiting the use of the latter to periods not exceeding three months, discontinuing them if there is no improvement. Remembering to fixed combinations of topical preparations offers the possibility of acting more specifically on the mechanisms that cause acne, also increasing adherence to therapy, making the application of only one product sufficient.

Gastroenteritis and food poisoning: a pitfall not only in summer

25 February 20246 January 2024 by psalari

For children, too, summer means sunny days, to be spent-sun and mugginess permitting-outdoors, simple nutrition rich in fresh foods, such as fruit, milk, ice cream-in short, freedom. Be careful, though. Some pitfalls are constantly lurking, and among them are no shortage of bacteria and viruses that prefer the
digestive system
. In short gastroenteritis and food poisoning are always around the corner, not only in the summer time but can be a danger all year round: the former are due to the entry of a germ, while the others are caused by the production by some particular bacterial species (salmonellae, clostridia, staphylococci, escherichia, to name a few), of toxins, that is, substances that can trigger fever, abdominal pain, vomiting and diarrhea within a few hours. Instead, toxins are said to occur when a food is a vehicle for both germs and related toxins.

Eye on food hygiene and beyond

Transmission of these forms is as simple as it is rapid: use of toilets not followed by proper handwashing, expired or inadequately handled, prepared, cooked or stored food, contaminated water, inadequately sanitized environments (especially kitchen and refrigerator) and dishes, and so on. Creams and egg products, for example, or vegetables that have not been well rinsed, artisanal cheeses of uncertain origin are all potential vehicles for microorganisms and toxins.

Children are even more vulnerable than adults, posing two problems: first, the massive loss of water and minerals, leading to the risk of dehydration (an emergency that, especially in the early years of life, may necessitate hospitalization). Second, subsequent inappetence and possible maldigestion, particularly of lactose. Often, in fact, with enteritis the absorptive cells of the intestine are damaged and thus lactase, the enzyme that breaks down lactose into its two constituent units, is reduced.

Symptoms

Thus, additional discomfort factors may be added to the initial manifestations, responsible for general malaise, decreased liveliness, and poor appetite. For this reason, after an episode of vomiting and/or diarrhea, it is prudent to limit the amount o fmilk and dairy products, reintroducing them gradually if possible. If, on the other hand, once the gastroenteritis has passed, lactose-containing foods become associated with abdominal bloating, meteorism, or other digestive disturbances, it is advisable to consult the pediatrician. The key word, in any case, always remains prevention: by adhering to simple hygienic rules and tricks, including paying attention to the origin of raw materials and checking the potability of water, many unpleasant mishaps can be avoided. Not only to the little ones but also to all their family members.

Meteorism: a disorder that affects young and old alike

25 February 20246 January 2024 by psalari

IMeteorism means distention of the abdominal wall due to gas accumulation in the intestines. It is a term widely used in adult and sometimes proposed not so much as a symptom, which in fact it is, but almost as a disease. It can actually occur in children as well, in whom it takes on a different meaning depending on the age group and the consequences it can have on both digestion and general well-being.

The causes

In other words, it is a phenomenon, or, if you prefer, disorder, which can be entirely nonspecific or become a valuable clue pointing toward a precise diagnosis. In the infant, for example, the most common cause is aerophagia, which is the ingestion of air, most often promoted by suboptimal breast anchorage or, in the case of formula feeding, a hole in the teat that is too small. Also in the first weeks of life, another determining factor is the feeding of the baby not at the first signs of hunger (waking from sleep, eye movement, tongue snapping and lip movements) but after the “explosion” of crying, which causes the baby to swallow air. Colic is then another physiological phenomenon that results in tension of the abdominal wall and, according to some, is an expression of a maturing process of the digestive tract.

The role of milk

Meteorism, however, can also be due to gastroenteritis, digestive difficulties, and food allergies: in the infant in first place we find cow’s milk protein allergy, while from weaning the most likely events are lactose and gluten intolerance. Lactose, in particular, in order to be absorbed, requires the intervention of lactase, which breaks it down into its two constituent units, glucose and galactose. The reduction of this enzyme, which occurs in some individuals, results in the retention of this sugar and its fermentation by the intestinal bacterial flora: hence the two unmistakable signs, meteorism and diarrhea, that occur after the intake of milk, dairy products and other foods containing Lactose. The suspicion initially arises on the basis of this direct association, but it can be easily and definitively confirmed by performing a simple test suggested by the pediatrician.Once the diagnosis is made, however, for the child it does not mean having to give up such an important food as milk and all foods that are sources of lactose: thanks to research, in fact, a preparation has been prepared that allows it to be degraded, thus obviating the lactase deficiency.

If a child, therefore, has not previously suffered from meteorism, it is always good to first observe the progress of this disorder and particularly whether it is affected by diet. In the case of its persistence or accentuation, it is always a good idea to consult your pediatrician in order to make a careful assessment, which will allow the appropriate investigations and necessary steps to be taken to limit or possibly avoid discomfort to the child, whether small or large.

The first task in resuming school: following proper nutrition

25 February 20246 January 2024 by psalari

Experts from the Grana Padano Nutrition Observatory (Ogp) to coincide with the resumption of school studies have investigated the eating habits of 500 school-age females and males, estimating the number of daily meals and total intake of daily macronutrients (protein, carbohydrates, and lipids) to make dietary suggestions that can improve the state nutrition of children. The study shows that as age increases, the number of meals decreases, and in particular the number of meals goes from the 5% Of children who do not eat breakfast in the under-6 age group at the 20% of 14- to 17-year-olds, despite the fact that the first meal of the day is crucial for them to cope with the morning’s study hours. The decrease in the number of daily meals increases with increasing age, ranging from 4.2% of children under 6 years old having only 3 daily meals to 22.1% over 14 years old. As people get older, they tend to lose the snack eo habit, which is 100% present in younger children.

Expert advice

To improve the nutrition of toddlers, experts from the Observatory have compiled 5 tips that should be strictly followed to feed children in the right way. Here they are:

Breakfast: is an important meal and should never be skipped, we recommend a carbohydrate portion (complex sugars needed by the brain) such as bread or rusk or cereal, preferably whole grain, with milk or yogurt. A small amount of jam or honey can also be used for spreading or to sweeten drinks.
Snacks/meal: prefer fresh seasonal fruit, or a low-fat yogurt including fruit, in some cases salty snacks, bread and cheese can also be recommended, especially if the kid has to sustain physical activity.
Fruits and vegetables: consume 3 servings of fruits and 2 servings of vegetables daily to ensure vitamins, minerals and the right amount of fiber.
Sweets: in moderation, ice cream or pastries once a week, limit added sugar and sugary drinks, prefer smoot hies or juices, drink only water at the table.
Fish: at least two to three times a week, ideally cooked simply, steamed or baked.
Nuts: walnuts, almonds hazelnuts, contain Omega 3 fats, 10-20 grams daily as a snack.

Infant and toddler (digestive) comfort: a new concept

25 February 20246 January 2024 by psalari

Comfort is synonymous with well-being. But what exactly does it mean? As is implicit in the manifesto of the Italian Society of Pediatrics published 3 years ago, well-being can be equated with the right of every child to have “a healthy life,” guaranteed by the “early acquisition of lifestyle healthy“, access to specialized care, prevention, and appropriate protection against of environmental risks and uncomfortable situations. In practice, however, well-being finds its own declination from time to time that suggests how much a disorder or even a seemingly physiological condition can take a physical and behavioral toll on the child and consequently on his or her family.

Digestive comfort

Thus, the concept of digestive “comfort” has been introduced in recent years, applied especially to the infant, who is notoriously prone to annoying gas colic. But what do parents need to know (and know how to observe)? The most common concern, but also the least alarming in the eyes of the pediatrician, is constipation, which, however, most of the time, is easily corrected by simple dietary measures (e.g., increasing water and fiber intake). Instead, it would be more important to pay attention to the child’s digestive behavior ( crying, for example, is a clue to suspicion), the ease, rather than the frequency, with which he or she evacuates, and the appearance of manifestations such as liquid discharges, copious gas emission, and discomfort.

All of these should be reported to the pediatrician on a timely basis, along with information about the child’s diet: this is because, especially in the first year of life, an allergy may manifest itself in an atypical manner, for example, with repeated episodes of acid reflux or marked abdominal bloating.

The risk of intolerance

Among the possible factors that can undermine digestive comfort from generally the age of one year and up is lactose intolerance: this is not an allergy but the inability to break down this sugar, which, accumulating in the intestine due to lack of absorption, ferments. In any case, digestive comfort is something that should always be assessed in the context of each child’s daily life, as it is closely integrated with his or her overall state of well-being. Parental attention is an invaluable support for the pediatrician in tracing the possible cause of the manifestations and identifying the most appropriate subsequent strategy.

Questions about lesser-known practical aspects of vaccination

25 February 20246 January 2024 by psalari

Here are some examples that report very common questions among parents about vaccination for their children.

Giorgia
My son is 13 years old and has his vaccination booster on June 1: is it the case
Have him do the papilloma virus one as well? (I would keep it, heh)
– Yes, if the center allows it

Donatella
I was wondering, since there is some misinformation about it, if there are any
special contraindications for children prone to allergies, and in case, for
what types of allergies you need to proceed with caution!
– Only severe allergy sufferers require special precautions (for example, with the vaccines containing traces of gelatin), which more often than not result in.
In protected site vaccination. A small minority of children do not
can also be vaccinated in a protected environment and benefits from the
ground protection.

Flavia
I would like to get information about the new meningitis vaccine and whether those who have done
The unique one more than 10 years ago should do it again.
– The latest vaccine released on meningitis covers meningococcal B and is now included in vaccinations to be given to newborns. For comprehensive protection coverage against serogroups A, C, W135 and Y is also appropriate

Vittorio
What does a doctor respond to when faced with side effects that I read about a
Lombardy region circular addressed to doctors “child paralysis ”
“brain damage “? What is the rate of this collateral damage?
In the circular as the last collateral damage was … death of the child …. but
I don’t want to believe it.
– Vaccines, like drugs, can give rise to side effects even
serious and unforeseeable. The incidence data are the result of reports
from the local area and can be found at www.epicentro.it. They must
be read with caution, however (for example, for a combination vaccine the
individual components are included among the undesirable effects). It is always
appropriate to consult with your pediatrician and be clear that the logic
of vaccinations is that of cost-effectiveness, just as
an insurance policy involves, yes, a cost, but it offers enormous advantages in
case of need.

Simona
I would like to know more about the papilloma virus vaccine, if there is a
casuistry and at what age to do it, and whether we should inform ourselves or whether like other vaccines
we are contacted by the ASL.
– Not all ASLs routinely send the summons, which, moreover, could
also not to be received in case of postal mismatch. Instead, it is appropriate that the parents, with the vaccination calendar in hand, directly request
information to the area vaccination center. Regarding HPV in the
www.epicentro.it finds a wealth of authoritative information.

Federica

My daughter has to do it in a year, and honestly if it was also for adults I would do it too
– HPV exposure follows a behavioral risk profile. Nothing
would prohibit vaccination (privately) at any age, but it makes sense to
protect individuals who are not yet sexually active.

Victory
For the Lombardy region, so far papilloma virus vaccination is
provided for girls between the ages of 11 and 12 (notice home by letter).
Although it has now been extended to males in all regions of Italy with the
new Vaccine Plan, the vaccination centers in Milan that I contacted did not
they carry out. It needs to be done privately. Where and at what price I have not yet understood.
– The vaccination plan takes a few months to be applied to
regime. Vaccines can also be given privately, in some
Co-payment cases where not yet available or outside the
stipulated age limits.

Alessandra
A boy and his family are against vaccines because they argue that a vaccine
caused type 1 diabetes in his older brother. Thank you
– Type 1 diabetes recognizes a clear familiarity and is believed to be triggered by
A nonspecific viral infection. There is no evidence that vaccines can
trigger it, regardless of the fact that if a child is genetically
predisposed, with the frequency of the community runs a high risk not
Otherwise avoidable.

Jordan
I would be interested to know what vaccines are recommended for adults today
(hepatitis?) and which recalls (tetanus shot?).
– For adults, vaccines should be remembered in case of travel/stay in areas
endemic (for example, there is an ongoing hepatitis A epidemic in Apulia), the
dTPa to be recalled every 10 years (or during pregnancy), and the vaccine against
pneumonia and zoster after age 64.

Celiac disease: characteristics and numbers in Italy

25 February 20246 January 2024 by psalari

Celiac disease: What it is

Celiac disease is one of the most common hereditary diseases of pediatric age but fortunately also one of the treatable conditions: in fact, the remedy is to eliminate all foods containing gluten (bread, pasta, cookies, rusks, cakes, and even some medications). Gluten comprises a family of plant proteins, the polyamines, contained in wheat (gliadins), barley (hordeins), rye (secalins) and, still controversially, oats (avenins). Such proteins have little nutritional value-that is, they are not essential to the body-and gluten gives flour, once mixed with water, the ability to form a compact and elastic dough, which is among other things an essential prerequisite to breadmaking.

The numbers

A large survey had already estimated in 1994 a prevalence of people with celiac disease at a 1:200 ratio, which in fact is even higher today (1:100-1:150). On the other hand, celiac disease until the 1990s was misrecognized, but the advent of increasingly simple, rapid, and widespread laboratory techniques has enabled the recognition of more cases and thus a significant improvement in diagnostic possibilities.

It is currently believed that there are at least 100 individuals with celiac disease in a population sample of 100 thousand individuals. A number, therefore, that certainly does not justify the characterization as a rare disease, considering also the fact that there are 35,000 certified celiacs and every year new diagnoses increase by 10 percent, amounting to 5,000 cases of which 2,800 are in newborns. The intake of gluten, suggested in children as young as 6 months of age, basically activates an immune response that leads to flattening of the intestinal villi, resulting in generalized malabsorption and stunting of growth, which is the most striking sign (although some cases, which escaped initial diagnosis, are recognized in later life ages).

The consequences and risks

Numerous gastroenterological diseases, each burdened with a different clinical impact, such as irritable bowel syndrome, recurrent aphthous stomatitis, and hypertransaminemia (i.e., increased transaminases, enzymes produced by the liver, assayed in the blood) may be associated with celiac disease with different prevalence.

From celiac disease, with the unavoidable support of the physician, should be distinguished from the wheat allergy, which mainly affects the skin and respiratory tract, and the “gluten sensitivity“, which is always caused by ingestion of this food, but does not affect patients with celiac disease or allergy to wheat (in Italy, it is estimated that it could affect between 5 and 10 percent of the population). The latter causes clinical symptoms similar to those of irritable bowel syndrome (abdominal pain, bloating, and so on) and nonspecific extraintestinal manifestations (eczema, itching, headache), which usually arise within a short distance of gluten intake and just as quickly regress following an exclusion diet.

Are there supplements that improve memory and school performance in the child?

25 February 20246 January 2024 by psalari

An interesting study recently published in the prestigious journal Nature points out how, to “build and maintain a complex brain,” our ancestors used nutrients found primarily in meat: iron, zinc, vitamin B12 and fatty acids. This is at the expense of plant-based foods that, while containing them, are still less rich in them. A diet low in meat, therefore, would expose one to risks of deficiencies in nutrients that are essential for the proper functioning of the central nervous system; on the other hand, it is now known that an excess of animal products has negative aspects, as it can promote serious chronic-degenerative diseases, such as cancer or cardiovascular disease, for example. Therefore, there must be a delicate balance in nutrition as well, and this is especially true in the very early stages of life, especially in the period between conception and the age of 2 years.

The most important nutrients

Two nutrients deserve special attention, precisely because they are strongly involved in brain development and, therefore, indirectly in memory as well: long-chain polyunsaturated fatty acids (LC-PUFAs) and iron.
LC-PUFAs regulate the fluidity and enzymatic activities of cell membranes. Among them, the effect of DHA is especially noticeable during the delicate period when the nervous system of the fetus and infant/infant is formed: it preferentially accumulates in the frontal cortex and retina, thus assuming a key role in the structural development of the brain. It has been reported that infants fed formula containing DHA have better eye and motor coordination, greater concentration and higher scores on intellectual tests, and better logic skills. DHA and in general and LC-PUFAs are therefore considered essential nutrients for the development and maintenance of memory during all stages of life.

Iron is the second essential micronutrient: in addition to being critical for oxygen transport to peripheral tissues, it is involved in the production of myelin (the sheath that surrounds nerve fibers) and the neurotransmitters dopamine and serotonin. Several studies report that its deficiency has negative effects on memory, learning, and social interactions. The periods most at risk are those of intense growth of the body, thus pregnancy and fetal development, childhood and adolescence. The effects are reduced spatial memory in adolescence, reduced attention, and worse cognitive performance, manifested by lower school performance, poor test performance, and increased irritability and restlessness.

Functional gastrointestinal disorders

25 February 20246 January 2024 by psalari

Medicine, accustomed as it is to conventions and classifications, distinguishes diseases into organic and functional. The former are those associated with actual damage: this is the case, for example, with gastroenteritis caused by infection by a bacterium or virus, which settles in the intestines giving rise to diarrhea. Functional diseases, on the other hand, despite the occurrence of sometimes even intense symptoms, are characterized by the absence of injuries documentable: diarrhea, to refer to the situation just hypothesized (but an entirely similar consideration applies to the diametrically opposite condition, constipation), is triggered or maintained by factors that are not clearly identifiable or quantifiable, such as a particular emotional state.

Gastrointestinal functional disorders

What then are functional gastrointestinal disorders? They can be defined as a set of recurrent or chronic, age-varying symptoms that are independent of an underlying disease. In the first 2 years of life they may be physiological, that is, an expression of normal development, such as infant regurgitation, or, later, they may result from abnormal behavioral responses to internal or external stimuli, such as functional constipation caused by painful defecation.

Thus, at the basis of functional gastrointestinal disorders we find physiological, psychological and sociocultural factors capable of amplifying the perception of symptoms, which are experienced as severe, disabling and burdened with major repercussions on daily activities. Examples of functional disorders, in addition to those mentioned above, include colic, cyclic vomiting syndrome, and dyschezia (pain at the time of stool emission) in early childhood, abdominal migraine, functional dyspepsia, and irritable bowel syndrome in preschool, school, and adolescent ages.

Diagnosis and treatment

Two other elements need to be highlighted: first, there are no diagnostic indicators. In other words, there are no laboratory tests or benchmarks to be able to make the diagnosis, which is therefore based on as objective a set of symptoms as possible. Secondly, the care cannot be limited to medication but requires an approach that takes into account genetic and environmental factors (family influences, emotionally important events, infections, and so on), which may influence the child’s psychosocial development and cause him or her to be more susceptible to stress or bowel dysfunction (altered motility, altered immune system or visceral hypersensitivity). If, for example, a child suffers from functional diarrhea, treatment will have to contemplate the use not so much of medication but of dietary and especially behavioral measures, both for the child and his or her family members.

In the current view, in short, every intestinal disorder deserves to be transcoded not under the trivial label of a pretext contrived by the child to avoid a challenging test, but in the logic of a more complex effect resulting from the interaction between the organic sphere and the environment.

Is there such a thing as intestinal flu in children?

25 February 20246 January 2024 by psalari

Sometimes the popular imagination creates expressions that, while making no claim to scientificity, render the concept or impact of a particular condition so well that they enter common usage and even medical jargon. One example is the so-called “intestinal flu“-a designation that is not among the official diseases and yet it always catches on, raising no objections, for at least two reasons. First of all, because the real flu, that is, the flu caused by influenza viruses, in addition to the respiratory tract, especially in children, can also lead to digestive disorders. Second, because the very term “influence” suggests the idea of alteration.

The danger of viruses

But beyond these linguistic disquisitions, let us see why and how really many viruses in children can affect the airway and intestines. There are basically two mechanisms: first, the most prevalent viruses have the ability to attack the mucous membranes, that is, the internal lining tissues. As much as some have a greater propensity for one district, they may in fact find different routes of access, taking advantage of some structural similarities between respiratory and intestinal mucosa. This justifies why in children even a trivial cold can be associated with digestive disorders (nausea, vomiting, diarrhea).

Second, we should not forget that the entry of a germ into the gut often disrupts its bacterial flora, thus changing that delicate balance that is fundamental to its very functioning. Here then is the onset, once again, of bothersome manifestations, ranging from inappetence (instinctively the child has little motivation to eat because he or she associates the introduction of food with an unpleasant sensation) to liquid discharges. It may also happen, then, that a virus, by its mere presence, although not devastating, promotes the establishment or proliferation of more aggressive bacteria, which can worsen the already existing clinical picture, leading to further momentary discomfort and difficulty in the absorption and digestion of some components, including the lactose (the possible use of a lactase preparation, if necessary, will allow continued intake).

In conclusion, when we hear about stomach flu, we must always try to understand how this wording is understood: is it, in short, an actual flu that has gone beyond the airways or a full-fledged gastroenteritis? In any case, the use of a probiotic will be useful and advisable, both to stimulate the immune system and to counteract the pathogen and promote its elimination.

Between the digestive system and the immune system: the gut in the early ages of life

25 February 20246 January 2024 by psalari

The bowel, anyone would say, is the body in charge of the digestion and assimilation: its conformation to tube and its motility, in fact, enable it, thanks to enzymes, to break down ingested foods into their individual components (so-called nutrients), absorb them into the circulatory stream, and finally “push” unusable food residues so that they are eliminated in the form of feces.

The gut as an immune organ

Nothing to object to except for the fact that in this cursory overview another function no less important than those described has been omitted: the gut, in fact, is also an immune organ whose task is crucial in the early ages of life. Let us reflect for a moment: the absorbent mucosa, which in the adult individual has an area of as much as 400 square meters, can be considered on a par with the skin. Similarly to it, in fact, although it constitutes the inner lining of the intestine, it is constantly in contact with what comes from outside and thus plays a role as both a sentinel and a barrier.

The wall of the intestine, on the other hand, is rich not only in blood vessels, which receive nutrients and distribute them to all tissues of the body, but also in lymph vessels, where lymphocytes circulate. In fact, these particular highly specialized white blood cells, after forming in the bone marrow, need to be “trained” to perform their defensive task and find precisely in the digestive tract the optimal site for their break-in, also thanks to the presence of the bacterial flora.

A protection for the little ones

In the young child, then, let us not forget that the introduction of any new food is perceived as a potential aggression. In practice, the immune system cannot distinguish between a virus and a food protein, but thanks to special systems it develops what is known as tolerance: that is, it suppresses the mechanism by which contact with various foods would trigger the reaction underlying intolerance, namely the allergic response.

Those strange recurring stomach aches

24 February 20246 January 2024 by psalari

If we think back to our childhood, among the many experiences we are able to recall, there is certainly no shortage of at least one stomach ache: associated with classic indigestion, gastroenteritis, the intake of an expired food rather than a trip. An episode, in short, that left a memorable mark. Usually, in fact, stomach ache is an acute and mostly occasional event.

In some children, especially around school age, however, it becomes recurrent: pain attacks, in practice, recur with a fairly regular, indeed cyclical, cadence, usually monthly. Initially, one would come to think of the classic subterfuge that children resort to in order to evade their commitments and responsibilities. But what is surprising sooner or later is that these “seizures” appear regardless of school or other factors: perhaps before an outing, a party, or another pleasant moment, which the child will be forced to give up. If we then investigate further we find that in most of these cases there is familiarity with migraine. And perhaps kinetosis, i.e., motion sickness, seasickness, or similar transportation-related disorder, also emerges. What does all this mean then?

These recurrent bellyaches, which almost never miss an appointment, delineate what is known as the periodic syndrome or abdominal migraine: a curious manifestation that can last up to 72 hours accompanied by cramping in the center of the abdomen, vomiting, poor appetite, and often pallor, ringing in the ears, and visual changes. The designation of “migraine” is not coincidental considering that the gut has been aptly dubbed the “second brain” and shares with the central nervous system numerous mediators including in particular the serotonin: Indeed, it plays a decisive role in the periodic syndrome, the dynamics of which, moreover, are not entirely clear. Treatment must necessarily be individualized and, above all, must take into account any related symptoms, starting with those that may lead back to an initial and still nuanced form of migraine.

Of course, it is crucial to differentiate recurrent stomach pain from other types, for example, from that due to lactose intolerance. In fact, the latter can often take on a rather insidious character, resulting in abdominal pain, diarrhea, and sometimes vomiting not immediately after ingestion of this sugar but upon exceeding a certain threshold.

High Cholesterol? A new strategy on how to lower cholesterol

24 February 20246 January 2024 by psalari

How to lower high cholesterol

There are several drugs that can lower cholesterol (cholesterol values), one of the key factors in heart health. Chief among these are statins. However, a group of specialists has identified ezetimibe, a drug that has been on the market for years, as particularly effective not only in combination with statins, but also when used alone. Indeed, ezetimibe reduces intestinal absorption of cholesterol and, consequently, also plasma levels of ‘bad’ cholesterol (C-LDL), with a good tolerability profile.

So-called “high cholesterol” is a major challenge for physicians today, especially in patients at high cardiovascular risk and in cases where first-choice treatment with statins is not well tolerated or does not achieve guideline-recommended cholesterol levels. Indeed, let us not forget that hypercholesterolemia is a direct cause of cardiovascular disease, which in Italy alone is responsible for more than 200,000 deaths a year, including 70,000 from ischemic heart disease, including heart attack, the most feared.

According to specialists, ezetimibe is particularly effective in decreasing the risk of adverse cardiovascular events, even in patients who have already experienced some cardiovascular complication: unlike statins, which have a direct action on cholesterol production, ezetimibe inhibits the absorption of cholesterol in the intestine. The combined use of both drugs – statins and ezetimibe – makes it possible to achieve the so-called “double blockade,” which is especially indicated for certain categories of patients, for example, diabetics, in whom intestinal cholesterol absorption is rather high.

Although statins are relatively safe for most patients, they can sometimes induce side effects, including serious ones. Numerous clinical studies show, in fact, that 30 percent of patients on statin therapy may develop significant adverse reactions such as myalgias, myositis, hepatopathy and headache, making it impossible to continue treatment. In contrast, ezetimibe, due to its unique mechanism of action, has no significant interactions with other
drugs and is extremely tolerable both hepatically and muscularly.

Therefore, ezetimibe is a viable alternative for all those patients who are contraindicated from using statins.

Spontaneous chronic urticaria

24 February 20246 January 2024 by psalari

Pomphi, itching (often nocturnal) and swelling of certain parts of the body, sometimes disfiguring, with no known cause and disappearing only to recur suddenly and unpredictably. These are the symptoms of the chronic spontaneous urticaria, a particular form of urticaria unrelated to allergic factors that mainly affects individuals between the ages of 20 and 40 years (women twice as frequently), though it can appear at any time of life, and lasts on average for 3-4 years but sometimes even for decades. Although it affects 1 percent of the population, it is underestimated in both frequency and impact, leading to repercussions on school and work performance, social relationships, and psychological well-being.

This problem negatively affects quality of life to a greater extent than patients with even more serious skin problems, such as psoriasis. The presence of autoimmune diseases, especially thyroid disease, such as Hashimoto’s thyroiditis present in 10% of cases, celiac disease, and type 1 diabetes appears to correlate with an increased risk of chronic spontaneous urticaria. For the reasons explained above, it is easy to see why recognition of the disease is often delayed.

Diagnosis and treatment

The diagnostic pathway first proceeds with the search for any pathology associated with urticaria. Second step is to try to avoid factors that can aggravate urticaria, such as stress and especially the use of nonsteroidal anti-inflammatory drugs capable of inducing a flare-up or aggravation of urticaria in 20-30% of patients. The pharmacological approach involves the use of second-generation antihistamines at standard dosage, which can be doubled or quadrupled if symptoms persist after 2-4 weeks of therapy.

As a next step, omalizumab, a biologic drug that can improve symptoms in many cases and probably change the course of the disease, is used. If necessary, the fourth line of treatment relies on immunosuppressants, such as cyclosporine A, and the fifth on montelukast, an antileukotrienic. Unlike other chronic diseases, there is still no national patient registry and an organized network of services, and there are still numerous interregional disparities and limits to the Health Service’s coverage of treatment with antihistamines (in fact, they are reimbursed only at the standard dosage) and omalizumab, which is provided in the treatment plan for only 6 months.

How to help your child in the strenuous “recovery” of the intestines after the holidays

24 February 20246 January 2024 by psalari

A classic request that parents make to the pediatrician at this time is whether there is any provision for “Getting your child’s gut back on track” after the holidays. In fact, especially with regard to the Christmas season, it should be remembered that it is not only the dietary transgressions to cause disorders, but the many circulating viruses are also to blame, which can disrupt the Digestive system, sometimes in mutual concatenation

It may also be the case, for example, that classic indigestion, in addition to causing discomfort, alters the bacterial flora, making the gut more vulnerable to pathogens. Or a microorganism, which initially causes fever, cough, and other respiratory symptoms, may also promote nausea, vomiting, liquid discharges, and interfere with digestive processes.

What then are the best measures to help the child get better? First of all, let us remember that children, although they appear voracious and able to metabolize any mess, are no less delicate than adults: the difference lies in the fact that in the latter the symptoms are perhaps more pronounced but tend to resolve more quickly, whereas in children, if acute attacks of (liberating) vomiting or diarrhea are excluded, recovery times are slower, as well as longer vague abdominal pain, bloating or changes in fecal consistency and characteristics may persist, subtly.

To combat all these symptoms, it is first of all advisable to follow a simple diet: not necessarily “plain,” but characterized by lightly seasoned and elaborate dishes, such as spaghetti with tomato sauce, grilled steak or fish, pasta and beans, and minestrone. Also crucial is a proper balance between animal and vegetable foods: fruits and vegetables should never be missing from the table, and if they were really not liked by the child, we remember that, albeit with a loss of fiber, these sources of very important nutrients can be offered in the form of juices and centrifuges, prepared at home and consumed at the moment.

Pay attention, then, to the quantities of meals eaten throughout the day. If disturbances are present, it is better for them to be light and frequent rather than sparse and abundant. Fats deserve special mention; their intake should be moderated not only as a matter of calories but also because these substances slow down and weigh down digestion.

Finally, let’s not forget the importance of physical activity, which acts as a favorable stimulus on the motility of the digestive tract, and the intake of probiotic preparations, which are useful in restoring a balanced intestinal microflora arrangement.

Insomnia, hypertension, and diabetes: a sneaky and underestimated link

24 February 20246 January 2024 by psalari

Insomnia, hypertension and diabetes: watch out for those three!

Recent studies have shown that there is a close correlation between sleep disorders and diseases of the cardio-metabolic system, such as hypertension and diabetes. According to the numbers, 4 out of 5 diabetic patients And 2 out of 5 hypertensive patients frequently present with symptoms of insomnia. The question from those who have this disorder is as follows: I can’t sleep.

This confirms the theory that alterations in the internal biological clock can adversely affect some of our body’s basic physiological functions, affecting not only performance and mood, but also hormone levels, body temperature, blood pressure and energy metabolism.

According to research, insomniac individuals have a 300-500% higher risk of high blood pressure than non-insomniac individuals, regardless of age, body mass index, diabetes, alcohol consumption and smoking. Probable cause of the link between sleep disorders, hypertension, and diabetes could be a low melatonin level, a natural hormone produced in the pineal gland that regulates circadian rhythms and the proper functioning of our internal biological clock over the 24 hours. In addition to acting on the sleep-wake rhythm, in fact, melatonin has a direct action in regulating energy and glucose metabolism. Moreover, by acting on circadian rhythms and consequently on blood pressure, it can also affect the cardiovascular system.

Intervening on sleep disorders can be instrumental in improving one’s overall health. And it is in this context that, thanks to the contribution of Fidia Pharmaceuticals, continues the Sleep & Health Project, in its second edition, whose goal, under the auspices of the World Sleep Society and with the support of Italian associations and scientific societies, is a Early identification of patients with insomnia or other sleep disorders, in order to set them on a suitable course of treatment.

The first step in treating insomnia is definitely behavioral and aims to correct habits, expectations, and conduct that may trigger or maintain the disorder. As for drugs, the following are frequently used sedative-hypnotics with a short half-life and 2 mg of melatonin extended-release. It is preferable to use sedative-hypnotics for short periods, no more than four weeks, because they tend to lose their effectiveness if taken systematically every night for a long time; in addition, chronic intake can have negative effects on sleep structure itself as well as on daytime vigilance levels and some cognitive functions such as memory and attention.

In contrast, the administration of extended-release melatonin 2mg is especially recommended for insomniacs over the age of 55. The treatment is non addictive and is approved for 13 weeks’ continuous administration, even with other therapies for the treatment of hypertension and diabetes.

Oral hygiene in children: instructions for use

24 February 20246 January 2024 by psalari

Children’s mouths are characterized by rapid growth and deserve special attention. Aesthetic appearance is important, but what really matters is that the teeth are healthy and that chewing function takes place properly, without, for example, areas of abnormal contact, overloading, or malocclusion. But how to address the issue of proper oral hygiene in children? How to brush teeth?

Oral hygiene in children

Children are easily infected by the enthusiasm of play and the driving force of the example of adults.

Ministry of Health’s suggestions.

The first good rule for parents is therefore to avoid making oral hygiene an imposition: every gesture and invitation should occur as naturally as possible, like any ritual associated with a particular time of day. After all, even we adults, if we get used to always having a clean mouth, do not mind brushing our teeth; on the contrary, it becomes an indispensable requirement. First oral hygiene should begin by passing gauze over the dental arches to remove milk clots. As the first teeth erupt, they recommend twice-daily brushing with a small soft-bristled toothbrush and parental supervision until the child becomes sufficiently familiar.

Also the guidelines point out that the use of an electric toothbrush with a rotary-oscillating motion further increases the effectiveness of manual brushing and is indicated to improve the performance of oral hygiene tasks and in children with poor manual dexterity. In addition, the pleasure of using such a device, designed specifically to strike the imagination, can also become an excuse that entices the child to pay attention to oral hygiene and, above all, to devote the right amount of time to it (an average of 30 seconds per hemiarch, 2 minutes in total). The availability of different heads and appliances in various cost ranges, among other things, allows each parent to choose the solution he or she feels is best, with the understanding that an electric toothbrush is a small investment that pays for itself in a short time in terms of convenience and effectiveness.

Toothpaste, mouthwash, and dental floss are essential garrisons to be introduced as the child learns to use them properly. Periodic visits to the dentist, beginning in preschool and repeated 1-2 times a year, are of course an indispensable adjunct, with the aim of tracking mouth development and dental health.

Citrus and Umberto Veronesi Foundation together in the fight against cancer

24 February 20246 January 2024 by psalari

It is called “Citrus – the Italian Garden” and is a fruit and vegetable company in Cesena committed to the front line in the fight against cancer. For years, in fact, Citrus supports the Umberto Veronesi Foundation by funding scholarships for scientific research, five of which were disbursed just this year. Aware protagonists of Citrus’ charitable campaigns are its own consumers, who are always informed in supermarkets about the proceeds donated to scientific research.

In 2018, 188 physicians and researchers benefited from research grants allocated by the Umberto Veronesi Foundation. Citrus, in 3 years of operation, has managed to fund as many as eight research grants, worth 240,000 euros. “We are a young company that collaborated with the Umberto Veronesi Foundation from the very beginning because. We believe in the civic action of involving companies and citizens in the ongoing commitment to scientific research,” says Marianna Palella, 25-year-old managing director of ‘Citrus – L’Orto Italiano’ -. Since we have solicited the help of consumers, we feel it is our duty to communicate in great transparency the names and research of the scholars we have supported.”

And here are the names of researchers supported by Citrus in 2018. These are. Lorena Coretti, Sergio Occhipinti, Benedetta Raspini, Tiziana Schioppa and Laura Simoni. Scholars have developed projects on a variety of fronts, from autism and epilepsy to prostate and colon cancer treatment, neurological cells, and bacterial microflora in one-year-olds. Such research will be conducted at the universities of Malta, Milan, Pavia and Brescia and at the “City of Health and Science” Hospital of Turin.

Photo: source Fruitbookmagazine.co.uk

Valvulopathies: Diseases of the heart valves

23 February 20246 January 2024 by psalari

Out of 100 people, 60 know what an heart attack is but only 7 know about heart valve disease (valvulopathy). This is according to asurvey conducted last year among nearly 13,000 people over the age of 60 in 11 European countries and presented in Milan on Sept. 11 at the celebration of the first European Heart Valve Disease Day.”

“The perception of these conditions, which mainly affect the elderly, is unfortunately low not only in the general population but also among territorial physicians, who should spend more time listening to patients, particularly when they report chest pain, breathlessness, fatigue or irregular heartbeat.” says Battistina Castiglioni, GISE councilor, Italian Society of Interventional Cardiology.

“Auscultation of the chest takes only one minute and is sufficient to formulate a suspicion and prescribe an investigation that can make a diagnosis,” points out Sergio Berti, of the Italian Society of Interventional Cardiology. In the case of valvulopathy, which affects about 10% of the over-65s, early intervention in the case is decisive and enables the resumption of a completely normal life. Today of the 12,000 valve replacements (of aorta or mitral) performed each year in Italy, 5,500 are done by transcatheter, under local anesthesia only.