Agendo sulla vis a tergo della microcircolazione, sul “cuore” della

1. D.T.A. Medical Service

2. Il termine “carbossiterapia” venne introdotto da Luigi Parassoni nel 1995, in occasione del XVI Congresso Nazionale di Medicina Estetica di Roma organizzato dalla Società Italiana di Medicina Estetica. Negli anni 20, a Parigi, vennero effettuate le prime somministrazioni di anidride carbonica per via sottocutanea. Lo scopo iniziale delle somministrazioni sottocutanee di CO2 fu quello di valutarne l’innocuità. Nel 1932, presso la stazione termale di Royat (Clermont Ferrand), in Francia, si iniziò ad iniettare anidride carbonica per via sottocutanea per sfruttarne gli effetti farmacologici. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

3. Uno dei principi fondamentali della funzione circolatoria è la capacità di ciascun distretto tessutale di regolare il proprio flusso ematico tessutale locale in relazione alle esigenze metaboliche tessutali stesse. Così, come i bisogni tessutali mutano, anche il flusso ematico tessutale locale si modifica. • Le necessità specifiche dei tessuti alle quali il flusso ematico tessutale locale si deve adeguare sono molteplici: • l’apporto di ossigeno • l’apporto di nutrienti (glucosio, aminoacidi, acidi grassi, …) • la rimozione di CO2 dai tessuti • il mantenimento di un’appropriata concentrazione di svariati ioni nei tessuti; • il trasporto di diversi ormoni e di altre specifiche sostanze ai diversi tessuti; lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

4. llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

5. I fattori locali che regolano il flusso ematico tessutale locale a brevetermine sono l’anidride carbonica, l’adenosina, l’acido lattico, icomposti di adenosina, i fosfati, l’istamina, gli ioni potassio, gli ioniidrogeno. I fattori locali che regolano il flusso ematico tessutale locale a lungotermine sono i fattori di crescita delle cellule endoteliali, i fattori dicrescita dei fibroblasti, l’angiogenina. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

6. Una unità tessutale è costituita da una metarteriola, un singolo capillare e dal tessuto circostante. All’origine del capillare c’è lo sfintere precapillare e intorno alla metarteriola parecchie fibre muscolari lisce. Se si osserva al microscopio un tessuto sottile come quello dell’ala di un pipistrello si nota che gli sfinteri precapillari sono o completamente aperti o completamente chiusi e che il grado di costrizione della metarteriola varia con il tempo. Il numero degli sfinteri precapillari che sono aperti in un dato periodo è all’incirca proporzionale alla richiesta di ossigeno (e di altri nutrienti) dei tessuti. Inoltre gli sfinteri precapillari e le metarteriole si aprono spesso in modo ciclico per parecchie volte al minuto e la fase di apertura è anch’essa proporzionale alle necessità metaboliche dei tessuti. Questo aprirsi e chiudersi ciclico delle metarteriole e degli sfinteri precapillari è detto vasomotion.Poiché i muscoli lisci richiedono ossigeno per rimanere in contrazionesi può ritenere che la forza di contrazione degli sfinteri aumenta conl’incremento della concentrazione dell’ossigeno. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

7. La carbossiterapia serve a riequilibrare la microcircolazione quando la • stessa è alterata come in svariate situazioni cliniche: nelle angiopatie • organiche e funzionali, nella pannicolopatia edemato-fibro-sclerotica • (PEFS), nella psoriasi. • Con la carbossiterapia si effettua un trattamento riabilitativo della • microcircolazione. • La carbossiterapia esplica i suoi effetti interferendo sia con i fattori che • regolano a breve termine il flusso ematico tessutale locale, sia con i fattori • che regolano a lungo termine il flusso ematico tessutale locale. • La carbossiterapia determina: • Aumento della velocità del flusso ematico tessutale locale: • aumento dell’entità del letto vascolare della microcircolazione tessutale (angiogenesi) lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

8. Agendo sulla vis a tergo della microcircolazione, sul “cuore” della microcircolazione, cioè, a livello arteriolare e metarteriolare, determinando una vasodilatazione arteriolare e metarteriolare e la conseguente retrazione elastica delle pareti arteriolari e metarteriolari, determinando, insomma, un aumento della sfigmicità arteriolare e metarteriolare ; agendo sugli sfinteri precapillari della microcircolazione determinando un rilassamento delle fibrocellule muscolari lisce che caratterizzano strutturalmente gli sfinteri precapillari e, quindi, favorendo un aumento della velocità del flusso ematico tessutale locale; determinando un aumento della deformabilità eritrocitaria. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

9. llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

10. La CO2 determina un rilassamento della muscolatura liscia dellemetarteriole, degli sfinteri precapillari, quindi un aumento dellavelocità del flusso ematico tessutale locale e, di conseguenza, unaumento della entità del flusso ematico tessutale locale. Nel caso di una situazione di PEFS, ha un ruolo importante proprio il “cuore” della microcircolazione: è l’iposfigmia delle arteriole e dellemetarteriole la causa principale della stasi microcircolatoria veno-linfatica distrettuale. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

11. llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

12. llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

13. Già negli anni 20 venne dimostrato che la somministrazione sottocutanea di CO2 era priva di tossicità. In medicina, in particolare nella chirurgia ginecologica per via laparoscopica, la CO2, viene utilizzata per distendere Il cavo endoaddominale. In tali casi si introducono nel cavo endoaddominale 2-4 litri di anidride carbonica senza alcun problema di tossicità. Insomma il nostro organismo in condizioni di riposo elimina 200 ml/minuto di CO2 mentre in condizioni di iperventilazione elimina 4500 ml/minuto di CO2. Quando si effettua una seduta di carbossiterapia si somministrano, per via sottocutanea, in media, 50 ml/minuto. E’ facilmente comprensibile come una lieve iperventilazione alla fine del trattamento di carbossiterapia possa eliminare del tutto il rischio di una ipotetica ipercapnia (acidosi). lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

14. LA CARBOSSITERAPIA NEL TRATTAMENTO DELLA CELLULITE • La cellulite il più delle volte è di tipo misto ed è caratterizzata dal punto di vista istopatologico sia da una situazione di adiposità localizzata (AL) ipertrofica-iperplasica in accesso, sia da una situazione di pannicolopatia edemato-fibro-sclerotica (PEFS). • Il trattamento della cellulite, pertanto, per essere adeguato deve essere sia di tipo lipolitico, sia di tipo riabilitativo della microcircolazione. • La carbossiterapia realizza: • un’azione riabilitativa della microcircolazione; • un’azione lipolitica lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

15. L’azione riabilitativa della microcircolazione torna vantaggiosa nel trattamento della cellulite perché agisce sulla componente vascolare che caratterizza la fisiopatologia microcircolatoria della PEFS. Intervenendo sulla vis a tergo della microcircolazione, correggendo, cioè, l’iposfigmiadelle metarteriole e delle arteriole si risolve quella situazione di stasi veno-linfatica che caratterizza, appunto, la PEFS. L’azione lipolitica della carbossiterapia torna vantaggiosa nel trattamento della cellulite perché agisce sulla componente adiposa, cioè sulla adiposità localizzata ipertrofica-iperplasica in eccesso determinando la lipolisi dei trigliceridi intradipocitari in acidi grassi e glicerolo. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

16. L’azione lipolitica della carbossiterapia è legata principalmente a tre meccanismi: • Aumento del flusso ematico tessutale locale • Attivazione recettoriale • amplificazione dell’effetto”Bohr” e effetto “Haldane” lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

17. LE TECNICHE DI SOMMINISTRAZIONE. • Le tecniche di somministrazione di CO2 sono principalmente due: • Percutanea • Iniettiva La somministrazione percutanea prevede diverse metodiche: bagni di gas secco o acqua carbonica e docce di gas secco puntiforme o loco- regionale (trattamento ulcere distrofiche degli arti inferiori). lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

18. L’iniezione sottocutanea è la tecnica più utilizzata. Mentre i bagni di gas secco, i bagni in acqua carbonica, le docce di gas secco, le docce di acqua carbonica sono metodiche curative termali, quella iniettiva è una metodica curativa che può essere effettuata in un ambulatorio medico. Inizialmente, per le somministrazioni sottocutanee, veniva utilizzato uno strumentario spartano: una bombola di CO2 e una siringa. Oggi si possono utilizzare apparecchiature sofisticate di ultima generazione( D.T.A. CARBO2), erogatore elettronico con controlli di retroazione che permette non solo di poter dosare l’anidride carbonica ma anche di poter assicurare al gas un certo grado di purezza, pressione e temperatura per mezzo di particolari valvole proporzionali brevettate: una serie di filtri purificano la CO2 da possibili contaminanti come, ad esempio, dalle spore di Clostridium sporogenes. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

19. Il gas dosato da un apparecchio centrale e purificato da una serie di filtri, arriva in un deflussore che termina con un ago 30 G(anche 27, 28) da 13 mm. Mediante l’attivazione dell’apparecchiatura inizia l’erogazione dell’anidride carbonica., si infigge l’ago stesso nel sottocutaneo provocando un graduale enfisema sottocutaneo. Una volta che la CO2 comincia a diffondere nel sottocutaneo si fissa l’ago sulla pelle con un cerotto e si lascia che la diffusione sottocutanea, attraverso percorsi virtuali, si realizzi fino alle quantità stabilite. La facilità di diffusione dell’anidride carbonica nel sottocutaneo dipende dal grado di lassità del tessuto sottocutaneo stesso per cui è variabile da soggetto a soggetto. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll GENEX S.r.l.

20. IL DOSAGGIO Si somministrano da pochi millilitri sino a 2000 ml (1000 massimo per lato) di CO2 per seduta. La dose dipende dalla patologia e dall’estensione dell’area da trattare. In genere si eroga la CO2 erogando un flusso medio di 50/150ml/min con possibilità (con strumentazioni specifiche e di nuova generazione come CARBO2 D.T.A.) di erogare sino a 150ml/min.(REALI 450CC/MIN grazie al brevetto delle valvole proporzionali) Inizialmente l’erogazione inizia con quantità ridotte per raggiungere in pochi minuti il flusso prestabilito. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

21. LE SEDI DELL’INIEZIONI. Nella cellulite le iniezioni vengono effettuate a livello sottotrocanterico o a livello peritrocanterico o a livello dei fianchi. Solitamente si effettua una sola infissione per emilato. Si fissa l’ago sulla pelle con un cerotto e si lascia che il gas diffonda fino a 1000 ml per emilato con un flusso medio di 50 ml/ minuto. In tal modo il gas si distribuisce a tutto l’arto inferiore e fino ai fianchi. Nei casi di insufficienza venosa cronica si può adottare la stessa strategia utilizzata per il trattamento della cellulite: stessa tecnica di somministrazione e stesso dosaggio del gas. Nelle reumoartropatie del rachide le iniezioni sottocutanee si effettuano a livello paravertebrale. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll

22. Nelle flogosi acute (periartriti, epicondiliti, tendiniti, reumoartropatie acute,…) le iniezioni si effettuano in prossimità della parte interessata dal processo infiammatorio. Nella psoriasi localizzata le iniezioni si effettuano in prossimità della lesione psoriasica mentre nella psoriasi diffusa si può adottare la medesima metodica adottata per il trattamento della cellulite. Nelle arteriopatie l'iniezione viene effettuata in prossimità dell’arteriopatia stessa: nelle arteriopatie degli arti inferiori a livello della coscia o della gamba. Nell’acrocianosi l’iniezione viene effettuata a livello dei polsi, del dorso della mano, del dorso dei piedi. Nel fenomeno di Raynaud l'iniezione viene effettuata, previo bagno in acqua tiepida delle mani, a livello dei polsi. lllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll GENEX S.r.l.

23. llllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllllll