Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

The impact of a history of status epilepticus for epilepsy surgery outcome

OBJECTIVE

Patients with focal drug resistant epilepsy are excellent candidates for epilepsy surgery. Status epilepticus (SE) and seizure clusters (SC), described in a subset of patients, have both been associated with extended epileptogenic cerebral networks within one or both hemispheres. In this retrospective study, we were interested to determine if a history of SE or SC is associated with a worse surgical outcome.

METHODS

Data of 244 patients operated between 2000 to 2018 were reviewed, with a follow-up of at least 2 years. Patients with a previous history of SE or SC were compared to operated patients without these conditions (control group, CG).

RESULTS

We identified 27 (11%) and 38 (15.5%) patients with history of SE or SC, respectively. No difference in post-operative outcome was found for SE and SC patients. Compared to the control group, patients with a history of SE were diagnosed and operated significantly at earlier age(p = 0.01), and after a shorter duration of the disease (p = 0.027), but with a similar age of onset.

SIGNIFICANCE

A history of SE or SC was not associated with a worse post-operative prognosis. Earlier referral of SE patients for surgery suggests a heightened awareness regarding serious complications of recurrent SE by the referring neurologist or neuropediatrician. While the danger of SE is evident, policies to underline the impact for SC or very frequent seizures might be an efficient approach to accelerate patient referral also for this patient group.

Probing artificial intelligence in neurosurgical training: ChatGPT takes a neurosurgical residents written exam

Introduction

Artificial Intelligence tools are being introduced in almost every field of human life, including medical sciences and medical education, among scepticism and enthusiasm.

Research question

to assess how a generative language tool (Generative Pretrained Transformer 3.5, ChatGPT) performs at both generating questions and answering a neurosurgical residents' written exam. Namely, to assess how ChatGPT generates questions, how it answers human-generated questions, how residents answer AI-generated questions and how AI answers its self-generated question.

Materials and methods

50 questions were included in the written exam, 46 questions were generated by humans (senior staff members) and 4 were generated by ChatGPT. 11 participants took the exam (ChatGPT and 10 residents). Questions were both open-ended and multiple-choice.8 questions were not submitted to ChatGPT since they contained images or schematic drawings to interpret.

Results

formulating requests to ChatGPT required an iterative process to precise both questions and answers. Chat GPT scored among the lowest ranks (9/11) among all the participants). There was no difference in response rate for residents' between human-generated vs AI-generated questions that could have been attributed to less clarity of the question. ChatGPT answered correctly to all its self-generated questions.

Discussion and conclusions

AI is a promising and powerful tool for medical education and for specific medical purposes, which need to be further determined. To request AI to generate logical and sound questions, that request must be formulated as precise as possible, framing the content, the type of question and its correct answers.

Free tendon grafts for surgical management of chronic tears of the main body of the Achilles tendon: a systematic review

PURPOSE

After four weeks from injury, tears of the Achilles tendon are considered chronic. Their management is challenging, and the use of a graft is suggested when the gap between proximal and distal stumps is greater than 6 cm. The present study systematically reviews the outcome of free tendon grafts in chronic ruptures of the Achilles tendon, evaluating clinical outcomes, complications and return to sport.

METHODS

The present study was conducted according to the PRISMA 2020 guidelines. PubMed, Google Scholar, Embase, and Web of Science databases were accessed in February 2023. All the published clinical studies reporting clinical outcome, return to sport and complications of free tendon grafts used the treatment of chronic rupture of the midportion of the Achilles Tendon were accessed. The mean CMS (Coleman Methodology Score) of 65.7 suggested an overall good quality of the available published articles, attesting to the low risk of bias.

RESULTS

Data from 22 articles (368 patients with a mean age of 47 years) were retrieved. The average time from rupture to surgery was 25.1 week. At last follow-up, the AOFAS (American Orthopaedic Foot and Ankle Surgery) and ATRS (Achilles Tendon Total Rupture Score) scores improved of 33.8 (P = 0.0004), and 45.1 points (P = 0.0001) respectively. Return to activity was reported in 105 patients, and 82 (78.1%) had no activity limitations, while 19 (18.1%) had limited recreational but not daily activity limitations, and 4 (3.8%) reported limitations in daily activities. Return to sport data was reported in six studies, and 45 of 93 (48.4%) patients returned to sport at an average of 22.6 weeks.

CONCLUSION

In chronic tears of the Achilles tendon, with a gap of at least 6 cm, free tendon grafts allow predictable return to sport and acceptable recovery function.

LEVEL OF EVIDENCE

Level IV.

Endovascular therapies for hepatic artery stenosis post liver transplantation

PURPOSE

To evaluate primary patency at 12 months after endovascular therapies in hepatic artery stenosis.

METHODS

A retrospective review of all endovascular interventions for hepatic artery stenosis (HAS) after liver transplantation that occurred between June 2013 and November 2020 was performed at a single institution in France. Follow up occurred from 1 month to 4 years (median 15 months). The treatment consisted of dilation with a balloon or stent. We analyzed short-term (technical success and complications) and long-term outcomes (liver function, arterial patency, graft survival at 12 months (GS), and reintervention). We also compared percutaneous balloon angioplasty (PBA) with stent placement. PBA alone was used if < 30% residual stenosis of the hepatic artery was achieved. Stenting was performed if there was greater than 30% residual stenosis and in the case of complications (dissection or rupture).

RESULTS

A total of 18 stenoses were suspected on the basis of routine surveillance duplex ultrasound imaging (peak systolic velocity > 200 cm/s, systolic accelerating time > 10 ms and resistive index < 0.5), all of which were confirmed by angio CT, but only 17 were confirmed by angiography. Seventeen patients were included (14 males, mean age 57 years; and three females, mean age 58 years). Interventions were performed in 17 cases (95%) with PBA only (5/17), stent only (5/17) or both (4/17). Immediate technical success was 100%. Major complications occurred in 1 of 17 cases (5.8%), consisting of target vessel dissection. The analysis of the three (groups PBA only, stent only or both) showed the same procedural success (100%), GS (100%) and normal liver function after the procedures but different rates of complications (20% vs. 0% vs. 0%), arterial patency at 12 months (60% vs. 80% vs. 85%) (p = 0.4), early stenosis (40% vs. 80% vs. 0%) or late stenosis (60% vs. 20% vs. 100%) and requirement for reintervention (40% vs. 20% vs. 14%) (p = 0.56).

CONCLUSION

This study suggests that PBA, stent, or both procedures show the same primary patency at 12 months. It is probably not a definitive answer, but these treatments are safe and effective for extending graft survival in the context of graft shortages.

Augmented Reality Guided Laparoscopic Surgery of the Uterus

A major research area in Computer Assisted Intervention (CAI) is to aid laparoscopic surgery teams with Augmented Reality (AR) guidance. This involves registering data from other modalities such as MR and fusing it with the laparoscopic video in real-time, to reveal the location of hidden critical structures. We present the first system for AR guided laparoscopic surgery of the uterus. This works with pre-operative MR or CT data and monocular laparoscopes, without requiring any additional interventional hardware such as optical trackers. We present novel and robust solutions to two main sub-problems: the initial registration, which is solved using a short exploratory video, and update registration, which is solved with real-time tracking-by-detection. These problems are challenging for the uterus because it is a weakly-textured, highly mobile organ that moves independently of surrounding structures. In the broader context, our system is the first that has successfully performed markerless real-time registration and AR of a mobile human organ with monocular laparoscopes in the OR.

Joint Position Paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology (SFC) and the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV) on magnetic resonance imaging in patients with cardiac electronic implantable devices

Magnetic resonance imaging (MRI) has become the reference imaging for the management of a large number of diseases. The number of MR examinations increases every year, simultaneously with the number of patients receiving a cardiac electronic implantable device (CEID). A CEID was considered an absolute contraindication for MRI for years. The progressive replacement of conventional pacemakers and defibrillators by MR-conditional CEIDs and recent data on the safety of MRI in patients with "MR-nonconditional" CEIDs have progressively increased the demand for MRI in patients with a CEID. However, some risks are associated with MRI in CEID carriers, even with "MR-conditional" devices because these devices are not "MR-safe". A specific programing of the device in "MR-mode" and monitoring patients during MRI remain mandatory for all patients with a CEID. A standardized patient workflow based on an institutional protocol should be established in each institution performing such examinations. This joint position paper of the Working Group of Pacing and Electrophysiology of the French Society of Cardiology and the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV) describes the effect and risks associated with MRI in CEID carriers. We propose recommendations for patient workflow and monitoring and CEID programming in MR-conditional, "MR-conditional nonguaranteed" and MR-nonconditional devices.

Quantification of diffuse myocardial fibrosis using CMR extracellular volume fraction and serum biomarkers of collagen turnover with histologic quantification as standard of reference

PURPOSE

To compare the assessment of diffuse interstitial myocardial fibrosis in valvular diseases using cardiac magnetic resonance (CMR) extracellular volume fraction (ECV) quantification and serum biomarkers of collagen turnover using results of myocardial biopsy as standard of reference.

MATERIALS AND METHODS

This prospective monocentric study included consecutive patients before aortic valvular replacement. All patients underwent: i), 1.5T CMR with pre and post contrast T₁ mapping sequence and ECV computation; ii), serum quantification of matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs) and iii), myocardial biopsies were collected during surgery to assess collagen volume fraction (CVF). Patients with coronary artery disease were excluded. Correlation between native T1, ECV, CVF and serum biomarkers were assessed using Pearson correlation test. Agreement between basal anteroseptal ECV with global ECV was assessed using Bland-Altman test.

RESULTS

Twenty-one patients, 16 with aortic stenosis and 5 with aortic regurgitation were included. There were 12 men and 9 women with a mean age of 74.1±6.8 (SD) years (range: 32-84 years). Mean global ECV value was 26.7±2.7 (SD) % (range: 23.4-32.5%) and mean CVF value was 12.4±9.7% (range: 3.2-25.7%). ECV assessed at the basal anteroseptal segment correlated moderately with CVF (r=0.6; P=0.0026). There was a strong correlation and agreement between basal anteroseptal ECV and global ECV, (r=0.8; P<0.0001; bias 5.4±6.1%) but no correlation between global ECV and CVF (r=0.5; P=0.10). Global ECV poorly correlated with serum TIMP-1 (r=0.4; P=0.037) and MMP-2 (r=0.4; P=0.047). No correlation was found between serum biomarkers and basal anteroseptal- ECV or native T1.

CONCLUSION

In patients with severe aortic valvulopathy, diffuse myocardial fibrosis assessed by anterosepto-basal ECV correlates with histological myocardial fibrosis. Anteroseptobasal ECV strongly correlates with global ECV, which poorly correlates with TIMP-1 and MMP-2, serum biomarkers involved in the progression of heart failure.

Tipificación en <em>Gutierrezia</em> (Asteraceae, Astereae)

Durante el transcurso de la revisión de las especies sudamericanas de Gutierrezia, hemos podido hallar nombres que requieren tipificación. Luego del análisis de los protologos y especímenes de herbario, hemos designado ocho lectótipos y un neótipo para nueve nombres del género Gutierrezia. Además, se asignó la categoría de hólotipo a un especimen. Se provee una discusión detallada para cada nombre.

Adrenal hemorrhage in newborn: how, when and why- from case report to literature review

Background

Neonatal adrenal hemorrhage is a relatively uncommon condition (0.2–0.55%). Various risk factors have been reported in addition to birth asphyxia, such as sepsis, coagulation disorders, traumatic delivery, and perinatal injuries. Adrenal hemorrhage usually affects the right adrenal gland (about 70% of cases) while it involves the bilateral adrenal gland only in 10% of cases. In most cases, the event is asymptomatic but, in others, it may be so devastating to determine death by bleeding or adrenal insufficiency.

Case presentation

A case of bilateral neonatal adrenal hemorrhage, with adrenal insufficiency, but with no important risk factors and favorable evolution in a male infant.

Conclusions

This case emphasizes the importance of keeping a non-interventional attitude, avoiding early surgery but carrying out a serial sonographic follow-up. Serial ultrasound monitoring is the most reliable approach during conservative management.

Electronic supplementary material

The online version of this article (10.1186/s13052-019-0651-9) contains supplementary material, which is available to authorized users.

Una nueva especie de <em>Gutierrezia</em> (Asteraceae, Astereae) de Argentina

Se describe e ilustra Gutierrezia tortosae Ratto & Adr. Bartoli, una nueva especie de Argentina. Se asemeja a Gutierrezia mandonii (Sch. Bip.) Solbrig por presentar xilopodio, por la forma de las hojas y por el color amarillo de las flores liguladas, pero difiere de ella por tener tallos erectos y rígidos, hojas erectas y capítulos menores. Se presenta una clave para diferenciarla de las especies que habitan en el noroeste de Argentina.

Iron-dependent lysosomal dysfunction mediated by a natural product hybrid

Marmycin A and artemisinin join forces as the molecular hybrid artesumycin, a new fluorescent lysosomotropic small molecule that targets lysosomal iron to kill cancer cells.

Fine-tuning of Th17 Cytokines in Periodontal Disease by IL-10

Periodontitis (PD) is a chronic disease caused by the host inflammatory response to bacteria colonizing the oral cavity. In addition to tolerance to oral microbiome, a fine-tuned balance of IL-10 levels is critical to efficiently mount antimicrobial resistance without causing immunopathology. Clinical and animal studies support that adaptive T-helper (Th) cytokines are involved in the pathogenesis of alveolar bone destruction in PD. However, it remains unclear what type of Th response is related to human PD progression and what role IL-10 has on this process. We addressed the contribution of IL-10 in limiting Th1 and Th17 inflammatory response in murine and human PD. Through a combination of basic and translational approaches involving selected cytokine-deficient mice as well as human genetic epidemiology, our results demonstrate the requirement for IL-10 in fine-tuning the levels of Th17 (IL-17A and IL-17F) cytokines in experimental and human PD. Of novelty, we found that IL-17F correlated with protection in murine and human PD and was positively regulated by IL-10. To our knowledge, this is the first demonstration of the protective role for IL-17F in PD, its positive regulation by IL-10, and the potential differential role for IL-17A and IL-17F in periodontal disease.

<em>Gutierrezia mendocina (Asteraceae, Astereae)</em>, una nueva especie sudamericana

En el marco de la revisión taxonómica del género Gutierrezia para Sudamérica fue hallada una nueva especie de Argentina, caracterizada por sus tallos con la porción basal postrada, enraizante en los nudos, capítulos con involucro turbinado y flores liguladas blancas. Se describe e ilustra la especie encontrada en el Departamento de Tunuyán de la Provincia de Mendoza (Argentina), y se incluye una clave para diferenciarla de las especies afines.

Comparative validation of single-shot optical techniques for laparoscopic 3-D surface reconstruction

Intra-operative imaging techniques for obtaining the shape and morphology of soft-tissue surfaces in vivo are a key enabling technology for advanced surgical systems. Different optical techniques for 3-D surface reconstruction in laparoscopy have been proposed, however, so far no quantitative and comparative validation has been performed. Furthermore, robustness of the methods to clinically important factors like smoke or bleeding has not yet been assessed. To address these issues, we have formed a joint international initiative with the aim of validating different state-of-the-art passive and active reconstruction methods in a comparative manner. In this comprehensive in vitro study, we investigated reconstruction accuracy using different organs with various shape and texture and also tested reconstruction robustness with respect to a number of factors like the pose of the endoscope as well as the amount of blood or smoke present in the scene. The study suggests complementary advantages of the different techniques with respect to accuracy, robustness, point density, hardware complexity and computation time. While reconstruction accuracy under ideal conditions was generally high, robustness is a remaining issue to be addressed. Future work should include sensor fusion and in vivo validation studies in a specific clinical context. To trigger further research in surface reconstruction, stereoscopic data of the study will be made publically available at www.open-CAS.com upon publication of the paper.

How big is this neoplasia? live colonoscopic size measurement using the Infocus-Breakpoint

Colonoscopy is the reference medical examination for early diagnosis and treatment of colonic diseases. This minimally invasive technique allows endoscopists to explore the colon cavity and remove neoplasias - abnormal growths of tissue - which may develop into malignant tumors. The size, shape and appearance of a neoplasia are essential cues for diagnostic. However, the size is difficult to estimate because the absolute scale of the observed tissue is not directly conveyed in the 2D colonoscopic images. An erroneous size estimate may lead to inappropriate treatment. There currently exist no solutions to reproducible neoplasia size measurement adapted to colonoscopy. We propose a colonoscopic size measurement system for neoplasias. By using a simple planar geometry, the key technical problem is reduced to resolving scale. Our core contribution is introducing the Infocus-Breakpoint (IB) that allows us to resolve scale from a regular colonoscopic video. We define the IB as the lower limit of the colonoscope's depth of field. The IB corresponds to a precise colonoscope to tissue distance, called the reference depth, which we calibrate preoperatively. We detect the IB intraoperatively thanks to two novel modules: deformable Blur-Estimating Tracking (BET) and Blur-Model Fitting (BMF). With our system, the endoscopist may interactively measure the length and area of a neoplasia in a 2D colonoscopic image directly. Our system needs no hardware modification to standard monocular colonoscopes, yet reaching a size measurement accuracy of the order of a millimeter, as shown on several phantom and patient datasets.

Recommendations of the Sleep Study Group of the Italian Dementia Research Association (SINDem) on clinical assessment and management of sleep disorders in individuals with mild cognitive impairment and dementia: a clinical review

Clinical assessment and management of sleep disturbances in patients with mild cognitive impairment and dementia has important clinical and social implications. Poor sleep results in an increased risk of morbidities and mortality in demented patients and is a source of stress for caregivers. Sleep disturbances show high prevalence in mild cognitive impairment and dementia patients and they are often associated one to another in the same patient. A careful clinical evaluation of sleep disorders should be performed routinely in the clinical setting of individuals with cognitive decline. The Sleep Study Group of the Italian Dementia Research Association (SINDem) reviewed evidence from original research articles, meta-analyses and systematic reviews published up to December 2013. The evidence was classified in quality levels (I, II, III) and strength of recommendations (A, B, C, D, E). Where there was a lack of evidence, but clear consensus, good practice points were provided. These recommendations may not be appropriate for all circumstances and should therefore be adopted only after a patient's individual characteristics have been carefully evaluated.

Thyroid-stimulating hormone levels in the first days of life and perinatal factors associated with sub-optimal neuromotor outcome in pre-term infants

AIM

To identify perinatal factors associated with sub-optimal neuromotor outcome in infants without evident central nervous system lesions (intraventricular hemorrhage/ periventricular leukomalacia), with gestational age ≤30 (group I) and of 31-32 weeks (group II).

PATIENTS AND METHODS

A total of 102 premature infants admitted to the Neonatal Intensive Care Unit of Pisa, at 26-32 weeks of gestation, were studied. Data about perinatal factors and TSH values at 3-4 days of life were collected. The assessment of neuromotor development was performed at 18 months of corrected age, using the locomotor subscale of the Griffiths Scales of Mental Development.

RESULTS

Risk factors supposed to be predictive of sub-optimal neuromotor outcome (odds ratio >1) were at ≤30 weeks: male sex, small for gestational age, patent duct arterious, respiratory distress syndrome, and at 31-32 weeks: Apgar at 5 min <7, respiratory distress syndrome, patent duct arterious and birth weight <1500 g. A strong correlation was also found between TSH screening values >4,3 mU/l and suboptimal neuromotor outcome in both groups.

CONCLUSIONS

Several perinatal factors, acting on an immature and more vulnerable nervous system, such as the pre-term one, different for different gestational ages, are associated with a sub-optimal neuromotor outcome. Higher, but within the normal range, TSH values at screening seem to be a strong risk factor for neuromotor outcome in preterm infants without intraventricular hemorrhage or periventricular leukomalacia.

Perspective of robotic rectal surgery

Laparoscopy is widely recognized as a feasible and safe approach to rectal cancer associated with an improved early outcome. Robotic surgery overcomes intrinsic limitation of laparoscopic surgery by a three-dimensional view and wristed instruments, improving its outcome as well. Robot-assisted rectal surgery resulted to be safe and feasible. Prospective studies demonstrated its efficacy in allowing a high rate of negative circumferential resection margins with a consequent reduction in solitary loco-regional recurrences. A better local disease control and a reduced surgical trauma will be the conceivable benefit of this surgery.

Retinol-binding protein 4 in neonates born small for gestational age

BACKGROUND

Retinol-binding protein 4 (RBP4) is an adipocyte-derived 'signal' that may contribute to the pathogenesis of insulin resistance and Type 2 diabetes. The relationship of RBP4 with insulin resistance and metabolic risk in human beings has been the subject of several studies. Subjects born small for gestational age (SGA) are at risk of insulin resistance and Type 2 diabetes. Though RBP4 could represent an early marker of insulin resistance, to date, none have determined RBP4 in SGA children.

AIM

Our aim was to measure RBP4 concentrations in cord blood of SGA newborns compared with those in children born with a birth weight appropriate for gestational age (AGA) and to determine whether serum RBP4 levels at birth correlate with insulin sensitivity markers.

SUBJECTS AND METHODS

Sixty-four newborns, 17 born SGA (mean gestational age: 36.4+/-2.1 weeks), and 47 born AGA (mean gestational age: 37.0+/-3.6 weeks) were studied. The main outcome measures included anthropometry, lipid profile, insulin, homeostasis model assessment, quantitative insulin-sensitivity check index, adiponectin, and RBP4.

RESULTS

RBP4 concentrations were significantly reduced in SGA newborns (p<0.002). No relationship was found between RBP4 and insulin sensitivity parameters. Stepwise regression analysis revealed that birth weight was the major predictor of RBP4 serum concentrations (p<0.001).

CONCLUSION

RBP4 is reduced in SGA newborns, birth weight representing the major determinant of RBP4 concentrations, and is not related to insulin sensitivity. No significant difference in adiponectin levels and insulin sensitivity markers was found between SGA and AGA neonates.

Omeprazole Induces Apoptosis in Normal Human Polymorphonuclear Leucocytes

We investigated in vitro apoptosis in human polymorphonuclear neutrophils (PMN) induced by omeprazole. This drug, both in the native (OM) and acidified (OM-HCl) form, is a potent inducer of PMN apoptosis. The effect is time- and dose-dependent. OM-HCl is more efficient than OM in inducing PMN apoptosis. In fact, after 24 h incubation in vitro at 1×10 −4M OM-HCl induces apoptosis in 70% of the cell population compared to 37% induced by OM. Apoptosis induced by both forms of the drug is caspase dependent being significantly reduced by pretreating cells with the caspase 3 inhibitor (DEVDH-CHO). However, some differences in the apoptosis mechanisms between the two forms of the drug seem to exist because PMN treatment with the specific caspase 8 inhibitor (Z-IETD-FMK) only blocks OM-HCl mediated apoptosis. We observed cleavage of caspase 8 only in the cells incubated with OM-HCl while the executioner caspase 3 was activated with both forms of the drug. Furthermore, pretreatment with GM-CSF, a known activator of intracellular survival pathways in PMN, partially protected cells from OM-HCl induced apoptosis but did not contrast the apoptotic effect of OM. Cysteine cathepsin proteases also seem involved in the apoptotic mechanism of both drug forms since the specific inhibitor E64d gave a significant protection. To verify if OM-HCl induced apoptosis was dependent on the sulfenamide bound with the cell sulfhydryl groups we used molecules with thiol groups such as β-mercaptoethanol (β-ME) and reduced glutathione (GSH). Reactions of OM-HCl with cellular sulfhydryl groups are strongly involved in both the triggering and evolving phase of the apoptotic mechanism since significant protection from apoptosis was obtained when PMN were pretreated for 1h with β-ME (lipid-permeable) or GSH (lipid-impermeable). These results show that OM and OM-HCl induce apoptosis in human PMN and suggest that the second binds the sulfhydryl groups, present on the cell membrane, to then penetrate the cell thus causing a further significant increase in apoptosis. OM-induced PMN apoptosis during the treatment of gastric inflammatory disease could be an advantage for the resolution of the phlogosis state. However, this aspect should be further elucidated to assess the optimal therapeutical regimen for gastric diseases which are related to infective agents.

[Laparoscopic repair of incisional and umbilical hernias. Our experience]

BACKGROUND

Incisional hernia is a frequent complication of abdominal surgery (2-20% of all cases). Recurrence rate after simple repair without mesh is very high. The use of prosthetic materials has reduced the recurrences. Over the past decade, laparoscopic repair of incisional and umbilical hernias has become an interesting alternative to open procedure.

PATIENTS AND METHODS

The aim of this retrospective study was to evaluate efficacy, safety and advantages of laparoscopic approach in the treatment of incisional and umbilical hernias. From February 2000 through June 2006, a total of 127 incisional hernias (primary and recurrent), 21 umbilical and 19 epigastric hernias, were treated by laparoscopic approach. The exclusions for laparoscopy were: defect size less than 2 cm or more 20 cm, anesthesiologic problems, hemocoagulative disorders. The females/males ratio was 0/7, with a mean age of 59 years (range 24-83). The abdominal associated disease treated were 26. Three cases were treated as urgencies (strangulated hernias).

RESULTS

The conversion rate was 2 cases (1.2%). Mean operative time was 78 min (range 25-170). The mean postoperative hospital stay was 2.1 days (range: 1-5). The intra- and postoperative complication rate was 5% (above all seromas). The recurrence rate was 1.8% (3 cases).

CONCLUSIONS

More studies with long-term follow-up are necessary to prove the advantages of laparoscopic technique, but this large experience of more than 5 years, demonstrates that in selected cases the laparoscopic approach may be an interesting and effective alternative to open technique.

Enamel hypoplasia in coeliac children: a potential clinical marker of early diagnosis

AIM

To assess at the scansion electron microscope (SEM) the structural aspects of enamel hypoplasia (EH) in coeliac disease (CD) with the aim to investigate our hypothesis of a possible significant difference between structural characteristics of EH in CD affected patients and EH of non-coeliac patients. If the presence of specific features of the EH associated with CD were demonstrated, these findings would represent for the dentist early non-invasive clinical markers of diagnosis of CD in case of suspected disease.

METHODS

We analysed at SEM two samples of enamel fragments from hypoplasic teeth, both deciduous and permanent, harvested from 10 coeliac children (18 permanent teeth, 6 deciduous teeth; study group) and 10 non-coeliac children (16 permanent teeth, 4 deciduous teeth; control group) treated for dental caries, dental extractions for extensive caries lesions or deciduous teeth exfoliation.

RESULTS

Significant structural differences were noted between EH of non-coeliac patients and same dental ? lesion in the group with CD. In the study group, EH defects were predominantly located on the central and lateral incisors, upper and lower, both deciduous and permanent, and on the first permanent molars, and were always simmetrical. EH of permanent teeth of CD affected patients was characterised by prisms more irregularly distributed with irregular margins and less interprismatic substance than observed in non-coeliac EH. The deciduous teeth of the study group showed shorter enamel prisms with a non-parallel direction up to convergence and less interprismatic substance than observed in the control group.

CONCLUSION

This morphological analysis at SEM of the hypoplasic enamel defects of a group of coeliac children, the first published in literature, demonstrates that the EH of deciduous and permanent teeth in CD is highly hypomineralised with shorter prisms, more irregularly distributed and less interprismatic substance than observed in the non-coeliac EH. More data are needed to validate the significance OF our observations with the aim to assess if this simple, non-invasive microscopic analysis can be considered effective for the early identification of silent cases of CD that otherwise would not be diagnosed in the paediatric age.

Glycogen Storage Disease type Ib: a paediatric case report

AIM

This paper addresses the need of the dental literature to document cases of Glycogen Storage Disease (GSD) type Ib with focus on the paediatric management of oral and dental problems and the potential complications arising from the increased susceptibility to bacterial infections, cariogenicity, and blood diathesis.

METHODS

Previous medical and dental papers on GSD type Ib published from 1980 to 2006 have been searched in the electronic databases PubMed and EMBASE using keywords of the NLM's Thesaurus, with the aim to retrieve important implications of treatment and preventive measures for an evidence-based multidisciplinary medical and dental management of the oral health problems of a 9-year old boy affected by GSD type Ib.

CASE REPORT

Oral and dental manifestations observed during a period of two years and relative treatments are reported from our case. Data on pharmacologic, oral hygienic, dietary, and surgical preventive measures for the control of recurrent oral infections, dental caries, gingival inflammation and risk of surgical bleeding are described. In addition, an electronic microscope structural analysis at SEM of the enamel tooth surface was conducted to identify any characteristic difference in the enamel architecture of this GSD type Ib affected patient compared with the normal enamel structure.

CONCLUSION

The oral manifestations of our case included uncommon findings such as multiple deep oral ulcers of the tongue, labial and vestibular mucosa, which could be related with a severe impairment of the neutrophil-related immune system of the patient. At SEM, the enamel of the deciduous teeth showed dark spots of hypomineralisation which are the first published data of an enamel-related susceptibility to dental caries. The quality of life of our patient increased thanks to the oral and dental treatments and preventive oral health measures given at clinical appointments. The dentist should be prepared to face the possible complications of surgery in these patients and the hospital setting seems to allow for this clinical safety.

The biliopancreatic diversion. A comparison of laparoscopic and laparotomic techniques

AIM

Morbid obesity has increased its frequency in the last 20 years in association with the increase of a country's richness. Bariatric surgery has developed a role which is becoming more and more important. The aim of this study, after 10 years of experience with the biliopancreatic diversion, is to compare the laparoscopic versus open technique

RESULTS

METHODS

From March 1993 to December 2004, 150 patients were operated by biliopancreatic diversion. We divided our experience into 2 groups: laparotomic and laparoscopic techniques. We compared the following variables in the 2 groups: total operating time, intestinal functions, postoperative pain, patient's discharge and recovery time, major postoperative complications, postoperative mortality, late complications, incisional hernia incidence and anastomotic ulceration.

RESULTS

We found a significant difference in both the reduction of the postoperative pain and the recanalization time in the laparoscopic group. Equally, we found a reduction in the incidence of abdominal wall complications, especially the reduction of incisional hernia and infections. The mean operative time was longer in the laparoscopic group, in particular due to the hard learning curve.

CONCLUSIONS

The laparoscopic biliopancreatic diversion is a feasible and safe operation with good results: less postoperative discomfort, shorter recanalization and ospedalization time, less incidence of abdominal wall morbidity (incisional hernia). However, the procedure may prove difficult and it needs a highly experienced surgeon in laparoscopic technique.

Central odontogenic fibroma interesting the maxillary sinus. A case report and literature survey

Odontogenic fibroma (OF) is a rare benign odontogenic tumor deriving from the dental mesenchymal tissue and accounting for less than 5% of all odontogenic tumors. This paper presents an aggressive histologically diagnosed central odontogenic fibroma (COF) in a 17-year-old girl characterized by asymptomatic rapid growth with massive replenishment of the left maxillary sinus. We carried out a review of the literature to retrieve all published cases of COF especially focused on radiographic aspects and surgical treatment of cases characterized by clinical aggressive behaviour, as we observed in our patient. Search strategy included retrieval of English language papers, published from 1966 to today, in dental journals on MEDLINE/PubMed and EMBASE, and hand-searching of the bibliography of retrieved papers. Sixty-nine cases of COF were identified from 1954 to 2003 and a new one was added. We have compared characteristics of COFs according to age, gender, location, clinical and radiographic findings of aggressive development, and histology. We discuss clinical and radiographic aspects of our case compared with COFs previously published. We give suggestions for surgical treatment of COF in case of aggression to important anatomical structures.

[Laparoscopic colon-sigmoid resection with mesenteric artery preservation for diverticular disease]

AIM

About 2/3 of the Western population over the age of 80 years are affected by colic diverticulosis; 25% will develop diverticular disease with or without complications: fistula, obstruction, pericolic abscess, free perforation or hemorrhage. Laparoscopic approach for benign diseases of the colon such as diverticulosis, Chrohn's disease, etc. is unanimously considered as a very effective procedure. We have performed a retrospective analysis of 9 years with laparoscopic approach of the diverticular disease. The purpose of this study was to determine the feasibility, safety and benefits of laparoscopic approach.

METHODS

From May 1994 to November 2002, 69 patients affected by non-complicated diverticular disease, were treated laparoscopically, at the Mininvasive Surgery Department of Spoleto. In the same period other 213 patients suffering from cancer of the colon-rectum were operated through laparoscopic surgery. A colosigmoid resection with mesenteric inferior artery preservation was performed in 46 cases (67%).

RESULTS

We have performed only a laparoscopic colectomy technique (no hand-assisted procedures); the convertion rate was of 7.2%, the mean operative time was 145 min, no intraoperative complications were observed and finally the mean hospital stay was of 7.4 days (6-9). The postoperative complications were 1 case of infection of the umbilical scar and 1 case of pleural effusion with bronchopneumonia.

CONCLUSIONS

Elective laparoscopic colectomy for diverticular disease is feasible, safe and gives very good results: minimum postoperative discomfort, rapid recovery, low mobility and postoperative stay, rapid return to normal activities. However, in some cases, this procedure can be extremely difficult because of previous inflammatory complications (adhesions, fistulas or stenosis), therefore, high surgical skills in laparoscopic-colic surgery are required.

[Non palpable lesions of the breast: the Mammotome-biopsy in the preoperative management of breast cancer]

BACKGROUND

Breast tumour takes first place for frequency in women in Western Countries and is in constant increase. The diagnosis of the so-called non palpable lesions is increased remarkably above all due to the diffusion of mammographic screening and to a greater awareness of the problem. Furthermore it is helped by an important development of mininvasive diagnostic methods: the traditonal cytology with fine needle is supported by various trans-skin bioptic procedures (micro-histological examination). This methods almost always replaces the surgical excisional biopsy and frozen intraoperative examination, still used but reserved for particular cases.

PATIENTS AND METHODS

In our Department of General and Mininvasive Surgery, from December 1999 to September 2004, we carried out 214 biopsies, with the collaboration of the radiological Service, under echographic guidance using vacuum--assisted biopsy (Mammotome) with 11-Gauge needle. The results are examined and discussed here in this report with regard to diagnostic accuracy, quantity and quality of information, significant for subsequent surgical management.

RESULTS

Of 214 biopsies carried out with Mammotome technique, 89.3% of the cases are clinically non palpable lesions, with a average diameter of 8 mm. The average age of patients was 57.6 years (range 31-88). There are 90 cases of positive malignant pathology (42%). In the atypical ductal iperplasia and radial scar cases (6%) surgical removal of lesion was carried out which confirmed the previous bioptic diagnosis in 100% of cases. The 19% of patients submitted to a Mammotome biopsy was subject previously to cytology with fine needle. Comparing the results of both methods the diagnostic reliability of Mammotome was significantly superior (p < 0.05) as also the amount of information obtained (histotype, invasivity, grading, estrogen receptor, etc.); discomfort linked to the procedure, valued as pain (VAS), resulted inferior to the discomfort of biopsy with fine needle. The only complication of Mammotome biopsy is represented by haematoma in the biopsy site (8% of cases). The number of false negatives was one case due to incorrect targeting.

CONCLUSION

In the present situation, the choice of method is conditioned by the degree of radiological suspicion, taking into account the information obtained thereby, in order to ensure the appropriate surgise management. Mammotome biopsy of non palpable lesions of the breast, in our experience, is preferable if suspicion of malignancy is high. In this way a correct preoperative strategy can be prepared. Including the sentinel lymphnode method. Consequently a decision regarding the type of surgery can be taken (generally conservative), as well as making easier the intraoperative localisation of lesion by positioning the metallic clips during biopsy.

Energetics of midvelocity emissions in peripheral heavy ion collisions at Fermi energies

Peripheral and semiperipheral collisions have been studied in the system 93Nb+93Nb at 38A MeV. The evaporative and midvelocity components of the light charged particle and intermediate mass fragment emissions have been carefully disentangled. In this way it was possible to obtain the average amount not only of charge and mass, but also of energy, pertaining to the midvelocity emission, as a function of an impact parameter estimator. This emission has a very important role in the overall balance of the reaction, as it accounts for a large fraction of the emitted mass and for more than half of the dissipated energy. As such, it may give precious clues on the microscopic mechanism of energy transport from the interaction zone toward the target and projectile remnants.

Benign cementoblastoma: a clinical case of conservative surgical treatment of the involved tooth

The benign cementoblastoma (BC) or ''true'' cementoma is a rare benign neoplasm arising from the odontogenic ectomesenchyme and representing about 1% to 6.2% of all odontogenic tumors. The BC more frequently affects young males in an age range of 20-30 years, occurring in the mandible about 3 times more than in the maxilla, and it is always physically attached to the tooth roots. This tumor is often asymptomatic until it produces pain, expansion or swelling of the jaw segment or compression of the inferior alveolar nerve. Early diagnosis is essential to save the tooth by enucleating the tumor, filling the root canals and apicectomy or curettage of the affected roots. A case of BC embedding the mandibular first right molar and resorbing the vestibular cortical bone, in a 48 year-old male, is reported. The radiographic examination showed a well-defined mixed-density unilocular mass, confluent with both the tooth roots of the mandibular first molar and surrounded by a radiolucent rim. A combined endodontic-surgical treatment was performed with the aim to remove the tumor while saving the tooth. Histological findings, differential diagnosis and surgical treatment of the tumor are discussed and compared with similar cases in the literature.

Calcifying epithelial odontogenic (Pindborg) tumor. A clinical case

Calcifying epithelial odontogenic tumor (CEOT), Pindborg tumor, is a rare benign odontogenic neoplasm representing about 0.4-3% of all odontogenic tumors. This tumor more frequently affects adults in an age range of 20-60 years, with a peak of incidence between 40 and 60 years. About 190 cases of CEOT have been reported in the dental literature. Fifty-two percent of cases of CEOT is associated with a tooth impacted and/or displaced by the tumor. The primary CEOT has a recurrence rate of 10-15%, after total excision, and its malignant transformation is a very rare occurrence. The authors report a case of primary intra-osseous CEOT, embedding the mandibular right second molar, in a 24 year-old male. Radiographs showed a well-defined unilocular osteolytic lesion, swelling and reabsorbing the mandible and displacing the inferior alveolar nerve. It was possible to perform conservative surgical treatment consisting of the enucleation of the tumor together with a portion of tumor-free bone cavity margin and the debridement of the inferior alveolar neuro-vascular bundle, which was surrounded by a tumor capsule-like structure. The postoperative histological examination of the tumor revealed typical benign features. The differential diagnosis and work-up of the tumor treatment are discussed in relation with its histological typing and localization in the jaws.

[Neoplastic residues in the trocar tract in oncologic laparoscopic surgery]

AIM

The laparoscopic approach to malignant diseases runs up against both old and new problems: respect for the principles of radicality, operating times, the postoperative course and surgical complications, long-term oncological results in terms of survival and recurrence of the disease. One of the problems which has received most attention regards the onset of a metastasis on a trocar scar or a mini-laparotomy recurrence. Trocar site tumor recurrences have been described in the literature following laparoscopic surgery in almost all abdominal malignant pathologies (colorectal, gynaecological, pancreatic, etc.) and even after thoracoscopy. The real frequency is currently of the order of 1% (0-2%) in colic surgery and of 14% (10-17%) after cholecystectomy for occult gallbladder carcinoma.

METHODS

A retrospective survey was carried out of our laparoscopic experience; between 1994 and 2002 213 colic resections were carried out for cancer; we also observed 18 occult carcinomas of the gallbladder in 2386 laparoscopic cholecystectomies for lithiasis.

RESULTS

Respectively 2 cases (11%) of trocar site neoplastic recurrences in gallbladder carcinoma and 2 cases (0.9%) from colon carcinoma were observed.

CONCLUSIONS

The real extent of the problem would appear to be on a much lesser scale at the moment than was initially thought, especially as regards colic surgery. The multifactorial aetiology of the problem explains the importance of their prevention, on the basis above all of rigorous respect for the rules and protocols of laparoscopic technique.

[Laparoscopic right hemicolectomy with intracorporeal anastomosis. Technical aspects and personal experience]

BACKGROUND

Laparoscopic colo-rectal surgery has gained wide acceptance as a treatment in a variety of benign and malignant diseases. The reproducibility and safety of all the principal colo-rectal procedures has been demonstrated, but some indications are still controversial. A great part of surgeons perform right hemicolectomy by laparo-assisted technique and consider it more difficult than left hemicolectomy.

METHODS

A retrospective analysis of a series of 180 laparoscopic colon resections performed between 1994 and 2001 is presented. Surgical indications were: 46 cases of benign disorders and 134 colonic malignancy. The right hemicolectomy were 27 (15%): 2 benign and 25 malignant diseases. The technical aspects of completely laparoscopic right hemicolectomy is described in details. A completely mechanical intra-corporeal anastomosis is always performed. To remove the bowel specimen from the abdominal cavity it is put it in a large bag and pull it out of a 3-4 cm enlargement of a trocar-site (in the umbilical scar).

RESULTS

Data of the 27 laparoscopic right hemicolectomy were analysed: there was 1 conversion to open surgery; no intra-operative complications were observed; the postoperative period was complicated by 1 anastomotic fistula. The median operative time was of 150 minutes. No case of port-site recurrence was observed.

CONCLUSIONS

The laparoscopic colo-rectal surgery can reproduce in selected patients, the techniques performed in open surgery with minimally invasive treatment. It is possible to perform a completely laparoscopic right hemicolectomy after an adequate training in advanced laparoscopy, anyway there are many advantages: less postoperative pain, short-term postoperative ileus, earlier return to daily activity.

Factors influencing pricking pain threshold using a CO2 laser

The purpose of this study was the evaluation of the best experimental conditions in healthy subjects for the measurement of the minimal thermal energy density E1 which induced pricking pain on the volar surface of the left forearm by means of CO2 laser pulses. E1 was measured on a well-defined area, using laser pulses of different durations and constant power P. The dependence of E1 on the stimulus power P, the size A of the radiated area and the surface temperature T(e) were explored. In the first part of the study, these relations were obtained using a computer program, from the calculated spatio-temporal distribution of the skin temperature during, and following, a laser pulse which caused pricking pain. The second part studied a set of subsequent measurements carried out on a group of five healthy trained subjects and agreed only in part with the calculated data. We found that the measurement error on E(t) was less than 10% with P between 1.5 and 3 W, and A between 0.15 and 0.25 cm2, respectively. The influence of sensitization and adaptation phenomena on the measured data was also explored. We also show a rhythmic annual change of T(e) and E1.