A Short Update on the Use of Monoclonal Antibodies in COVID-19

Monoclonal antibodies in the prophylaxis and treatment of COVID-19 have been crucial in reducing severe infections when vaccines were unavailable. However, as the virus and its variants have changed over time, the effectiveness of monoclonal antibodies has been questioned. This technical note highlights the need to assess the antiviral activity of these antibodies against new variants and adapt treatment strategies accordingly. On the one hand, in vitro studies have suggested reduced susceptibility of the latest variants to monoclonal antibodies, whereas clinical data still show benefits in reducing severe illness and mortality, indicating that laboratory results do not always mirror real-world outcomes. As a result, although resistance to monoclonal antibodies can develop over time, they could still have an important role in COVID-19 treatment, especially when used in combination, and ongoing research aims to identify effective antibodies against new variants.

Advances in Therapeutic Strategies for the Management of Clostridioides difficile Infection

The infection caused by Clostridioides difficile represents one of the bacterial infections with the greatest increase in incidence among nosocomial infections in recent years. C. difficile is a Gram-positive bacterium able to produce toxins and spores. In some cases, infection results in severe diarrhoea and fulminant colitis, which cause prolonged hospitalisation and can be fatal, with repercussions also in terms of health economics. C. difficile is the most common cause of antibiotic-associated diarrhoea in the healthcare setting. The problem of bacterial forms that are increasingly resistant to common antibiotic treatments is also reflected in C. difficile infection (CDI). One of the causes of CDI is intestinal dysmicrobialism induced by prolonged antibiotic therapy. Moreover, in recent years, the emergence of increasingly virulent strains resistant to antibiotic treatment has made the picture even more complex. Evidence on preventive treatments to avoid recurrence is unclear. Current guidelines indicate the following antibiotics for the treatment of CDI: metronidazole, vancomycin, and fidaxomycin. This short narrative review provides an overview of CDI, antibiotic resistance, and emerging treatments.

Could CT finding of gas in the sole mesenteric artery be a sign of a severe acute ischemia? Presentation of a rare fatal case and a literature review

Contrast-enhanced abdominal CT is the gold standard for the diagnosis of acute mesenteric ischemia (AMI). CT findings include several anomalies like bowel wall thickening, thinning, attenuation, decreased enhancement, dilated fluid-filled loops, pneumatosis, and portal venous gas. A rare case of gas found only in the superior mesenteric artery (SMA) is presented. A contrast-enhanced CT scan was performed in emergency on an 80-year-old man with vague and diffuse abdominal pain, which showed findings of occlusive AMI. Gas was found in the context of the SMA and its branches, but not in the mesenteric and portal veins. The patient underwent emergency surgery but he died the next day in the intensive care unit for complications. The rare CT finding of gas in SMA during an AMI should be considered a radiological sign of irreversible intestinal damage: surgical prompt intervention is needed, even if the mortality rate is high.

Cost-effectiveness analysis of revisional Roux-en-Y gastric bypass: laparoscopic vs. robot assisted

There is controversy over the possible advantages of the robotic technology in revisional bariatric surgery. The aim of this study is to report the experience of a high-volume bariatric center on revisional Roux-en-Y gastric bypass with robot-assisted (R-rRYGB) and laparoscopic (L-rRYGB) approaches, with regards to operative outcomes and costs. Patients who underwent R-rRYGB and L-rRYGB between 2008 and 2021 were included. Patients' baseline characteristics and perioperative data were recorded. The primary endpoint was the overall postoperative morbidity. A full economic evaluation was performed. One-way and two-way sensitivity analyses were performed on laparoscopic anastomotic leak and reoperation rates. A total of 194 patients were included: 44 (22.7%) L-rRYGB and 150 (77.3%) R-rRYGB. The robotic approach was associated with lower overall complication rate (10% vs. 22.7%, p = 0.038), longer operative time, and a reduced length of stay compared to L-rRYGB. R-rRYGB was more expensive than L-rRYGB (mean difference 2401.1€, p < 0.001). The incremental cost-effective ratio (ICER) was 18,906.3€/complication and the incremental cost-utility ratio was 48,022.0€/QALY (quality-adjusted life years), that is below the willingness-to-pay threshold. Decision tree analysis showed that L-rRYGB was the most cost-effective strategy in the base-case scenario; a probability of leak ≥ 13%, or a probability of reoperation ≥ 14% following L-rRYGB, or a 12.7% reduction in robotic costs would be required for R-rRYGB to become the most cost-effective strategy. R-rRYGB was associated with higher costs than L-rRYGB in our base-case scenario. However, it is an acceptable alternative from a cost-effectiveness perspective.

Laparoscopic bariatric surgery is safe during phase 2-3 of COVID-19 pandemic in Italy: A multicenter, prospective, observational study

BACKGROUND

Sars-Cov-2 epidemic in Italy caused one of the greatest 2020 European outbreaks, with suspension of elective bariatric/metabolic surgery (BMS). From May 2020 a significant decline of the epidemic has been observed (phase 2); National Health Service protocols permitted elective BMS' resumption. A new, more severe COVID-19 surge, the "second wave", started on October 2020 (phase 3).

AIM

The primary end point was to analyze the outcomes of any Sars-Cov-2 infection and related morbidity/mortality within 30 POD after laparoscopic BMS during phase 2-3; secondary end points were readmission and reoperation rates.

METHODS

Study design prospective, multicenter, observational.

SETTING

Eight Italian high-volume bariatric centers. All patients undergoing BMS from July 2020 through January 2021 were enrolled according to the following criteria: no Sars-Cov-2 infection; primary procedures; no concomitant procedure; age > 18 < 60 years; compensated comorbidities; informed consent including COVID-19 addendum; adherence to specific admission, in-hospital and follow-up protocols. Data were collected in a prospective database. Patients undergone BMS during July-December 2019 were considered a control group.

RESULTS

1258 patients were enrolled and compared with 1451 operated on in 2019, with no differences for demographics, complications, readmission, and reintervention rates. Eight patients (0·6%) tested positive for Sars-Cov-2 infection after discharge, as well as and 15 healthcare professionals, with no related complications or mortality.

CONCLUSIONS

Introduction of strict COVID-19 protocols concerning the protection of patients and health-care professionals guaranteed a safe resumption of elective BMS in Italy. The safety profile was, also, maintained during the second wave of outbreak, thus allowing access to a cure for the obese population.

COVID-19 Related Acro-Ischemic Neuropathic-like Painful Lesions in Pediatric Patients: A Case Series

BACKGROUND

A variety of skin manifestations have been associated with COVID-19 infection. Acral lesions on hands and feet, closely resembling chilblains, have been reported in association with COVID-19, which are nonspecific. These acro-ischemic painful lesions have been described mainly in asymptomatic and mildly symptomatic pediatric COVID-19 positive patients, without a precise pathogenetic mechanism. COVID-19-induced chilblains may portend an indolent course and a good outcome. In young patients, the IFN-1 response induces microangiopathic changes and produces a chilblain lupus erythematosus-like eruption with vasculitic neuropathic pain features.

OBJECTIVES

This paper presented a case series of pediatric patients with COVID-19-related skin lesions and neuropathic-like pain.

METHODS

Clinical outcomes were collected from 11 patients diagnosed with painful erythematous skin lesions with neuropathic-like pain and positive IgG for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

RESULTS

It is a mildly symptomatic condition not related to severe pain rates, and it is treated with paracetamol due to the transitory nature of the problem, which provides good results.

CONCLUSIONS

A particular point of interest is skin lesion manifestation as a further indirect sign of SARS-CoV-2 infection. Due to the initial manifestation of chilblains in pauci-symptomatic pediatric patients, they need to be immediately tested and isolated. Chilblains can be considered a clinical clue to suspect SARS-CoV-2 infection and help in early diagnosis, patient triage, and infection control.

Management of Hemorrhoidal Disease in Special Conditions: A Word of Caution

BACKGROUND

Hemorrhoids are a common disease that is often considered an easy problem to solve. Unfortunately, some particular clinical conditions, including Inflammatory Bowel Diseases (IBD), pregnancy, immunosuppression, coagulopathy, cirrhosis with portal hypertension, and proctitis after radiotherapy, challenge hemorrhoids management and the outcomes.

METHODS

Research and online contents related to hemorrhoids' treatment in special conditions are reviewed in order to help colorectal surgeons in daily practice.

RESULTS

There are very limited data about the outcomes of hemorrhoids treatment in these subgroups of patients. Patients in pregnancy can be effectively treated with medical therapy, reserving surgical intervention in highly selected and urgent cases. In case of thrombosed haemorrhoids, the excision allows a fast symptoms' resolution, with a low incidence of recurrence and a long remission interval. In case of immunosuppressed patients, there is no consensus for the best treatment, even in most HIV positive patients, a surgical procedure can be safely proposed when indicated. There is no sufficient data in the literature related to transplanted patients. The surgical treatment of hemorrhoids in patients with IBD, especially Crohn's Disease, can be unsafe, although there is a paucity of literature on this topic. In case of previous pelvic radiotherapy, it must always be considered that severe complications, like abscesses and fistulas with subsequent pelvic and retroperitoneal sepsis, can occur after surgical treatment of hemorrhoids, so a conservative treatment is advocated. Moreover, caution is recommended in treating patients with coagulopathy, considering possible complications (mostly bleeding) also after outpatient treatments. In case of portal hypertension and cirrhosis, a 'conservative treatment' is recommended. Bleeding hemorrhoids can be treated with hemorrhoidectomy when they do not respond to other treatments.

CONCLUSION

International literature is very scant about the treatment of patients affected by hemorrhoids in particular situations. A word of caution and concern even about the indication for minor outpatient procedures must be expressed in these patients, in order to avoid possible life-threatening complications. The first-line treatment is the conservative medical approach associated with the treatment of the primary disease.

Effects of aging and dietary supplementation with polyphenols from Pinus taeda hydrolysed lignin on quality parameters, fatty acid profile and oxidative stability of beef

Context The inclusion of Pinus taeda hydrolysed lignin (PTHL) in beef diets could improve quality and stability of meat, but effects could vary through the aging period (AP). Aim The aim was to evaluate the effects of the PTHL inclusion in the diet of finishing beef cattle on meat quality, fatty acid composition and oxidative stability at Days 1, 8, 11 and 15 of aging. Methods Forty Limousin bulls (340 ± 42 kg) were fed ad libitum on a total mixed ration (TMR). The control group received exclusively TMR for 120 days, while the experimental group received the same TMR as the control group but supplemented with PTHL (Oxifenol, I-Green, Padua, Italy; 35 g/day per head at 1–90 days and 70 g/day per head at 91–120 days). Key results Diet did not influence the chemical composition, pH, cooking loss, Warner–Bratzler shear force and hydroperoxide content. The Warner–Bratzler shear force (P &lt; 0.001) decreased, while lightness (P &lt; 0.01) and hydroperoxides (P &lt; 0.001) increased through the aging period. Thiobarbituric acid reactive substances were similar for both diets at 1 and 15 days. However, thiobarbituric acid reactive substances at 8 and 11 days were higher for control than for the PTHL diet (P = 0.023 for interaction). Protein carbonyls were higher for control than for the PTHL diet at 8 days (P = 0.003 for interaction), but similar for both diets for the other dates. Saturated, monounsaturated and polyunsaturated fatty acids varied through the AP with PTHL diet, while no changes were observed with control diet (P &lt; 0.01 for interactions). At 11 days, the n-6:n-3 ratio passed from being the minimum value with the PTHL diet to be the maximum with control diet (P &lt; 0.01 for interaction). Conclusions The effects of PTHL inclusion in bull finishing diets depends on the AP but, generally, may result in beef with meat with beneficial effects on human health. Implications Including PTHL in the diet of finishing bulls can be useful to improve meat quality, favouring the use of natural waste substances deriving from vegetal production.

P2635Prevalence of appropriate treatment in elderly heart failure patients and impact on clinical outcomes: a subgroup analysis from REPOSI registry

Introduction

Therapeutic appropriateness in chronic diseases is a key factor in obtaining better clinical outcomes over clinical follow-up, in particular in elderly patients. Data about therapeutic appropriateness in elderly patients with heart failure (HF) are scarce.

Purpose

To describe the prevalence of appropriate treatment in elderly HF patients and its impact on clinical outcomes.

Methods

REgistro POliterapie SIMI (REPOSI) cohort was used to assess study aims. REPOSI is an Italian Nationwide Registry of elderly (≥65 years) hospitalized patients in Internal Medicine and Geriatric wards. HF diagnosis was assessed at hospital admission according to ICD-9 code 428.XX. Therapeutic appropriateness was defined according to International Guidelines.

Results

Among the 7003 patients originally enrolled, a total of 1095 (15.6%) patients reported a diagnosis of HF at hospital admission. At admission, 230 (21.0%) patients were considered as treated appropriately, with 245 (22.4%) treated appropriately during hospitalization and 249 (22.7%) at discharge (p=0.0.248). Focusing on patients aged ≥80 years, prevalence of appropriate treatment was respectively: 18.9% at admission, 20.3% during hospitalization and 21.0% at discharge (p=0.266). Among the 1095 patients with HF, 815 (74.4%) had available follow-up data. Patients appropriately treated at discharge, compared to those not treated appropriately, had a lower rate of CV death (5.1% vs. 11.9%, p=0.006) and all-cause death (7.2% vs. 26.1%, p<0.001) during follow-up, with no difference in rates of rehospitalization and CV rehospitalization. A logistic regression analysis adjusted for age, sex, risk factors, comorbidities and polypharmacy, showed that appropriate therapy at discharge was inversely associated with the risk of CV death and all-cause death (Table). In patients ≥80 years, appropriate HF treatment was inversely associated with risk of all-cause death (Table).

Logistic Regression Analysis All Patients ≥80 years OR (95% CI) OR (95% CI) CV Death 0.46 (0.23–0.94) 0.59 (0.26–1.36) All-Cause Death 0.26 (0.14–0.46) 0.27 (0.14–0.53) CI = Confidence Interval; CV = Cardiovascular; OR = Odds Ratio.

Conclusions

In elderly hospitalized HF patients, prevalence of therapeutic appropriateness was consistently low at admission, during hospitalization and at discharge, particularly in patients ≥80 years. Appropriate HF therapy was inversely associated with the risk of CV death and all-cause death in all patients and with the risk of all-cause death in patients ≥80 years.

Acknowledgement/Funding

None

P4517Heart failure in elderly and very elderly hospitalized patients: an epidemiological analysis from the REPOSI registry

Introduction

Epidemiological data about heart failure (HF) in the elderly and, in particular, very elderly patients are lacking.

Purpose

To provide the epidemiological profile of elderly and very elderly HF patients in terms of prevalence, associated clinical factors, burden of multimorbidity and functional status.

Methods

Overall cohort of the REgistro POliterapie SIMI (REPOSI) was used to assess study aims. REPOSI is an Italian Nationwide Registry of elderly hospitalized patients in Internal Medicine and Geriatric wards. HF diagnosis was assessed at hospital admission according to ICD-9 code 428.XX.

Results

Among the 7003 patients originally enrolled, a total of 1095 (15.6%) patients reported a diagnosis of HF at hospital admission. Prevalence of HF progressively increased according to age strata, up to 26.8% in patients ≥90 [Figure]. A logistic regression analysis found that increasing age, body mass index and total cumulative illness rating scale (CIRS) were associated with HF (Table). Moreover, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease and polypharmacy (≥5 drugs) were associated with HF, while liver disease and neoplasm were inversely associated (Table). According to CIRS severity index and comorbidity index quartile, HF patients reported more likely values in the highest quartile than those without HF (47.4% vs. 26.6%, p<0.001 and 34.4% vs. 18.5%, p<0.001 respectively). According to short blessed test, geriatric depression scale and Barthel index, patients with HF had significantly more cognitive impairment and dementia, depression and dependent from others in daily activities than those without HF (all p<0.001).

Prevalence of HF according to Age Strata

Conclusions

In a cohort of elderly patients hospitalized in Internal Medicine and Geriatric wards HF was highly prevalent, in particular in those very elderly. HF was associated with several clinical factors, emphasizing a stronger clinical complexity. HF patients were more burdened with multimorbidity and showed an impaired functional status.

Acknowledgement/Funding

None

Multiple hormonal and metabolic deficiency syndrome in chronic heart failure: rationale, design, and demographic characteristics of the T.O.S.CA. Registry

Recent evidence supports the concept that progression of chronic heart failure (CHF) depends upon an imbalance of catabolic forces over the anabolic drive. In this regard, multiple hormonal deficiency syndrome (MHDS) significantly has impacts upon CHF progression, and is associated with a worse clinical status and increased mortality. The T.O.S.CA. (Trattamento Ormonale nello Scompenso CArdiaco; Hormone Therapy in Heart Failure) Registry (clinicaltrial.gov = NCT02335801) tests the hypothesis that anabolic deficiencies reduce survival in a large population of mild-to-moderate CHF patients. The T.O.S.CA. Registry is a prospective multicenter observational study coordinated by "Federico II" University of Naples, and involves 19 centers situated throughout Italy. Thyroid hormones, insulin-like growth factor-1, total testosterone, dehydroepiandrosterone , and insulin are measured at baseline and every year for a patient-average follow-up of 3 years. Subjects with CHF are divided into two groups: patients with one or no anabolic deficiency, and patients with two or more anabolic deficiencies at baseline. The primary endpoint is the composite of all-cause mortality and cardiovascular hospitalization. Secondary endpoints include the composite of all-cause mortality and hospitalization, the composite of cardiovascular mortality and cardiovascular hospitalization, and change of VO₂ peak. Patient enrollment started in April 2013, and was completed in July 2017. Demographics and main clinical characteristics of enrolled patients are provided in this article. Detailed cross-sectional results will be available in late 2018. The T.O.S.CA. Registry represents the most robust prospective observational trial on MHDS in the field of CHF. The study findings will advance our knowledge with regard to the intimate mechanisms of CHF progression and hopefully pave the way for future randomized clinical trials of single or multiple hormonal replacement therapies in CHF.

Genome-wide association studies to identify quantitative trait loci affecting milk production traits in water buffalo

Water buffalo is the second largest resource of milk supply around the world, and it is well known for its distinctive milk quality in terms of fat, protein, lactose, vitamin, and mineral contents. Understanding the genetic architecture of milk production traits is important for future improvement by the buffalo breeding industry. The advance of genome-wide association studies (GWAS) provides an opportunity to identify potential genetic variants affecting important economical traits. In the present study, GWAS was performed for 489 buffaloes with 1,424 lactation records using the 90K Affymetrix Buffalo SNP Array (Affymetrix/Thermo Fisher Scientific, Santa Clara, CA). Collectively, 4 candidate single nucleotide polymorphisms (SNP) in 2 genomic regions were found to associate with buffalo milk production traits. One region affecting milk fat and protein percentage was located on the equivalent of Bos taurus autosome (BTA)3, spanning 43.3 to 43.8 Mb, which harbored the most likely candidate genes MFSD14A, SLC35A3, and PALMD. The other region on the equivalent of BTA14 at 66.5 to 67.0 Mb contained candidate genes RGS22 and VPS13B and influenced buffalo total milk yield, fat yield, and protein yield. Interestingly, both of the regions were reported to have quantitative trait loci affecting milk performance in dairy cattle. Furthermore, we suggest that buffaloes with the C allele at AX-85148558 and AX-85073877 loci and the G allele at AX-85106096 locus can be selected to improve milk fat yield in this buffalo-breeding program. Meanwhile, the G allele at AX-85063131 locus can be used as the favorable allele for improving milk protein percentage. Genomic prediction showed that the reliability of genomic estimated breeding values (GEBV) of 6 milk production traits ranged from 0.06 to 0.22, and the correlation between estimated breeding values and GEBV ranged from 0.23 to 0.35. These findings provide useful information to understand the genetic basis of buffalo milk properties and may play a role in accelerating buffalo breeding programs using genomic approaches.

164 CARNITINE IMPROVES POST-THAWING SPERM MOTILITY BY INCREASING ADENOSINE TRIPHOSPHATE CONTENT IN BUFFALO (Bubalus bubalis)

Semen cryopreservation plays a critical role for a wide application of both AI and in vitro embryo production in buffalo. In this species, spermatozoa are more susceptible to hazards during freezing and thawing than cattle spermatozoa, thus resulting in lower fertilizing potential (Andrabi et al. 2008 Anim. Reprod. Sci. 104, 427–433). Carnitine is a quaternary ammonium compound with antioxidant capacities, able to reduce the availability of lipids for peroxidation by transporting fatty acids into the mitochondria for β-oxidation to generate adenosine triphosphate (ATP) energy (Tanphaichitr and Leelahagul 1993 Nutrition 9, 246–54). It is known that cryopreservation processes decreases the intracellular concentration of carnitine in spermatozoa (Reyes-Moreno et al. 2000 J. Androl. 21, 876–86). In cattle, supplementation of semen extender with carnitine improves sperm motility and DNA integrity (Bucak et al. 2010 Cryobiology 61, 248–53). The aim of this study was to evaluate whether supplementation of semen extender with carnitine would increase ATP content in buffalo sperm and affect post-thawing motility. Eight ejaculates from 4 bulls were used for the trial. Each ejaculate was split into 3 equal aliquots and diluted at 37°C with BioXcell extender containing 0 (control), 2.5, and 7.5 mM carnitine to a final concentration of 30 × 106 spermatozoa/mL. After 4 h at 4°C, the straws were frozen in an automated system. At thawing, sperm motility was evaluated by phase contrast microscopy at 40× magnification (Gillan et al. 2008 Anim. Reprod. Sci. 103, 201–204). Adenosine triphosphate content was measured using a Colourimetric ATP Assay Kit (Biovision, Milpitas, CA, USA). Briefly, Percoll-separated spermatozoa were homogenised and then deproteinized using 10-kDa spin columns. Samples were incubated at RT for 30 min and absorbance was measured at 570 nM in a microplate reader. Differences in sperm motility and ATP content among groups were analysed by ANOVA. Both concentrations of carnitine increased post-thawing sperm motility compared with the control (44.4 ± 3.5, 53.1 ± 3.9, and 52.5 ± 3.6, respectively, with 0, 2.5, and 7.5 mM carnitine; P < 0.05). Interestingly, carnitine increased ATP content of buffalo frozen–thawed sperm in a dose-dependent manner (4.1 ± 0.1, 5.3 ± 0.1, and 8.2 ± 0.4 nM × 108 sperm, respectively, with 0, 2.5, and 7.5 mM carnitine; P < 0.01). In conclusion, the enrichment of semen extender with carnitine improved post-thawing motility of buffalo sperm by boosting mitochondrial ATP production, hence providing energy for use by spermatozoa.

51 CASPASE-3 INHIBITOR Z-VAD-FMK ENHANCES CRYOTOLERANCE OF IN VITRO-PRODUCED BOVINE PRE-IMPLANTATION EMBRYOS

In vitro-produced (IVP) bovine embryos are still less viable and resistant to cryopreservation than their in vivo counterparts. Cryopreservation induces cell degeneration through the apoptotic pathway in bovine oocytes and embryos (Men et al. 2003 Cryobiology 47, 73–81). Apoptosis can be prevented by inhibition of caspase activity, leading to improved cryosurvival in mammalian cells (Stroh et al. 2002 FASEB J. 16, 1651–3). Interestingly, cryotolerance of porcine embryos was improved by inhibiting apoptosis using a caspase inhibitor, benzyloxycarbonyl-Val-Ala-Asp-fluoromethyl ketone (Z-VAD-FMK) during vitrification and subsequent culture (Men et al. 2006 Theriogenology 66, 2008–16). Aim of this work was to evaluate whether cryotolerance of bovine IVP embryos may be improved by using Z-VAD-FMK during cryopreservation and post-warming in vitro culture. Abattoir-derived bovine oocytes (n = 753, over 4 replicates) were in vitro matured and fertilized according to standard procedures (Rubessa et al. 2011 Theriogenology 76, 1347–55). Twenty hours after IVF, presumptive zygotes were cultured in SOF medium at 39°C with 5% CO2, 7% O2, and 88% N2. On Day 7, embryo yields were assessed and blastocysts (except the hatched blastocysts) were randomly divided in 2 groups: vitrification and post-warming culture in presence (n = 60) or absence (n = 54) of 20 µM Z-VAD-FMK. Vitrification was carried out by Cryotop in 16.5% ethylene glycol, 16.5% DMSO, and 0.5 M sucrose (Rubessa et al. 2011 Theriogenology 76, 1347–55). Blastocysts were warmed in decreasing sucrose solutions (0.25 M for 1 min and 0.15 M for 5 min) and cultured for 2 days. Resistance to cryopreservation was evaluated by assessing the survival rate, based on morphological criteria and hatching rate after 48 h culture. Furthermore, TUNEL staining was used to evaluate the total cell (TC) number and the apoptotic rate of vitrified blastocysts after 48-h post-warming culture. Differences between groups in survival and hatching rates after 48-h post-warming culture were analysed by Chi-squared test, whereas differences in TC number and in number and percentage of apoptotic cells were analysed by Student’s t-test. Inhibition of caspase activity induced by Z-VAD-FMK increased embryo cryotolerance, as indicated by higher survival (92.6 v. 55.0%; P < 0.01) and hatching rates (40.7 v. 23.3%; P < 0.05) after 48 h of post-warming culture. Furthermore, Z-VAD-FMK decreased both the average number (7.1 ± 0.6 v. 4.2 ± 0.3; P < 0.01) and the percentage (6.3 ± 0.6 v. 3.0 ± 0.2; P < 0.01) of apoptotic cells in blastocysts. No differences were recorded in TC number between groups (on average, 128.90 ± 1.6). These results suggest that addition of 20 µM Z-VAD-FMK during vitrification/warming and post-warming culture significantly inhibits apoptosis (DNA fragmentation) and improves the cryotolerance of IVP bovine embryos.

Crocetin improves the quality of in vitro-produced bovine embryos: Implications for blastocyst development, cryotolerance, and apoptosis

The aim of this work was to assess the effect of supplementation of bovine culture medium with the natural antioxidant crocetin on in vitro blastocyst development and quality. This was evaluated as cryotolerance, apoptosis index, and total cells number and allocation. Abattoir-derived oocytes were matured and fertilized in vitro according to standard procedure. Twenty hours after IVF, presumptive zygotes were cultured in synthetic oviduct fluid medium, supplemented with 0, 1, 2.5, and 5 μM crocetin (experiment 1) at 39 °C under humidified air with 5% CO2, 7% O2, and 88% N2. On Day 7, embryo yields were assessed and the blastocysts were vitrified by Cryotop method in 16.5% ethylene glycol, 16.5% DMSO, and 0.5 M sucrose. Finally, blastocysts produced on Day 8 in the absence (control) and presence of 1 μM crocetin were used for terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling and differential staining to evaluate, respectively, the apoptotic rate and the allocation of cells into inner cell mass (ICM) and trophectoderm (TE) lineages (experiment 2). Embryo development was higher in the 1 μM crocetin group compared to the control, both in terms of total embryo output (37.7 ± 4.2%, 52.9 ± 6.3%, 40.9 ± 7.6%, and 42.4 ± 8.7%, respectively, with 0, 1, 2.5, and 5 μM; P < 0.01) and grade 1 and 2 blastocysts (33.6 ± 4.9%, 46.1 ± 7.3%, 37.8 ± 7.9%, and 39.4 ± 7.9%, respectively, with 0, 1, 2.5, and 5 μM; P < 0.05). Moreover, the percentage of fast-developing embryos increased in 1 μM crocetin group compared to the control (23.4 ± 4.7%, 32.7 ± 6.6%, 27.2 ± 6.6%, and 30.1 ± 7.2%, respectively, with 0, 1, 2.5, and 5 μM; P < 0.05). In addition, the enrichment of culture medium with 1 μM crocetin improved embryo cryotolerance compared to the control, as indicated by higher hatching rates recorded after 48 hours postwarming culture (46.5% vs. 60.4%; P < 0.05). Furthermore, 1 μM crocetin decreased both the average number (9.9 ± 0.4 vs. 7.1 ± 0.3) and the percentage of apoptotic cells (7.1 ± 0.4 vs. 4.2 ± 0.2) in blastocysts compared to the control (P < 0.01). However, no differences were recorded in the average number of ICM, TE, and total cells between 1 μM crocetin and control groups. In conclusion, the enrichment of bovine culture medium with 1 μM crocetin increased both blastocyst yield and quality, as indicated by the improved chronology of embryo development, increased resistance to cryopreservation, and reduced incidence of apoptosis.

Effect of Relaxin on Fertility Parameters of Frozen-Thawed Buffalo (Bubalus bubalis) Sperm

The aim of this work was to evaluate the effect of relaxin on fertility parameters of buffalo frozen/thawed sperm. Sperm were incubated in the absence of capacitating agents (negative control), with a known capacitating agent such as heparin (positive control) and with 50 and 100 ng/ml relaxin for 2 and 4 h. Sperm viability, motility, capacitation and the effect of relaxin on the fertilizing ability after heterologous IVF were evaluated. Although viability was not affected, relaxin increased (p < 0.05) sperm motility compared to the negative and positive controls both after 2 h (60.0 ± 2.0, 60.0 ± 3.1, 68.3 ± 1.7 and 69.4 ± 2.7, respectively, in negative control, positive control, 50 and 100 ng/ml relaxin) and 4 h (55.0 ± 2.5, 53.3 ± 3.0, 62.2 ± 3.0 and 65.0 ± 3.2, respectively, in negative control, positive control, 50 and 100 ng/ml relaxin) incubation. When sperm were incubated with both 100 ng/ml relaxin and heparin, a decrease (p < 0.01) of pattern A, that is low capacitation level, was observed compared to the negative control both after 2 h (54.4, 34.3 and 36.4%, respectively, in negative control, positive control and 100 ng/ml relaxin) and 4 h (51.9, 35.0 and 34.3%, respectively, in negative control, positive control and 100 ng/ml relaxin). Moreover, an increase (p < 0.01) of pattern EA, that is high capacitation level, was recorded with 100 ng/ml relaxin and heparin compared to the negative control both after 2 h (44.1, 59.3 and 57.7%, respectively, in negative control, positive control and 100 ng/ml relaxin) and after 4 h (43.0, 54.4 and 56.0%, respectively, in negative control, positive control and 100 ng/ml relaxin). Finally, relaxin increased (p < 0.01) cleavage rate compared to the negative control (57.1 ± 4.4, 72.5 ± 6.0, 71.4 ± 5.5 and 73.6 ± 2.9, respectively, in negative control, positive control, 50 and 100 ng/ml relaxin). In conclusion, relaxin has a beneficial effect on motility, capacitation and fertilizing ability of frozen-thawed buffalo sperm.

The Tosca Registry: An Ongoing, Observational, Multicenter Registry for Chronic Heart Failure

The ageing of the population in western countries, the continuous increase of the prevalence of chronic diseases, the frequent coexistence of several morbid conditions (comorbidity) requires health professionals and Institutions to face difficult challenges, including increasing costs, need for more effective and sustainable therapies, and organizational issues. The European Innovation Partnership on Active and Healthy Ageing aims at enabling European citizens to lead healthy, active and independent lives while ageing. We herein discuss some key concepts bearing a special significance in the light of the Partnership aims, and present research and educational projects active in our local environment. Among these, the multicentre project TOSCA (Trattamento Ormonale nello Scompenso CArdiaco) that, although primarily focused on the understanding of the interactions between hormones and chronic heart failure (CHF), is also aimed at developing more effective models of clinical care. We provide the scientific background and current stage of the project. In the context of a growing complexity of the patients' clinical management, the polipharmacy is a new arising challenge for clinicians, bearing direct economic, organizational and clinical implications. A better understanding, characterization and management of this issue represent an additional target of the TOSCA network.

88 ENRICHMENT OF CULTURE MEDIUM WITH CROCETIN IMPROVES IN VITRO EMBRYO DEVELOPMENT IN CATTLE

The high incidence of developmental failure of bovine in vitro-produced embryos is due to suboptimal culture conditions that induce oxidative stress. Indeed, increased oxidative stress is one of the main factors affecting in vitro mammalian embryo development, decreasing the viability of IVP embryos. It is known that saffron has a powerful antioxidant capacity, mainly due to its active components crocin and crocetin. The aim of this study was to evaluate whether enriching the in vitro culture medium with crocetin improves in vitro embryo production efficiency in cattle. The range of concentrations of crocetin was chosen after a preliminary dose response trial (322 total presumptive zygotes were cultured with 0, 1, 10, and 50 μM, over 2 replicates) that showed beneficial and deleterious effects, respectively, with the lowest and highest concentration compared with the control (36.6 ± 5.6, 57.4 ± 4.5, 46.4 ± 4.4, and 6.8 ± 3.7% blastocyst rates, respectively, with 0, 1, 10, and 50 μM; P < 0.01). Therefore, the range of concentrations to test was reduced. Abattoir-derived bovine oocytes (n = 832, over 4 replicates) were in vitro matured and fertilized according to standard procedures (Rubessa et al. 2011 Theriogenology 76, 1347–1355). Twenty hours after IVF, presumptive zygotes were cultured in SOF medium with 0 (control; n = 208), 1 μM (n = 208), 2.5 μM (n = 208), and 5 μM (n = 208), at 39°C under humidified air with 5% CO2, 7% O2, and 88% N2. The embryos obtained by the end of culture (i.e. on Day 7 post-IVF) were scored for quality, based on morphological criteria, and for developmental stage, as previously described (Robertson and Nelson 2010, Manual of the IETS, 86–105). The percentages of total transferable embryos and grade 1 and 2 blastocysts were recorded. As the chronology of development is a reliable parameter to assess quality, the percentage of fast-developing embryos (i.e. hatched and expanded blastocysts) was also compared among groups. Differences among groups were analysed by ANOVA, and Tukey method was used as a post-hoc test. Data are presented as means ± s.d. The supplementation of crocetin during culture did not affect cleavage rate (74.9 ± 6.3, 76.4 ± 8.4, 81.4 ± 4.3, and 76.4 ± 8.4%, respectively, with 0, 1, 2.5, and 5 μM). However, post-fertilization embryo development improved with 1 µM crocetin compared with the control, both in terms of total embryo output (43.8 ± 4.4, 61.1 ± 5.2, 50.4 ± 6.7, and 53.3 ± 7.3%, respectively, with 0, 1, 2.5, and 5 μM; P < 0.01) and grade 1 and 2 blastocysts (41.0 ± 3.6, 54.3 ± 5.4, 46.2 ± 6.7, and 49.4 ± 6.5%, respectively, with 0, 1, 2.5, and 5 μM; P < 0.05), whereas no differences were observed among the other groups. Moreover, the percentage of fast developing embryos increased with 1 µM (P < 0.05) crocetin compared with the control, with no other differences recorded among groups (17.7 ± 5.8, 34.7 ± 5.7, 24.9 ± 5.1, and 28.7 ± 7.8%, respectively, with 0, 1, 2.5, and 5 μM). In conclusion, these results demonstrated a beneficial effect of low concentrations of crocetin (1 μM) during culture both on blastocyst yield and quality, as indicated by the improved chronology of embryo development.

40 CHOLESTEROL SUPPLEMENTATION REDUCES CRYOCAPACITATION DAMAGES IN BUFFALO (BUBALUS BUBALIS) SPERM

Buffalo sperm are more sensitive to cryopreservation and thawing-induced damages than cattle sperm, thus resulting in lower fertilizing ability. Cryopreservation induces considerable capacitation-like changes in buffalo sperm (Elkhawagah et al. 2014 J. Buffalo Sci. 3, 3–11). It is known that specific lipid mixtures, including cholesterol, stabilise and protect spermatozoa from freeze-thaw damage (Rajoriya et al. 2014 Vet. World. 7, 702–706). Therefore, the aim of this study was to investigate the effect of cholesterol loaded cyclodextrins (CLC) before cryopreservation on the capacitation status of buffalo frozen sperm. Four ejaculates from 4 bulls were selected, split in 3 aliquots, and diluted at 37°C with BULLXcell extender, containing 0 (control), 1.5, and 3 mg mL–1 CLC, to a final concentration of 30 × 106 sperm mL–1. Cyclodextrin was loaded with cholesterol as described earlier (Purdy and Graham 2004 Cryobiology 48(1), 36–45). The aliquots were frozen according to standard procedures. At thawing, sperm motility was evaluated by phase contrast microscopy, and viability and capacitation status were evaluated by Hoechst 33258/CTC. Briefly, Percoll separated spermatozoa were incubated with 1% (wt/vol) Hoechst 33258 in a protein-free medium. After centrifugation (900 × g, 5 min), the pellet was resuspended in CTC staining solution (750 mM CTC, 5 mM cysteine in 130 mM NaCl, and 20 mM Tris acid, pH 7.8), fixed with glutaraldehyde (12.5% vol/vol), and placed on a slide. At least 100 sperm per slide were analysed and classified into 1 of 3 CTC staining patterns: pattern F, with fluorescence over the entire sperm head (noncapacitated); pattern B, with a fluorescence-free band in the postacrosomal region (capacitated); pattern AR, with no acrosome and a thin band of fluorescence along the equatorial segment (acrosome reacted). Data were analysed by ANOVA. No differences among control, 1.5, and 3 mg mL–1 CLC-treated groups were recorded in both sperm motility (66.5 ± 5.6, 68.8 ± 4.8, and 68.8 ± 4.8, respectively) and viability (86.5 ± 1.9, 87.6 ± 1.5, 88.4 ± 2.3, respectively). The most interesting result arising was the strong reduction of sperm cryocapacitation observed when the extender was supplemented with CLC, as shown by the increased percentage of sperm displaying pattern F (28.6 ± 3.3, 61.5 ± 1.7, and 47.6 ± 4.3 in control, 1.5, and 3 mg mL–1 CLC groups, respectively; P < 0.01) and the decreased percentage of sperm displaying pattern B (69.6 ± 3.4, 37.8 ± 1.5, and 51.3 ± 4.7 in control, 1.5, and 3 mg mL–1 CLC groups, respectively; P < 0.01) compared with the control. The maximum beneficial effect on semen cryopreservation was recorded with the dose of 1.5 mg mL–1 CLC. However, no differences were detected in pattern AR that remained low in all groups (1.8 ± 0.7, 0.8 ± 0.4, and 1.1 ± 0.6 in the control, 1.5, and 3 mg mL–1 CLC groups, respectively). In conclusion, it was demonstrated that treating buffalo sperm with cholesterol before cryopreservation strongly decreases cryocapacitation damages, likely by stabilising sperm membrane, hence improving sperm quality.

263 ADDING RESVERATROL TO THE EXTENDER AFFECTS PROTEIN TYROSINE PHOSPHORYLATION IN BUFFALO SPERM

Cryopreservation induces remarkable capacitation- like changes in buffalo sperm (Kadirvel et al. 2011 Theriogenology 75, 1630–1639; Elkhawagah et al. 2014 J. Buffalo Sci. 3, 3–11). The aim of this study was to evaluate the effect of resveratrol, a natural phytoalexin with antioxidant properties, on capacitation status of frozen-thawed buffalo sperm, assessed by protein tyrosine phosphorylation assay. Three ejaculates from four bulls were used for the trial. Each ejaculate was split into two equal aliquots and diluted at 37°C with BioXcell extender containing no supplement (control) or 50 µM resveratrol, to a final concentration of 30 × 106 spermatozoa per mL. After 4 h at 4°C, straws were frozen in an automated system. Immediately after thawing, sperm motility was evaluated by phase-contrast microscopy, sperm viability by Trypan Blue/Giemsa staining and localization of phosphotyrosine proteins by indirect immunofluorescence, as described Kadirvel et al. (2011 Theriogenology 75, 1630–1639). Briefly, after thawing, semen was centrifuged (300 × g, 10 min), fixed in 2% formaldehyde for 1 h at 4°C, and sperm pellets were incubated overnight at 4°C in modified phosphate buffer saline containing 2% BSA. After centrifugation, sperm pellets were resuspended, diluted 1 : 10 in mPBS, smeared onto slides, air-dried, and permeabilized with absolute ethanol for 5 min. Then, spermatozoa were incubated with rabbit anti-phosphotyrosine primary antibody for 1 h at room temperature in a humid chamber. Slides were incubated with secondary antibody, FITC conjugated goat anti-rabbit IgG, for 1 h in a dark humid chamber at room temperature and mounted with 90% glycerol. A total of 100 spermatozoa were screened per slide and classified as described (Luño et al. 2013 Reproduction 146, 315–324): pattern A: uniform fluorescence over the entire acrosome (low capacitation level); pattern E: signal in the equatorial segment (medium capacitation level); and pattern EA: fluorescence at both equatorial and acrosomal areas (high capacitation level). Data were analysed by chi-square. There were no significant differences between control and treated groups for sperm motility (50.0 and 55.0%, respectively) or viability (77.4 and 72.9%). The percentage of sperm cells that did not exhibit fluorescence was very low (2.4 and 4.3% in the control and resveratrol groups, respectively). In resveratrol-treated group, pattern E was higher than the control (4.9 and 2.0%; P < 0.01). More interestingly, in the resveratrol-treated group, an increased percentage of sperm with pattern A (79.6 and 52.5%) and a decreased percentage of sperm with pattern EA (12.2 and 43.1%) were recorded. Based on decreased sperm with a high capacitation level (EA pattern) and increased sperm with low capacitation level (A pattern) at thawing, we concluded that adding resveratrol to semen extender before cryopreservation of buffalo was beneficial.

264 EFFECT OF SEASON ON CRYOCAPACITATION OF BUFFALO (BUBALUS BUBALIS) SEMEN

Buffalo are short-day breeders; at our latitudes, reproductive activity improves during autumn. Although extensive studies have been conducted on the female, seasonal variations were also reported on post-thaw motility and membrane integrity of buffalo sperm (Andrabi 2009 Reprod. Domest. Anim. 44, 552–569). It was reported that cryopreservation induces capacitation-like changes in buffalo spermatozoa, assessed by both chlortetracycline (CTC) fluorescent and protein tyrosine phosphorylation assays (Kadirvel et al. 2011 Theriogenology 75, 1630–1639; Elkhawagah et al. 2014 J. Buffalo Sci. 3, 3–11). The aim of this study was to evaluate the effect of season on cryocapacitation of buffalo semen. At least two ejaculates were collected from 4 bulls during 2 seasons with different daylength: spring (low season) and autumn (peak season). Each ejaculate was diluted at 37°C with BioXcell extender to a final concentration of 30 × 106 spermatozoa per mL. After 4 h at 4°C, straws were frozen in an automated system. Immediately after thawing, sperm motility was evaluated by phase-contrast microscopy and viability, as well as capacitation status, were assessed by CTC fluorescent staining, as reported (Kadirvel et al. 2011 Theriogenology 75, 1630–1639). Briefly, sperm suspensions were first stained with 0.1 µg mL–1 Hoechst 33258 for 2 min. Then, equal volumes of sperm suspension and CTC solution (750 mM CTC, 5 mM cysteine in 130 mM NaCl, and 20 mM Tris-HCl) were mixed at room temperature, and glutaraldehyde (12.5%) was added. Sperm suspensions were mounted on slides and stored at 4°C overnight (in the dark). Each sample was assessed twice under a microscope equipped with phase contrast and epifluorescent optics. At least 100 spermatozoa per slide were evaluated and classified into 3 CTC staining patterns: 1) uniform bright fluorescence over the entire head (uncapacitated spermatozoa, pattern F); 2) fluorescence-free band in the post-acrosomal region (capacitated spermatozoa, pattern B); and 3) dull fluorescence over the entire head, except for a thin punctuate band of fluorescence along the equatorial segment (acrosome-reacted spermatozoa, pattern AR). Data were analysed by chi-square. There were no differences in sperm viability between seasons (78.4 and 76.4%, respectively, in autumn and spring). However, post-thaw motility increased (P < 0.05) in autumn (60.0%) compared with spring (50.0%). The percentage of sperm displaying CTC pattern F increased in autumn compared with spring (40.5 and 27.3%, respectively; P < 0.01), whereas the percentage of sperm with both pattern B (57.9 and 66.6%, respectively; P < 0.01) and AR (1.6 and 6.1%, respectively; P < 0.01) decreased. The number of bulls and ejaculates used in this study was too low to draw definitive conclusions. However, these findings suggested that capacitation-like changes after sperm cryopreservation may be reduced during the favourable season in buffalo.

135 EFFECT OF L-ERGOTHIONEINE SUPPLEMENTATION DURING CULTURE ON IN VITRO EMBRYO DEVELOPMENT IN BUFFALO (BUBALUS BUBALIS)

It is known that in vitro mammalian embryo development is negatively affected by the increased oxidative stress occurring under culture conditions. The oxidative damage of cell components via reactive oxygen species interferes with proper cell function. Buffalo embryos are particularly sensitive to oxidative stress because of their high lipid content (Boni et al. 1992 Acta Med. Vet. 38, 153–161). l-Ergothioneine (LE) is a powerful scavenger of hydroxyl radicals (OH) and an inhibitor of iron or copper ion-dependent generation of OH from hydrogen peroxide (H2O2). The aim of this study was to evaluate whether enriching the in vitro-culture medium with LE improves in vitro embryo production efficiency in buffalo. Abattoir-derived buffalo oocytes (n = 854, over 6 replicates) were in vitro matured and fertilized according to standard procedures (Gasparrini et al. 2006 Theriogenology 65, 275–287). Twenty hours after IVF presumptive zygotes were cultured in SOFaa supplemented by 8 mg mL–1 BSA in a controlled gas atmosphere consisting of 5% CO2, 7% O2, 88% N2, in humidified air, at 38.5°C with 0 (control; n = 214), 0.05 mM LE (n = 217), 0.1 mM LE (n = 204), and 1 mM LE (n = 219). Cleavage rate was assessed at the time of change of culture (Day 5) and the cleaved elements were cultured for a further 2 days. The embryos obtained by the end of culture, i.e. on Day 7 post-IVF, were scored for quality, based on morphological criteria, and for developmental stage, as previously described (Robertson, Nelson 2010 Manual of the International Embryo Transfer Society 86–105). The percentages of total transferable embryos and Grade 1 and 2 blastocysts in relation to cleaved oocytes were recorded. Because the chronology of development is known to be one of the most reliable parameters for assessing quality, the percentage of fast-developing embryos, i.e. hatched and expanded blastocysts, was also recorded. Data were analysed by Chi-squared test. Cleavage rate was not affected by the treatment (71.4, 66.8, 68.7, and 63.0%, respectively, with 0, 0.05, 0.1, and 1 mM LE). The total embryo output increased in groups supplemented with 0.05 and 0.1 mM LE (31.3, 42.2, 43.8, and 21.7%, respectively, with 0, 0.05, 0.1, and 1 mM LE; P < 0.05). However, the enrichment of in vitro culture with 0.1 mM LE also increased the percentage of Grade 1 and 2 blastocysts compared with the control and to 1 mM LE (21.6, 30.9, 33.9, and 21.7%, respectively, with 0, 0.05, 0.1, and 1 mM LE; P < 0.05). Likewise, 0.1 mM LE gave higher percentages of fast developing embryos than the control and 1 mM LE groups. In conclusion, these results demonstrated a beneficial effect of LE during culture on buffalo in vitro embryo development. The dose response trial indicated that the optimal concentration is 0.1 mM that also influenced the chronology of development and hence embryo viability.

Effect of resveratrol supplementation during culture on the quality and cryotolerance of bovine in vitro produced embryos

The aim of the study was to evaluate whether resveratrol supplementation of bovine culture medium improves in vitro blastocyst development, embryo cryotolerance and cell numbers. Abattoir-derived oocytes were matured and fertilized in vitro according to standard procedure. Twenty hours after IVF, zygotes were cultured in SOF medium, supplemented with 0 (control, n=439), 0.25μM (n=422), 0.5μM (n=447) and 1μM resveratrol (n=416). On Day 7 (IVF=Day 0) blastocysts were vitrified by cryotop in 16.5% ethylene glycol, 16.5% dimethyl sulfoxide and 0.5M sucrose. Development rate, i.e. the percentage of embryos resuming development to reach a more advanced stage, and hatching rate were evaluated after 24 and 48h culture. Blastocysts cultured with (0.5μM) and without resveratrol underwent differential staining to count inner cell mass (ICM) and trophectoderm (TE) cells. Resveratrol during culture did not increase blastocyst yields (57.1, 57.7, 59.2 and 46.6%, respectively in 0, 0.25, 0.5 and 1μM resveratrol). However, 0.5μM resveratrol improved embryo cryotolerance compared to the control, as indicated by higher development rates (67.3% vs 50.3%, respectively; P<0.01) and hatching rates (58.9% vs 30.9%, respectively; P<0.01) recorded after 48h post-warming culture. Blastocysts produced in the control and in 0.5μM resveratrol groups had similar numbers of ICM (34.1 and 36.4, respectively), TE (88.1 and 85.3, respectively) and total (122.2 and 121.7, respectively) cells. In conclusion, low levels of resveratrol during in vitro culture improve the quality of IVP bovine embryos, as indicated by their increased resistance to cryopreservation.

145 EFFECT OF RELAXIN ON FERTILIZING ABILITY OF BUFFALO SPERM

The aim of this work was to evaluate the effect of relaxin, known to improve fertility parameters of frozen-thawed sperm in other species (Miah et al. 2006 J. Reprod. Dev. 52, 773–779; Miah et al. 2007 Anim. Sci. J. 78, 495–502), on buffalo sperm motility, capacitation, and fertilizing capability. Frozen-thawed sperm from 2 bulls (4 replicates each) were separated by Percoll, diluted to a 20 × 106 mL–1 concentration and incubated in TALP medium in the absence of capacitating agents (negative control), in the presence of 10 μg mL–1 of heparin (positive control) and 100 ng mL–1 of relaxin for 2 h. Following incubation, sperm were exposed for 15 min to 60 mg mL–1 of lysophosphatidylcholine, a fusogenic agent known to induce the acrosome reaction only on capacitated sperm. To evaluate acrosome-reacted (AR) live sperm, cells were fixed and stained with Trypan blue-Giemsa (Kovacs and Foote 1992 Biotech. Histochem. 67, 119–124) and evaluated (800 sperm counted/group). Sperm motility was examined by a phase contrast microscope, whereas the fertilizing capability was evaluated by heterologous IVF. Abattoir-derived bovine oocytes (n = 258, 86 per group) were in vitro matured and fertilized according to standard procedures (Rubessa et al. 2011 Theriogenology 76, 1347–1355) with buffalo sperm in the absence of capacitating agents and in the presence of 10 μg mL–1 of heparin and 100 ng mL–1 of relaxin. Twenty hours after IVF, presumptive zygotes were denuded and cultured in SOF for 24 h, when cleavage rate was evaluated and confirmed by fixation with absolute ethanol overnight and staining with 2.5 μg mL–1 of Hoechst 33342 after zona removal by pronase (2 mg mL–1) digestion. The differences in the percentages of AR sperm and cleavage among groups were analysed by a chi square test and those in sperm motility by Student's t-test. Acrosomal loss was observed in 10.8% of the sperm after thawing, which may indicate freezing-induced capacitation, and, hence, this value was detracted from the percentages of AR recorded following incubation. After 2 h of incubation, 100 ng mL–1 of relaxin significantly (P < 0.05) increased the percentages of live AR sperm (P < 0.05) compared with the negative control (31.3 ± 2.2 and 25.8 ± 2.8, respectively), with intermediate results in the positive control (27.0 ± 2.2). Motility was significantly improved (P < 0.05) when sperm were exposed to 100 ng mL–1 of relaxin compared with both the negative and positive control (73.7 ± 2.4, 60.0 ± 4.1, and 60.0 ± 7.1, respectively). A significant (P < 0.05) improvement of cleavage rate was recorded both in the positive control (71.5 ± 4.8) and in the group treated with 100 ng mL–1 of relaxin (70.7 ± 0.5) compared with negative control (52.1 ± 1.5). In conclusion, these preliminary results indicate that relaxin at the concentration of 100 ng mL–1 improves sperm motility, capacitation, and the IVF capability of buffalo sperm.

144 INFLUENCE OF REPEATED OVUM PICKUP ON BUFFALO WELFARE

The aim of this work was to evaluate the effect of repeated ovum pickup (OPU) on buffalo welfare. The OPU was carried out as previously described (Neglia et al. 2003 Theriogenology 59, 1123–1130) twice per week on 11 buffalo cows at 121 ± 15 days in milk for 2 months (end of October–end of December). Blood samples were collected before the beginning of the trial (time 0), after 1 month (time 1), and after 2 months (time 2) in animals that had undergone OPU and in control animals (n = 10) of the same herd. The following parameters of clinical immunology were evaluated on sera: haemolytic complement (Arya et al. 1992 Vet. Immunol. Immunopathol. 30, 411–418), lysozyme, bactericidal capacity (Amadori et al. 1997 J. Vet. Med. 44, 321–327), and haptoglobin (Phase Haptoglobin Colourimetric Assay kit, Tridelta Development Ltd., Maynooth, County Kildare, Ireland). Data, here reported as means ± s.e.m., were analysed by ANOVA taking into account treatment, time, and the interaction. The number of aspirated follicles and collected oocytes per buffalo per session was 6.6 ± 0.2 and 3.6 ± 0.2, respectively. Interestingly, the OPU treatment did not affect haptoglobin (a reliable marker of acute stress), lysozyme, complement, and bactericidal capacity, whereas the time influenced (P < 0.05) only the complement. In animals that had undergone OPU, no differences among times 0, 1, and 2 in lysozyme (3.9 ± 0.3, 4.0 ± 0.6, and 3.6 ± 0.4 μg mL–1, respectively), bactericidal capacity (92.8 ± 0.8, 92.1 ± 0.8, and 92.2 ± 0.9%, respectively), and haptoglobin (1.8 ± 0.4, 1.4 ± 0.2, and 1.9 ± 0.6 mg mL–1, respectively) were found. Likewise, similar values were recorded at times 0, 1, and 2 in the control group in lysozyme (3.2 ± 0.3, 2.9 ± 0.3, and 3.1 ± 0.8 μg mL–1, respectively), bactericidal capacity (94.2 ± 0.6, 93.0 ± 1.1, and 89.2 ± 3.2%, respectively), and haptoglobin (0.7 ± 0.5, 1.3 ± 0.5, and 1.4 ± 0.4 mg mL–1, respectively). A significant decrease (P < 0.05) of complement (UE/150 mL) in OPU-treated animals was recorded at times 1 (33.6 ± 1.4) and 2 (35.9 ± 2.9) compared to time 0 (67.3 ± 3.3). However, the same pattern was observed in the control (62.8 ± 4.0, 31.3 ± 0.3, and 31.0 ± 0.8, respectively at times 0, 1, and 2; P < 0.05). Therefore, it is not possible to rule out that the decrease was due to other factors, such as the cold winter temperatures incoming, as previously reported. Furthermore, the values recorded at times 1 and 2 fall in the physiological ranges of the species (De Carlo et al. 2011 Joint Annual Meeting, Riccione, Italy). During the whole period of the experiment (and few weeks after), there were neither signs of behavioural modifications nor clinical signs of any disease. Furthermore, there were no differences in average daily milk production between treated and control buffaloes both at the start (9.1 ± 0.8 v. 9.4 ± 0.8) and at the end of the trial (7.6 ± 0.6 v. 6.5 ± 0.7), and all the animals that had undergone OPU conceived within 113.0 ± 25.4 days from the last OPU session. These preliminary results indicate that a regimen of OPU carried out twice per week for 2 months do not affect the welfare of buffaloes.

Influence of preservation versus division of ilioinguinal, iliohypogastric, and genital nerves during open mesh herniorrhaphy: prospective multicentric study of chronic pain

OBJECTIVE

To evaluate whether the various surgical treatment reserved for ilioinguinal, iliohypogastric, and genital branch of the genitofemoral nerves, during open hernia mesh repair, is effective in reducing chronic postoperative pain.

BACKGROUND

Interest in chronic groin pain following herniorrhaphy has escalated, in recent years, due both to treatment and legal implications. However, much debate still exists concerning which treatment to reserve for the 3 inguinal sensory nerves.

METHODS

A multicentric prospective study involving 11 Italian institutions led to the recruitment of 973 cases of hernioplasty. All surgeons were asked to report whether or not each nerve had been identified and preserved or divided. The main endpoint of the study was the evaluation of moderate to severe chronic pain at 6 months and 1 year.

RESULTS

Overall, the presence of groin pain at the 6-month and 1-year follow-up was 9.7% and 4.1%, respectively. Pain was mild in 7.9% and moderate to severe in 2.1%, at 6 months, and mild in 3.6% and moderate to severe in 0.5%, at 1 year. Univariate and multivariate analysis showed that lack of identification of nerves is significantly correlated with presence of chronic pain, the risk of developing inguinal pain increasing with the number of nerves not detected. Likewise, division of nerves was clearly correlated with presence of chronic pain.

CONCLUSIONS

The present findings indicate that identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain and that, in the majority of patients with chronic pain at 6 months, the pain at 1 year is resolved only with conservative or medical treatment.

[Chronic pain after inguinal hernia mesh repair: possible role of surgical manipulation of the inguinal nerves. A prospective multicentre study of 973 cases]

The aim of the study was to evaluate whether the surgical treatment reserved for the ilioinguinal, iliohypogastric and genital branches of the genitofemoral nerves, during open hernia mesh repair, is effective in reducing chronic post-operative pain. A multicentre prospective study involving 11 Italian Institutions led to the recruitment of 973 cases of hernioplasty. All surgeons were asked to report whether or not each nerve had been identified and preserved or divided. The main endpoint of the study was the evaluation of moderate-severe chronic pain at 6 months and 1 year. Overall, presence of groin pain at 6 months and 1 year follow-up was 9.7% and 4.1%, respectively. Pain was mild in 7.9% and moderate-to-severe in 2.1% at 6 months, and mild in 3.6% and moderate-to-severe in 0.5% at 1 year. Univariate and multivariate analysis showed that lack of identification of nerves is significantly correlated with presence of chronic pain, the risk of developing inguinal pain increasing with the number of nerves not detected. Likewise, division of nerves was clearly correlated with presence of chronic pain. The present findings indicate that identification and preservation of nerves during open inguinal hernia repair reduce chronic incapacitating groin pain.

Infantile hypertrophic pyloric stenosis and asymptomatic joint hypermobility

A significant association with asymptomatic joint hypermobility was observed in 37 children with a history of infantile hypertrophic pyloric stenosis (P =.0016) and their parents (mothers, P <.0001; fathers, P <.05). The subjects with articular hypermobility showed an increased frequency of absent mandibular frenulum, thereby suggesting the presence of a previously unrecognized, systemic abnormality of the extracellular matrix.

[Personal experience with computerized tomography of shock and death in emergency situations]

PURPOSE

The wide availability of CT machines in hospitals specialising in emergency care has made it possible to observe CT features of severe shock and death of the patient during the CT examination. Unique radiological signs can be evaluated that testify to the state of shock or indicate arrest of the contrast medium in the cardiovascular system and parenchymatous organs, with different hemodynamic features from those found in living persons. This paper aims to report our personal experience with the role of CT in documenting states of shock or death. Our series, which is relatively large considering the infrequency of cases, seems to be of interest as it is one of the few to describe these rare CT findings, which have ethical implications for all healthcare providers and the field of diagnostic imaging.

MATERIAL AND METHODS

In the last 5 years we have observed 16 cases (12 males and 4 females; mean age 41 years; range 17-79) of death during CT examinations. Of these, 9 were severely polytraumatized patients, 2 had ruptured aneurysms of the abdominal aorta, and one had a cardiac arrest due to cardiac infarction. Death occurred in 3 patients with head trauma, in whom the CT examination had shown signs of inoperability.

RESULTS

The most frequent CT signs of death observed in the patients who died of polytrauma were contusive-hemorrhagic foci in the lung associated with pneumomediastinum and hemothorax (9 cases), diffuse subcutaneous emphysema of the chest wall and pneumothorax (8 cases). CT revealed bilateral costal fractures and areas of pulmonary subatelectasia in 8 cases, and rupture of the diaphragm in one. Multiple lacerations of the liver and spleen with marked hemoperitoneum, incompatible with survival, were observed in 3 cases. Vertebral traumatic alterations were present in 2 cases. In 5 cases, the last CT scans of the heart and hepatic cupula revealed massive enhancement of contrast medium within the heart and great vessels due to contrast-medium hypostasis. The diaphragm was hypotonic, an indirect sign of death, with the left hemicardium and hemidiaphragm in a lower position than found in living persons; the abdominal aorta had a reduced caliber.

DISCUSSION AND CONCLUSIONS

Such CT findings will probably become increasingly frequent in the future, because the need to avoid exploratory laparotomies or thoracotomies and unnecessary neurosurgical procedures will entail a greater demand for highly selective diagnostic examinations to be carried out on critical patients. This tendency is matched by the technological advances in diagnostic imaging, and particularly the availability of fast CT and spiral CT machines that give, in only a few seconds, an accurate diagnostic and clinical picture, on which immediate therapeutic decisions can be made.

Intestinal infarction: report of 98 cases

The Authors conducted a retrospective study on 98 patients with intestinal infarction observed from 1987 to 1999 in the Emergency Care Unit of the Loreto Hospital, Naples. In our hospital there are over 20,000 admissions, 3,900 of whom in the Emergency Care Unit. Intestinal infarction accounts for 0.049% of all admissions and 0.45% of emergency surgery admissions. About 500 laparotomies are performed annually, 1% of which for intestinal infarction. All patients in this series were operated on within 10 hours of admission. The following procedures were performed: 31 jejuno-ileal resections; 26 right hemicolectomies associated with small intestine resection; 5 upper mesenteric artery embolectomies plus wide gut resections (3 also underwent second-look operations within 36 hours of the initial surgery with further gut resection); 1 Hartmann's and 5 Volkmann's operations (all of these patients had colonic gangrene); 30 (30.5%) underwent exploratory laparotomy due to massive infarction. The prognosis of intestinal infarction is still ominous. Our mortality rate is 68%. Both clinical and laboratory data are non-specific and delayed diagnosis is the main cause of this mortality rate. Abdominal CT is an accurate and sensitive diagnostic tool. TPN enables us to achieve good nutritional support even for wider resections.

[Liver trauma due to penetrating lesions: miscellanea, personal case series, clinical and CT findings]

PURPOSE

Penetrating liver wounds are related to many causes and rank second after blunt abdominal and liver trauma. We will report the clinical and radiological findings of our personal series of patients with penetrating trauma, especially by firearms and stab and cut wounds. We will also try to define the diagnostic workup of these traumas, which is especially based on CT signs of liver damage and associated changes and which is of basic importance for following treatment, both surgical or conservative.

MATERIAL AND METHODS

In the last seven years we retrospectively reviewed 31 cases of penetrating liver trauma. The patients were 19 men and 12 women, ranging in age 18 to 73 (mean 42), with penetrating liver injuries from firearms (16 patients) and stab (9 cases) wounds; 6 patients had injuries from different causes. Abdominal CT was carried out in emergency with the CT Angiography (CTA) technique in all patients. In the patients with suspected chest and abdomen involvement CT was performed from the mid-chest for accurate assessment of diaphragm and lung bases and to exclude associated pleuropulmonary damage.

RESULTS

Penetrating liver wounds were caused by firearms in 70% of cases, by stabbing in 12% and, in the extant 18%, by other causes such as home accidents, road and work traumas, and liver biopsy. In our series, the liver was most frequently involved, especially by firearms wounds; in our 16 cases the most frequent injuries were hemorrhagic tears. We found bullets in the liver in 6 cases. In one case of home accident the patient wounded himself while slicing bread with a long knife, which cut into the anterior abdominal wall and tore the anterior liver capsule, as seen at CTA.

DISCUSSION AND CONCLUSIONS

Penetrating wounds to liver and abdomen are less frequent than those to the chest. In the past decade the use of CT has changed the diagnostic and therapeutic approach to such injuries completely, decreasing the resort to explorative laparotomy and hepatorrhaphy. Indeed, CT provides a clear picture of the extent and severity of damage, which permits to choose a conservative treatment in case of intraparenchymal hematomas and lacerocontusive foci without hemoperitoneum, which can be followed-up with physical and CT examinations. Moreover, Helical CT could provide the early diagnosis of active bleeding in the peritoneum and of focal bleeding in the liver, thus permitting prompt hepatorrhaphy or targeted hepatectomy. A diaphragm injury suspected at CT should always prompt the surgeon to intervention, especially when hemothorax, lung base pneumothorax, large liver hematoma or tear of the liver dome are associated. Finally, subdiaphragmatic free gas indicates gut perforation associated with liver damage, in which case surgery is necessary too.

[Radiologic investigation of external rectal prolapse. Assessment in 48 patients with defecography, seven of them also with dynamic CT of the pelvis]

PURPOSE

To report our personal experience in 48 patients with external rectal prolapse examined with defecography, evaluating radiological signs and the indications for surgical treatment. We also report the results of 7 patients with severe prolapse submitted to dynamic CT of pelvis.

MATERIAL AND METHODS

The findings relative to 48 patients suffering from external prolapse, 27 women and 21 men, (mean age 58 years), were retrospectively reviewed. In our study protocol the patient is made to sit on a defecographic commode with the pelvis in lateral projection and radiographic images are acquired at rest, on contraction and on evacuation. Dynamic CT of pelvis with axial and coronal scans of the pelvic floor was carried out in 7 patients with severe prolapses. Twenty-six of 48 patients underwent rectopexy.

RESULTS

The main symptoms were anorectal and perineal weight sensation (93%), perineal disturbance in the sitting position (91%) and anorectal pain extended to sacral area (83%). Manometry, which was performed in 36 cases, showed a rectoanal inhibitory reflex evokable at high volumes of air, especially in incontinent subjects. Defecography demonstrated external rectal prolapse in all cases; rectal intussusception in 32, mucosal prolapse in 30, abnormal widening of the anorectal angle in 24 (16 of them were incontinent), rectocele in 22 and perineal descent syndrome in 16 cases.

DISCUSSION AND CONCLUSIONS

External rectal prolapse is sometimes a dynamic progression of a rectal intussusception. In anorectal intussusceptions, the invaginatum involves the anal canal, thus causing the external prolapse. Defecography clearly shows the continuation of invagination out of the anus, with the formation of prolapse. Dynamic CT proved accurate in detecting the rectum morphology, but added no further information to defecography, except for the diastasis of anosphincterial muscles. Therefore, we conclude that defecography is the method of choice, though complementary to other instrumental techniques such as manometry, electromyography and endoscopy, in the diagnostic workup of these patients. Moreover, it can recognize other alterations, such as incontinence and rectocele, which can be submitted to surgical correction with rectopexy.

[CT findings in fire arm injuries of the pelvis. Personal experience]

PURPOSE

We investigated the yield of CT in firearms wounds with pelvis involvement by evaluating the CT features of pelvis, bone walls, and associated injuries, if any. CT plays a major role, while conventional radiography remains an important integration in the workup of pelvis bone injuries.

MATERIAL AND METHODS

We report a retrospective series of pelvis gunshot wounds studied with CT in a 5-year period; the patients were all men, with a mean age of 38 years (range 18-56). When only the pelvis was involved, CT was performed from the transverse umbilical plane to the pubis, in order to include the continuous abdomen. We used an intravenous contrast agent to study the aorta and its iliac branches, pelvic vessels, active hemorrhagic effusions and bladder filling.

RESULTS

Penetrating firearms wounds were found in 21 cases and perforating ones in 7. In the penetrating wounds, the bullet course was most frequently (75%) stopped by the pelvic bones, with retention and CT visualization within muscular and bone structures. The incidence of bone injuries, especially crash wounds, was high, with 18 cases (64%). In both types of wounds with anterior course, we demonstrated bladder perforation in 2 cases, vascular damage in 2 and perforation of intestinal loops in 6.

DISCUSSION AND CONCLUSION

Paradoxically, pelvic bone fractures may be "protective" for the pelvic content; however the involvement of large arteries and veins and multiple perforations of intestinal loops are no less dangerous than the upper abdominal wounds. CT is an important diagnostic tool that permits accurate and prompt evaluation of pelvic organs such as intestine, bladder and bone structures. Thus, CT permits prompt assessment of pelvic structures involvement by firearms wounds, which provides the clinician with useful imaging findings of bullet damage.

[The radiological diagnostic and clinical approach to the patient with stab and cut wounds of the chest. The authors' personal experience]

PURPOSE

To report our personal experience with the clinical and radiological diagnostic approach to stab and cut wounds of the thoracic cage and its content, a type of injury whose diagnosis and treatment, as well as the surgical approach, vary case by case. CT of deep penetrating wounds permits correct assessment of severe changes such as pneumothorax, hemothorax and pneumomediastinum.

MATERIAL AND METHODS

In the last three years we examined 57 patients (48 men and 9 women; mean age 34 years, range 16-54): chest radiography was performed in 51 of them, with orthogonal projections in the standing and sitting positions. Chest CT was performed in emergency with i.v. contrast agent injection, with scans from the midneck to the diaphragm insertion to study border regions. Thoracostomy with pleural drainage was performed in 35 patients with pneumothorax and hemothorax while thoracotomy was performed in 8 patients, namely 4 with injury to the diaphragm, 2 to the heart, 1 with tear of the main bronchial artery and 1 of the aortic arch.

RESULTS

The most frequent symptoms we found were chest pain (100% of cases) and dyspnea (84%); laboratory data showed anemia and decreased hematocrit levels in 28 cases. Chest radiography was negative in 14 cases. The patients were then examined with CT to exclude radiographic underestimation of minimal pneumothorax, small lacerocontusive or hemorrhagic foci and hemothorax, which were observed in 4, 2 and one cases, respectively, and where radiography was actually negative for traumatic changes. Chest radiography was positive in 43 cases: the most frequent finding was pneumothorax, with 37 cases (86%)--8 of them associated with hemothorax and 5 with pneumomediastinum. Lacero-hemorrhagic foci of lung parenchyma were found in 5 cases and single pulmonary hematoma from punch crossing was seen in 1 case.

DISCUSSION AND CONCLUSIONS

CT was an accurate tool and had higher sensitivity than chest radiography in detecting and detailing pneumothorax, pneumomediastinum and lacero-hemorrhagic foci, as well as in quantifying hemothorax. Chest radiography had 12% false negatives and therefore we decided to perform CT in all the patients with penetrating wounds to prevent radiographic underestimation. Given the low rate of false negatives (7/57 cases) CT might appear superfluous but since in 2 of these 7 cases we had massive pneumothorax and pneumomediastinum associated with neck emphysema we suggest its use to prevent complications, clinical failures and medicolegal problems. CT permits correct assessment of penetrating stab and cut wounds of the chest and efficient and targeted treatment, which can be conservative, with thoracostomy with pleural drainage, or surgical.

[Duodenal and pancreatic injuries]

BACKGROUND

Pancreatic and duodenal injuries occur rather infrequently and the incidence ranges between 1% and 12% of all abdominal injuries. The high rate of mortality and morbidity (10-40%) depends on associated complication rate of all intra-abdominal organs (90%).

METHODS

Twenty-five cases of pancreatic and duodenal injuries observed between 1987 and 1997, with an incidence of 0.7% of all abdominal injuries, are reported. In 16 cases the cause was penetrating injury (gunshot) and in 9 cases it was blunt abdominal trauma. Only two patients presented an isolated pancreatic lesion, all the others had at least an associated lesion. In all the cases the patients were male and they were submitted to emergency laparotomy.

RESULTS

The mortality rate was 20%, the morbidity was 24%.

CONCLUSIONS

The relatively low incidence of these injuries and the high rate of associated lesions cause a difficult diagnostic and therapeutic approach, the absence of a unified method to follow and the unsatisfactory results observed.

[Suburban amebiasis: the diagnostic aspects via computed tomography and echography and the percutaneous treatment of amebic liver abscesses]

INTRODUCTION

Liver is the most common site of extraintestinal amebiasis and hepatic abscesses are the most frequent symptom, occurring in 3-9% of patients with amebic infection. Several studies have shown that drug treatment is more efficacious when combined with percutaneous drainage of the abscess, yielding quicker recovery and a positive body response. We report our US and CT findings in 16 patients with amebic abscesses, 12 of whom lived in a temperate peripheral area north-east of Naples. All patients had a clinical-diagnostic condition that we called "suburban amebiasis". Finally we report our personal experience with the US-guided therapeutic drainage of amebic abscesses with repeated cavity washings, which is important for positive parasitology.

MATERIAL AND METHODS

We retrospectively reviewed the findings of 16 patients (11 men and 5 women; age range 36-78 years; mean 52) with amebic abscesses of liver examined with US and CT. US with a 3.5 MHz transducer was the technique of choice in all patients. 94% of liver abscesses and some extraintestinal complications were easily shown with this technique. CT angiography was then performed to detail and clarify US findings. Abscesses over 4 cm in diameter were submitted to US-guided percutaneous treatment which permitted abscess drainage, the collection of material for parasitology and repeated cavity washings.

RESULTS

US showed multiple liver abscesses in 12 patients, which were multiseptate and formed by multiple hypo-/hyperechoic microabscesses in 4 of them. Four non-European patients had a single abscess, which is typical of tropical endemic forms. CT showed the amebic abscesses as hypodense roundish masses with clear-cut outline most often localized in the right lobe in the 12 multiple cases. After percutaneous drainage 13/16 patients (81%) reported less pain in the right hypochondrium and had a lower temperature; their hospitalization was also shorter.

DISCUSSION AND CONCLUSIONS

Combined US and CT assessment facilitated the diagnosis of amebiasis and its differentiation from pyogenic abscess and hepatoma. The combination of US-guided drainage and drug treatment provides better results than either treatment alone and quicker improvement of patient conditions, with fewer extraintestinal complications. Percutaneous drainage should be used in abscesses bigger than 4-5 cm, those with questionable clinical-laboratory findings and finally those failing to respond to drug treatment alone. Positive parasitology of abscess content is related to repeated cavity washings after percutaneous drainage, likely because peripheral layers are much richer in amebae.

[Craniocerebral trauma from bullets: the correlation between computed tomography, the clinical picture, neurosurgical treatment and the long-term sequelae]

PURPOSE

To demonstrate the usefulness of CT findings in the planning of brain neurosurgery in gunshot victims, for prompt and successful treatment.

MATERIAL AND METHODS

Thirty patients with brain gunshot wounds were examined with CT over 5 years. The patients were 27 men and 3 women whose mean age was 33 years (range: 17-56). Brain CT was carried out with thin (5-mm) slices and 10-mm gap; dynamic scanning (3-mm interscan time) was used especially in case of posterior fossa involvement and diffuse brain damage. The examination was integrated with cervical scout views to detect bullets in the neck and cervical dislocation. CT follow-up was carried out in 20 patients 24 hours postoperatively and every 6 hours in 9 patients in a severe postoperative coma.

RESULTS

Twelve intracranial hematomas and 9 subdural hematomas, 3 of them bilateral, were treated and hemorrhage was resolved in 8 lacerocontusive foci. Skull plastic surgery was carried out in 5 cases. Surgical maneuvers were most difficult in the 5 crash bone injuries with wedged splinters; postoperative subarachnoid hemorrhage followed in 3 cases. Blood effusion in ventricles was drained in 6 cases; in 2 of them with permanent catheters. Eleven patients died: 4 right after surgery and 7 an average 15 days postoperatively.

DISCUSSION AND CONCLUSIONS

In our series the mortality rate of firearm wounds of the skull base was 34% higher than that of the hemisphere; this is due to carotid hemorrhage and midbrain damage. Such traumas require emergency radiological diagnosis and neurosurgical treatment because of their severity and early irreversible complications. Complex operations and skilled surgeons may prevent disabling postoperative sequels. CT findings are indispensable and must be correctly interpreted. The radiologist and the neurosurgeon must collaborate closely and both must consider several diagnostic and prognostic factors affecting surgical planning.

Negotiating to Prevent Child Abuse and Neglect

In a multi‐agency, multilevel and multisystem scenario, the Provincial Education Office in Naples promoted a training module for the prevention of child neglect and abuse through a successful partnership approach. A training course, presented on a modular basis, was directed at teachers and heads of the nursery and primary schools throughout Naples. The object was to raise awareness, competence and coping skills when incidences of child abuse and neglect were presented.The aims of the module were:█ to give participants the means to recognise both the signs of hidden problems in the child's behaviour and the disguised signs of maltreatment and abuse█ to support the school representatives and help them to acquire the necessary competencies to enable them to become a reference point for the child, so aiding the child in the disclosure of information and subsequent protection processes█ to promote an effective working methodology, through joint collaboration between school workers, health and social services staff and the magistracy█ to enable the course participants to acquire competence through acquiring appropriate knowledge and skills by the assimilation of relevant information.A semi‐structured questionnaire was drawn up to evaluate the training module. A hundred and seventy‐nine school teachers and school managers completed the questionnaire prior to receiving the training, and a hundred and fiftyfour after; the results provided positive evidence of the effectiveness of the programme. The analysis of the data and comparison of the results highlighted the interest in gaining more knowledge of the subject, especially among the younger participants. It is important to emphasise that while they were on the course participants welcomed the proposal for joint working between the school, health and social services and the legal authorities. However, no positive changes were observed in relation to the involvement of the judiciary, who have for some time been considered with suspicion and reserve. The course also encouraged the school workers to develop a greater appreciation of the benefits to be derived from a multidisciplinary approach to this issue.

[Gunshot wounds of the cranium studied with computerized tomography. Personal experience in 23 cases]

INTRODUCTION

Gunshot wounds to the head are usually mortal injuries. Their frequency has been increasing in the last years because of increasing crime rates. Gunshot wounds to the head require close clinical and diagnostic cooperation of the neurosurgeon and radiologist, detailed assessment of skull and brain damage, and finally prompt treatment. Emergency Computed Tomography (CT) makes a useful tool for depicting bullet course and brain damage, and thus helps plan treatment. We investigated the CT signs of subdural hematoma, lacerocontusive focus, subarachnoid hemorrhage, hemoencephalus, skull bone fracture and thecal hollow and report them as an aid to the neurosurgeon and the radiologist, for best treatment planning, and in an attempt to establish useful prognostic criteria.

MATERIAL AND METHODS

We retrospectively reviewed 23 cases of gunshot injuries to the head studied with CT at the Emergency Unit of Loreto Mare Hospital in Naples, Italy. Twenty patients were men and 3 women; their mean age was 31 years (range: 18-49). Three women and 2 men had been injured accidentally by wandering bullets, and one case was an attempted suicide; all the other cases resulted from shootings. CT slices were 10 mm thick, with 8 mm gap (5 mm in complex injuries and when posterior cranial fossa was involved); all scans were unenhanced.

RESULTS

We found 22 penetrating gunshot wounds: 13 of them with thecal entry hole and intracranial bullet retention and 9 with an entry and an exit hole. One case was a superficial wound. Crash skull fractures were seen in 22 cases and they were fragmented in 12, with overlapping thecal fragments in 4, and with deep fragments in 2 cases. There were scattered bone splinters in 3 cases and the bullet was retained in the mastoid bone in one case. Lacerocontusive foci were assessed in 22 cases, brain swelling in 20, subarachnoid hemorrhage in 19, brain hematoma in 15, blood in the ventricular system in 9, pneumoencephalus in 7, air bubbles along the bullet course in 7, impression on ventricula and linear structures in 7, interhemispheric blood in 5, and finally blood effusion in Sylvian scissure in 4 cases.

DISCUSSION AND CONCLUSIONS

Gunshot wounds to the head are complex and severe traumas with high mortality rates because of both early and late effects and complications. CT provides the neurosurgeon with abundant findings for diagnosis and surgical planning, which may result in improved survival rates. In these patients emergency CT plays a fundamental diagnostic role in depicting brain damage and thus remains the method of choice for thorough, rapid and accurate brain and skull studies, as well as to detect possible injury to the chest and abdomen.