Relationship between burnout and nursing practice environment in pediatric cardiology: a cross-sectional study

Introduction

The relationship between burnout and patient safety is widely demonstrated in the literature. Recent studies have shown that in pediatrics the burnout rates are even higher, thus increasing young patients' exposure to risks. Pediatric cardiology is often characterized by acute onset in the pre-natal period and requires long periods of hospitalization. Strategies to reduce burnout and its impact on patient safety is a priority.

Purpose

To test the relationship between nursing work environment and emotional exhaustion in nurses in pediatric cardiology.

Methods

Data were drawn from the database of a larger study, RN4CAST@IT-Ped, a cross-sectional study in which 13 Italian hospitals were involved.

Convenience sampling was adopted, and inclusion criteria were nurses providing direct routine care in wards. For this study, only data relating to nurses working in Pediatric Cardiology were extracted.

The data were collected through a web survey from September 2017 to January 2018. The questionnaire investigated several aspects relating to care and nursing staff including workload, skill mix, work environment measured with PES-NWI, and emotional exhaustion with the Maslach Burnout Inventory. Descriptive statistical analyses were conducted to describe the sample and variables taken into consideration; a binomial logistic regression model was built to test the relationships between the dependent variable “high Emotional Exhaustion” and the independent variables “PES-NWI composite score”, adjusted for “workload” and “skill mix”.

Results

The responses from eighty-five pediatric nurses from 7 units (mixed cardiology-cardiac surgery, cardiology, arrhythmology, cardiac surgery and a cardiology intensive care unit), in 5 hospitals, were analyzed.

These findings show that with the same skill mix and workload, the improvement of the workplace environment conditions decreased by 81% (OR 0.192; 95% CI 0.062–0.591) the risk that nurses working in pediatric cardiology would develop a high level of Emotional Exhaustion.

Conclusions

Demonstrating the association between emotional exhaustion and work environment in pediatric cardiology is only a first step towards improvement. Workplace environment includes relational, logistic, and organizational aspects that require further investigation to ensure that nursing in pediatric cardiology is even safer and of better quality in all its key aspects: urgency, intensity, chronicity and complexity.

Funding Acknowledgement

Type of funding source: None

Work environment and nurse outcomes: a secondary analysis from the RN4CAST@IT study

Introduction

Nursing care in cardiology requires advanced skills, continuity of care and global care of the chronic patient. The relationship with the patient requires a psychological and moral commitment which, combined with time-pressure and high workloads, increases the risk of negatively impacting nurses' well-being. Emotional exhaustion in nurses has negative consequences on care, therefore nursing leaders should monitor this outcome and ensure that its incidence is limited.

Purpose

To test the relationship between the nursing working environment and emotional exhaustion among nurses in cardiology wards.

Methods

The data are drawn from the database of the larger study, RN4CAST@IT. This was a multi-center and multi-level study.

A convenience sample of nurses providing bedside care was included. For the analyses presented here, the data relating to nurses working in Cardiology wards were extracted.

The data were collected through a web survey between September and December 2015.

The questionnaire investigated several topics about nursing staff including nurse-patient ratios, skill mix, working environment measured with PES-NWI, and emotional exhaustion with the Maslach Burnout Inventory.

Descriptive statistical analyses were conducted to describe the sample and variables taken into consideration; a binomial logistic regression model was built to test the relationships between the dependent variable “high Emotional Exhaustion;' and the independent variables “PES-NWI composite score”, “workload” and “skill mix”.

Results

Responses by 291 cardiology nurses were analysed. Binary logistic regression, adjusted for skill mix and staffing, showed that, better working environment conditions reduced the risk that nurses working in the cardiology develop high Emotional Exhaustion by 96% (OR 0.038; 95% CI 0.011–0.136).

Conclusions

Considering the relationship that these analyses have shown between a favourable working environment, capable of involving professionals, of providing adequate resources and leadership, and the risk that professionals may develop a high level of emotional exhaustion, we need to reflect how it impacts on patients. These results are the starting point for analysing the organization of clinical contexts, with their peculiarities, to make them more and more suitable for people, both patients and professionals.

Funding Acknowledgement

Type of funding source: None

Depression, apathy and impaired self-awareness following severe traumatic brain injury: a preliminary investigation

Primary Objective: The primary aim of this study was to determine the frequency of severe impaired self-awareness (ISA) in patients with severe traumatic brain injury (TBI) and the correlates of selected clinical, neuropsychiatric and cognitive variables. The secondary aim of the study was to assess depression and apathy on the basis of their level of self-awareness. Methods: Thirty patients with severe TBI and 30 demographically matched healthy control subjects (HCs) were compared on measures of ISA, depression, anxiety, alexithymia, neuropsychiatric symptoms and cognitive flexibility. Results: Twenty percent of the patients demonstrated severe ISA. Severe post-acute ISA was associated with more severe cognitive inflexibility, despite the absence of differences in TBI severity, as evidenced by a Glasgow Coma Scale (GCS) score lower than 9 in all cases in the acute phase. Patients with severe ISA showed lower levels of depression and anxiety but tended to show more apathy and to have greater difficulty describing their emotional state than patients with severe TBI who showed minimal or no disturbance in self-awareness. Conclusion: These findings support the general hypothesis that severe ISA following severe TBI is typically not associated with depression and anxiety, but rather with apathy and cognitive inflexibility.

BedMachine v3: Complete Bed Topography and Ocean Bathymetry Mapping of Greenland From Multibeam Echo Sounding Combined With Mass Conservation

Greenland's bed topography is a primary control on ice flow, grounding line migration, calving dynamics, and subglacial drainage. Moreover, fjord bathymetry regulates the penetration of warm Atlantic water (AW) that rapidly melts and undercuts Greenland's marine-terminating glaciers. Here we present a new compilation of Greenland bed topography that assimilates seafloor bathymetry and ice thickness data through a mass conservation approach. A new 150 m horizontal resolution bed topography/bathymetric map of Greenland is constructed with seamless transitions at the ice/ocean interface, yielding major improvements over previous data sets, particularly in the marine-terminating sectors of northwest and southeast Greenland. Our map reveals that the total sea level potential of the Greenland ice sheet is 7.42 ± 0.05 m, which is 7 cm greater than previous estimates. Furthermore, it explains recent calving front response of numerous outlet glaciers and reveals new pathways by which AW can access glaciers with marine-based basins, thereby highlighting sectors of Greenland that are most vulnerable to future oceanic forcing.

Developing a Stoma Acceptance Questionnaire to improve motivation to adhere to enterostoma self-care

INTRODUCTION

In stoma care, patient education is often weak in terms of improving patients' level of acceptance of living with a stoma. Self-care educational interventions in enterostomal patients, which according to Orem's Theory should take into account these patients' specific needs, require instruments that measure patients' stoma acceptance to improve motivation based on the resumption of activities they used to carry out before having a stoma. The aim of the study was to develop an instrument that measures the level of stoma acceptance to improve motivation to adhere to enterostoma self-care.

METHODS

Aspects that improve stoma acceptance and consequently motivation to adhere to enterostoma self-care were identified through 10 focus groups. In the focus groups, the motivation indicators were grouped, categorised and results entered into a Stoma Acceptance Questionnaire (SAQ). The SAQ was then piloted with 104 enterostomal patients from three general hospitals. To assess the construct validity of the SAQ, Mokken Scaling was used to explore the latent structure of the SAQ. Mokken scaling is a non-parametric method that falls under the umbrella of methods described as item response theories (IRT).

RESULTS

The theme "Living with a stoma"; "Autonomy"; "Support"; "Ability to deal with stoma", plus a common underlying theme: "Stoma acceptance" were dissussed by the Focus Groups. The experts identified the items of the (SAQ) through these themes. Mokken Scaling identified the "resumption of enterostomal patients' normal activities" as a measure of stoma acceptance, thus confirming the construct validity of the SAQ.

CONCLUSIONS

The tool proposed affords a pioneering example of how this gap can be bridged. Indeed, the SAQ could enable nurses adopting a standardized approach for the assessment of enterostomal patients' motivation to resume their normal activities and identify needs linked to this. The SAQ could also be used to measure the effectiveness of psychosocial and educational interventions aimed at improving stoma acceptance.

PO-03 - Khorana score and histotype predict the incidence of early venous thromboembolism (VTE) in Non Hodgkin Lymphoma (NHL). A pooled data analysis of twelve clinical trials of Fondazione Italiana Linfomi (FIL)

BACKGROUND

Recent studies show that the risk of VTE in NHL pts is similar to that observed in high risk solid tumors (i.e. pancreatic, ovarian cancer). VTE in NHL occurs in most cases within three months from diagnosis and can have substantial impact on treatment delivery and outcome as well as on quality of life. However few data are available on potential predictors.

AIMS

To better clarify the epidemiology of early (within six months from treatment start) VTE in NHL we conducted a pooled data analysis of 12 clinical trials from FIL. Our analysis included basic demographic features, lymphoma-related characteristics as well the Khorana score (based on histology, BMI, platelets WBC and HB counts) which is extensively used in solid tumors to predict VTE risk.

PATIENTS AND METHODS

From Jan. 2010 to Dec. 2014, all pts with B-cell NHL enrolled in prospective clinical trials from FIL for frontline treatment were included. For 9 studies study period included the entire trial population was included. The analyses were conducted based on CRFs as well as pharmacovigilance reports. VTE definition and grading was stated according to standard criteria of toxicity (CTCAE V4.0). Cumulative incidence of VTE from the study enrollment was estimated using the method described by Gooley et al. accounting for death from any causes as a competing risk. The Fine & Gray survival model was used to identify predictors of VTE among NHL pts. Factors predicting the grade of VTE were investigated using an ordinal logistic regression model. This pooled data analysis was approved by local IRB.

RESULTS

Overall, 1,717 patients belonging to 12 studies were evaluated. Eight were phase I/II or II (25% of pts) and 4 phase III (75% of pts). M/F ratio was 1.41, Median age was 57, (IQ range (IQR) 49-66). Histologies were: DLCL-B 34%, FL 41%, MCL 18%, other 6%. Median BMI was 25 (IQR 22-28). Median Hb, WBC and platelets counts were 13g/dl) (IQR 11.5-14.2), 7.1*10^(9)/l (IQR 5.6-10.3), 224*10^(9)/l (IQR 169-298), respectively. 1189 pts were evaluable Khorana score: 58% low risk, 30% intermediate risk, 12% were high risk. Human erythropoetin support was given to 9% of patients. All pts received Rituximab. Planned therapeutic programs included ASCT in 27% of pts, conventional chemotherapy in 67% a conventional chemotherapy plus lenalidomide in 6%. Overall 59 any grade VTE episodes occurred in 51 pts (2.9%), including 21 grade III-IV VTE (18 pts). None was fatal. Median time from study enrolment to VTE was 63 days (IQR: 35-110). Considering death as a competitive event the 6 months cumulative incidence of VTE was 2,2% in low risk Khorana score, 4.5% (95%IC: 2.3-6.7) in intermediate and 6.6% (95%IC: 2.4-10.8) in high risk (p=0.012) (figure 1). Khorana score was predictive also for grade III-IV events as they were 0,7% (95% CI:0.1-1.4) in low risk and 2.0% (95% CI:0.8-3.3) in intermediate-high risk (p=0.048). The results were similar also after excluding lenalidomide containing studies. The Fine and Gray multivariate analyses, adjusted for age and stage, showed that Khorana score (intermediate risk adjHR=1.96; 95%IC: 0.84-4.56 and high risk adjHR=3.81; 95%IC: 1.51-9.58) and DLCL-B histotype (adjHR=2.58; 95% CI: 1.01-6.55) were independently associated to an increased risk of VTE. Moreover an ordinal logistical regression model indicated that the increase of one point in the Khorana score resulted in an increased risk of VTE (OR=1.85; 95% CI: 1.23-2.79).

CONCLUSIONS

Our results suggest that DLCL-B histotype and Khorana score are predictors of VTE in NHL. The latter might become a simple and effective tool to assess the risk of VTE in NHL. Prospective validation including also patients not eligible for clinical trials is needed.

Nursing research priorities in internal medicine nursing practice: an Italian Delphi study

INTRODUCTION

In order to develop an effective and accountable nursing practice is necessary to launch research projects through coordinated studies and one of the main strategies to achieve this goal is to define research priorities.

METHODS

he aim of this study is define the nursing priority research in Internal Medicine and explore the possibility to define the nursing priority research in Internal Medicine. This is an observational study using a three-round Delphi method.

RESULTS

Fifty-five nurses (77%) completed all three rounds. Two hundred eighty-four research priorities were recorded, organized in eighty areas. The technical - care and organized - management are the areas in which were identify more priorities.

CONCLUSIONS

The top five priorities, identify as the most important, suggest the attention of Italian nurses in care of patients, management and in safe-care.

Familial SLE: sustained drug-free remission in a mother successfully treated for anal cancer, but development of SLE in a 16-year old daughter

The immunopathogenesis of systemic lupus erythematosus has been thoroughly investigated recently, and genome-wide association studies have identified genes statistically associated with lupus. However, the progression to overt disease is dependent on the activation of environmental factors ('triggers'), among which oestrogen stimulation is prominent. Here we report the case of a mother with long-standing SLE entering into long term drug-free remission following intensive, menopause-inducing chemoradiotherapy for cancer, and the opposite case of her daughter, who developed SLE following the initiation of her menstrual cycle.

Patients with systemic lupus erythematosus (SLE) having developed malignant lymphomas. Complete remission of lymphoma following high-dose chemotherapy, but not of SLE

The development of malignant lymphomas, generally of the non-Hodgkin type (NHL), and with a preference to diffuse large cell B lymphomas (DLCBL), in systemic lupus erythematosus (SLE), has been analysed in an exhaustive recent literature. The combination of germline and somatic mutations, persistent immune overstimulation and the impairment of immune surveillance facilitated by immunosuppressive drugs, is thought to be at the origin of the increased lymphoma genesis. However the treatment and course of such affected patients is less known, and prognosis is generally estimated as poor. Out of 258 patients with complete/incomplete lupus and secondary antiphospholipid syndrome (APS) seen and treated at the institutional Day Hospital between 1982 and 2009, 6 developed lymphomas (4 DLCBL, 1 Hodgkin's and 1 indolent lymphocytic lymphoma). The first 5 patients were treated with high dose chemotherapy (HDCT) and achieved complete remissions (CR) with a follow-up comprised between 13 and 172 months. One patient relapsed of lymphoma and died 15 months following CR, with persistent lupus serology. One patient achieved complete remission (CR) of both diseases. In the other 3 lupus serology, Antinuclear and antiphospholipid antibodies (ANA, aPL) persisted, with occasional lupus flares and vascular complications. While eradication of the last cancer stem cell is tantamount to cure in neoplastic disease, persistent autoantigenic overstimulation may contribute to the refractoriness of autoimmunity. The implications of these results for the increasing utilisation of haematopoietic stem cell transplantation for severe autoimmune diseases (SADS), with lupus as a paradigm, are discussed.

[Venous thromboembolism prophylaxis after general surgery: where are we now?]

Venous thromboembolism (VTE) is a frequent complication in patients undergoing major surgery, with the possibility of long-term disability or fatal outcome. The rationale of the thromboprophylaxis in all patients can be summarized in three points: 1) the VTE is common in some types of surgery; 2) the VTE can be fatal; 3) thromboprophylaxis is highly effective and safe and, besides these clinical benefits, leads to lower total costs of treatment without further diagnostic and a new shelter for treating venous thrombosis. The surgical patients may present at admission one or more risk factors for VTE, The effect of this risk is cumulative, it is important to stratify the risk and to established an adequate prophylactic strategy. Today there is a unanimous consensus that the low molecular weight heparins are both effective and safe in preventing VTE in surgical patients. Unanimously approved guidelines can help surgeons in making decisions regarding VTE prophylaxis.

[Our experience on the treatment of epigastric hernia]

The epigastric hernia represents a rare surgical affection, sometimes insidious, whose pathogenesis has been discussed for a long time, revealing, in the course of the years, multiple predisposing and responsible factors of its appearance. From our experience and the data reported in the literature, it is clear that a standard surgery does not exist for this pathology, and it is often necessary to perform preliminary uncommon diagnostic exams. Our retrospective study consists in the analysis of the surgical treatments executed, from 2003 to 2006, on 37 patients suffered from epigastric hernia, for everyone of which, on the basis of the clinical features, of the preoperative diagnostic results and of the characteristics of the hernia defect, it has been encouraged a personalized surgical procedure,obtaining therefore, for the same pathology, different treatment protocols (open or laparoscopic procedures, ordinary hospital stay or day-surgery, prosthetic or not surgical repair).

[The use of dermic substitutes in the repair of cutaneous defect due to a phlebostatic wound]

The use of dermic substitutes is a valid and effective choice in the treatment of the cutaneous defects with loss of substance. In our experience, the aesthetic and functional results of dermic substitutes is really positive and encouraging, with better tolerance by patients than the autologue grafts.

Peritoneal malignant mesothelioma: case report

Our study reports peritoneal diffuse malignant mesothelioma (DMM) in a 43 years old male patient, with no exposure to asbestos in his medical history; the partner of the patient was also not exposed to asbestos. The exposure to X-rays was also excluded. Different pathogenic mechanisms for the pathogenesis of a peritoneal diffuse malignant mesothelioma in this patient can be hypothesized, for example, SV40 infection and genetic susceptibility; a minimal domestic exposure to asbestos can be not excluded. Therefore, further studies in a larger number of subjects are necessary to determine whether one or all of these hypothetic pathogenic mechanisms are more significant for the development of malignant mesothelioma.

Gefitinib (G) treatment outcome after progression on erlotinib (E) in patients with advanced non-small cell lung cancer (NSCLC)

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Background: Two case reports describe a response to E after failure of G (Garfield DH, J Clin Oncol 2005) or to G after failure of E (Choong NW et al, Nat Clin Pract Oncol 2006) in patients (pts) with advanced NSCLC. Otherwise, a limited experience in 5 pts suggests that E is not effective in pts progressing on G (Viswanathan A et al, Lung Cancer 2005). Aim of this study was the evaluation of response and time to progression (TTP) in advanced NSCLC pts treated with G after failure of E. Methods: Pts received G 250 mg/day after disease progression (PD) with E 150 mg/day. Pts accrual was stopped on August 2006 after the approval of E for use in Italy and the consequent closure of the G compassionate-use program. Results: From May 2005 to August 2006, 15 pts were enrolled. Median age 65 years (50–85); males= 14 pts (93%); never/former smokers= 4/10 pts (26/67%); adenocarcinoma= 10 pts (67%); PS 0/1= 5/10 pts (33/67%); in 2 pts (13%) E was administered as first-line therapy, 8 pts (53%) received 2 prior lines of chemotherapy (CT) and 3 pts (20%) received CT between E and G. One patient (7%) had a partial response (PR) and 5 pts (33%) had disease stabilization (SD) with E; with G no PR and 6 SD (40%) were obtained. Five out of 6 RP/SD pts with E, had SD with G; 8 out of 9 PD pts with E, had PD with G; 1 SD patient with E, progressed with G and 1 vice versa. TTP in RP/SD pts was 7.2 and 3.4 months for E and G respectively; in PD pts TTP was 1.7 and 1.6 for E and G respectively. Conclusions: Our data suggest that there is a benefit with G in pts who had RP/SD with E and that is associated with a good TTP. Conversely G is not recommended in pts that immediately progressed after E. Moreover these results support the rationale of treating PD pts with an EGFR TKI with another one; it may be worthwhile to collect more data on E.

No significant financial relationships to disclose.

Difference between skin toxicities in erlotinib (E) and gefitinib (G) in the treatment of advanced non-small cell lung cancer (NSCLC)

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Background: Cutaneous toxicities due to E or G are common and reversible adverse effects. In the two large randomized trials with E (Shepherd F et al, NEJM 2005) and G (Thatcher N et al, Lancet 2005) skin rash toxicity incidence seems different between the two drugs: all grades (gr) were observed in 76% and 37% of patients (pts), gr 3–4 in 9% and 2% respectively. The aim of this study was to assess the incidence of the most common toxicities occurred in a cohort of pts treated with E or G in the same period of time and evaluated by the same medical staff according to the Common Toxicity Criteria version 3.0. Methods: From May 2005 to July 2006, 47 pts suitable for a treatment with an EGFR inhibitor were evaluated for their eligibility in an open label phase II trial with E 150 mg/day. Pts ineligible for the latter (16) were treated with G 250 mg/day in a compassionate-use program. Fifteen pts were treated with G at progression after E. Results: Toxicities (all gr, gr 3/3–4) for E vs G consisted in: acneiform rash (64 vs 25%, 13 vs 0%), rash/desquamation (83 vs 19%, 12 vs 0%), pruritus (38 vs 16%, 6 vs 0%), dry skin (48 vs 32%, 3 vs 0%), nail changes (15 vs 6%, 3 vs 0%), diarrhea (54 vs 19%). When pts were treated with both E and G the toxicities (all gr, gr 3/3–4) observed were: acneiform rash (93 vs 20%, 27 vs 0%), rash/desquamation (100 vs 20%, 20 vs 0%), pruritus (41 vs 13%, 7 vs 0%), dry skin (54 vs 27%, 7 vs 0%), nail changes (27 vs 7%, 7 vs 0%), diarrhea (53 vs 7%). Conclusions: Our data are not conclusive being a non-randomized trial. However, these results suggest that there are less cutaneous adverse effects with G. This difference may be probably attributed either to the dose or the bioavailability of E.

No significant financial relationships to disclose.

Disease stabilization (SD) as a surrogate end-point in advanced non-small cell lung cancer (NSCLC) patients treated with erlotinib (E) or gefitinib (G)

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Background: One retrospective study (Hotta K, Ann Oncol 2005), investigating the prognosis of patients (pts) obtaining SD as best response with G treatment, has demonstrated that both progression-free survival (PFS) and survival (S) were significantly longer than those in pts with progressive disease (PD). The aim of this retrospective study was to compare the PFS and S outcome in pts with advanced NSCLC who achieved SD or partial response (PR) after treatment with E or G. Methods: Pooled data from 62 pts, entered into an open label phase II program of E (n=31) and a compassionate-use program of G (n=31), were retrospectively analyzed. E and G were given orally at 150 and 250 mg per day respectively and were continued until disease progression, development of unacceptable toxicity or patient’s refusal. Results: Pts characteristics: median age 69 years (42–85); females= 21 pts (34%); never/former smokers= 16/38 pts (26/61%); adenocarcinoma/BAC= 35/10 pts (56/16%); PS 0/1= 18/38 pts (29/61%). In 16 pts (26%) E or G were given as first-line therapy; 21 pts (34%) had received =2 prior lines of chemotherapy. Six pts (10%) achieved a PR and 18 pts (29%) obtained SD. TTP and OS in pts obtaining PR and SD were comparable: 7 vs 5.5 and 9.7 vs 9.1 months respectively. In progressing pts median TTP and OS were 1.7 and 3.7 months. Conclusions: Our findings indicate the importance of achieving disease control with both E and G treatment. Pts obtaining SD had a similar PFS and S compared with those having PR. An analysis of the role of mutational status and other biomarkers in predicting clinical outcome is currently underway.

No significant financial relationships to disclose.

Pathological evaluation in colorectal polyps endoscopic treatment

This retrospective study shows that endoscopic polypectomy is the technique of choice to remove the majority of polyps; follow-up and pathologic examinations shed light on the carcinogenesis of colorectal lesions. From January 1990 to December 2001, 1302 adenomatous polyps were removed, 1175 endoscopically, 127 with surgical procedures. The anatomical and morphologic conditions of the colon and some characteristics of the polyps represent limits to the feasibility and to the efficacy of polypectomy, and the most important variables for the correct management of the patients affected by colorectal adenomatous polyps.

Abscess and cecum carcinoma in inguinal hernia: case report

Cecal adenocarcinoma within an inguinal hernial sac is an uncommon clinical condition. A primary adenocarcinoma of the cecum in a right sided inguinal hernia is presented and discussed. This case represents one of the unexpected findings in a hernia sac and also very rare septic evolution. This particular condition is a main dignostic and therapeutic challenge.

[Varicose disease of lower limbs: our actual orientation]

A retrospective analysis of a series of patients treated during 5 years was made evaluating, on the basis of the clinical and ultrasonographic examination, the results obtained in the treatment of the varicose disease of the lower limbs for each one of three surgical methodic employed (crossectomy, long or short stripping) as well as patients compliance. All the patients previously underwent ultrasonographic examination to evaluate the reflux rank of the internal saphena and to point out every insufficient veins. On the basis of specific indications, from routinary pre-operative and anaesthesiologic examinations, all the patients were operated. Totally, 784 operations were performed. Thanks to the follow-up, carried out through an objective evaluation (echocolor-Doppler) and subjective one (degree of satisfaction fullfilled through some tests), it is concluded that the most favourable method, among those used, is that of short stripping with wrapping up a silk thread, in accordance to Van der Stricht.

[Predictive factors and treatment of small bowel adhesive obstruction]

Our study is based on a retrospective analysis about a ten years' control on patients with a small bowel adhesive obstruction (SBAO) due to primitive abdominal surgical operations. From the valuation of the obtained data and through a literatures review we tried to better define the best treatment. On 297 admissions of 248 patients with a diagnosis of SBAO 196 operations were performed, which indication was based on every clinical data, haematologic and radiologic examinations. Moreover, it was analysed the responsive factor that caused adhesions with a careful valuation of the primitive surgical operation and the possibility of recurrences. From this study it is evicted that SBAO can be considered as a surgical differentiable urgency, where there aren't any signs of intestinal strangulation or peritonitis, and where the principal etiologic factor is represented by colorectal operations in the male and gynecologic operations in the female. Morbility and mortality in the surgical procedures for SBAO show greater percentages than the elderly patients.

[Gastric lymphomas: surgical indications]

Primary gastric lymphoma (PGL) are lymphomas with an exclusive gastric localization. Histologically they are B-like non-Hodgkin lymphomas. Aim of Authors' study is to define the role of surgery in the treatment of PGL, on the basis of their series casistics and a review of the more recent literature data. The Authors observed 41 patients (23 F and 18 M) in a period of 10 years: 35 patients underwent to surgical operation associated in 18 of them to chemotherapic treatment; in 6 cases medical eradication of Helicobacter Pylori (H.P.) was performed as unique treatment. Antibiothic treatment allows the eradication of H.P. in 97% of the patients and a histologic decreasing of MALT lymphoma in 70% of the patients in about 6 months. That represents the first therapeutic choice for the low grade of malignancy MALT PGL at I and II stages. In the cases of partial decreasing or progression of PGL, the Authors consider opportune surgical operation. In the majority of the cases the surgical option represents, according to our advise, the best choice for the high percentage of definitive recoveries, allowing a 10 or more years of surviving of the 90%, if it is done in the first stages of the disease. The results of the association with neoadjuvant or aduvant chemotherapy are still controversial. On the basis of their experience total gastrectomy can be considered the elective choice operation, with IID level lymphadenectomy and possible splenectomy.

[Metachronous carcinoma of the colon: report of a clinical case]

The Authors deal with a rare case of 'meta-metachronous' carcinoma of the colon. A seventy years old man was admitted to ward after being diagnosed an adenocarcinoma of the transverse colon. The anamnestic data pointed out that the patient had already been operated twice for the colon carcinoma, which had been diagnosed in the left colon and in the cecum respectively seven and two years before. A colonoscopy performed sixteen months before did not show any lesion of the residual colon. It is likely that tiny lesions, which were still in the adenoma phase, were not diagnosed by the endoscopy; it is also possible that the adenoma-carcinoma sequence was extremely fast. On the basis of this experience the Authors recommend that patients with metachronus carcinoma undergo either frequent controls or a preventive subtotal colectomy.

[The use of drainage in the "per primam" treatment of recurrent pilonidal cysts]

Recurrent pilonidal sinus treatment is still controversial, as more and more frequently methods used determine unpleasant discomforts to the patients ("open" method) or increase recurrences rate. According to this consideration, the Authors have made a review of their cases (27 patients with recurrences), selected by standardized criteria and treated by "en bloc" excision of all pathologic tissue and following closure "per primam" of the wound, previously placing an aspirative drainage, then removed after 2 or 3 days. Ordinary use of the drainage, antibiotic prophylaxis extended to postoperative sixth or seventh day and daily careful disinfection of the wound and surrounding skin until suture removal got them excellent results.

[Recurrence after hernioplasty according to Lichtenstein: analysis of the cause]

The performance of surgical interventions of tension-free hernia repair has certainly reduced the recurrence rate in comparison with the previous techniques; notwithstanding this it is not uncommon to observe some recurrences also after a Lichtenstein hernia repair. The aim of this study is that to analyse the causes. In the last 2 years, 42 patients (mean age of 68 years) with recurrent hernia have been operated by Lichtenstein technique; 11 of the 42 patients had been treated before with an useful mesh hernia repair. In 8 of these patients the recurrence was produced by an insufficient medial extension of the mesh; in the other 3 patients the cause was the presence of an unrecognized indirect hernia in patients operated for a direct inguinal hernia. All the patients treated have been submitted to a 18 months time of follow-up.

Switch of flow direction in an Antarctic ice stream

Fast-flowing ice streams transport ice from the interior of West Antarctica to the ocean, and fluctuations in their activity control the mass balance of the ice sheet. The mass balance of the Ross Sea sector of the West Antarctic ice sheet is now positive--that is, it is growing--mainly because one of the ice streams (ice stream C) slowed down about 150 years ago. Here we present evidence from both surface measurements and remote sensing that demonstrates the highly dynamic nature of the Ross drainage system. We show that the flow in an area that once discharged into ice stream C has changed direction, now draining into the Whillans ice stream (formerly ice stream B). This switch in flow direction is a result of continuing thinning of the Whillans ice stream and recent thickening of ice stream C. Further abrupt reorganization of the activity and configuration of the ice streams over short timescales is to be expected in the future as the surface topography of the ice sheet responds to the combined effects of internal dynamics and long-term climate change. We suggest that caution is needed when using observations of short-term mass changes to draw conclusions about the large-scale mass balance of the ice sheet.

[Surgical treatment of hemorrhoids in day-surgery]

The Authors report their own experience with day-surgery treatment of haemorrhoids and underline the advantages in terms of patients' compliance and reduction of the sanitary management in order to the cost that this way suggests. The serie here reported includes 72 patients treated, by two years, with day-surgery haemorrhoidectomy. Here are indicated criteria of selection of the patients, related to the state of the illness, association of other pathologies and social factors. All the patients, moreover, have been treated according to a scheme that generally includes: a careful preoperatory valuation, local anaesthesia, standardized surgical method (Milligan-Morgan intervention), dimission few hours after the operation, control of the patients at their own home. The results obtained, careful examinted through an objective valuation (complications, relapses, time or reability) and subjective one (index of satisfaction of the patients), can be considered extremely positive.

[Day-hospital treatment of inguinal hernia]

Aim of the Authors' research was to evaluate advantages of day-surgery treatment for inguinal hernias. The study has been performed on a series of 138 patients, operated because of unrelapsed and uncomplicated monolateral inguinal hernia. Up-to-date therapeutic behaviour relating to hernia is the result of brilliant intuitions: technical order (tension-free repair), technological progresses (using new prosthetic materials), and refinement of anaesthesiological procedures (local and loco-regional anaesthesia). As regards surgical and anaesthesiological methods, general principles have been accepted by now from the most of the Authors. The new frontier of hernias' treatment is the possibility of operate in a day-hospital way: that means real advantages, both as regards patients' compliance and, in consideration of the high incidence of such pathology, as regards the high economic savings and more reasonable management of hospital stays. The significative increase of day-hospital hernioplastic operations in last years is due to standardization of restrictiveless criteria of choice for patients who can be treated with such modality.

Malignant schwannoma of the rectum: a clinical and pathological contribution

Schwannomas of the rectum are uncommon and incompletely characterized tumours, and only a limited number of cases have been reported. On the basis of a case of rectal schwannoma and a review of the literature on this rare condition, we stress the importance of the clinical features, diagnostic difficulties and surgical indications for the various therapeutic approaches. The basis for radical operation, due to the tendency of such tumours to recur locally and the real possibility of malignant degeneration, is discussed. We also emphasize the difficulty of making a benign diagnosis with histological certainty.

[Use of PTF prosthesis in hernia in the elderly]

The paper reports the author's experience of the use intraperitoneal of Gore-Tex Dual Mesh Biomaterial in large incisional hernia operations in patients over seventy. From January 1999 to December 1999 we operated on 24 patients for treatment of abdominal wall defect. In all patients we used a Dual Mesh Plus Biomaterial. Overall mortality was 0. Morbility was 9.5%. Follow-up is too short for definitive considerations about the incidence of recurrences but our initial experience with this material encourages us to use it again for replacement of abdominal wall defects in the age.

Recurrent hernia of Petit's triangle: a case report

The Authors describe a case of recurrent hernia of Petit's triangle in a 43-year-old man. The most salient feature of lumbar hernias is the difficulty of their treatment. Numerous, more or less complex techniques have been proposed for the repair of lumbar hernias. The classic procedure is that of Dowd (1907). Repair in this case consists of a flap of fascia and aponeurosis from the gluteus medius muscle which is elevated and rotated to cover the defect. Many modifications of this technique have been proposed. The modern prosthetics mesh materials allow a tension-free repair of lumbar hernias without distortion of the normal anatomy. Correct placement of a prosthetic mesh is relatively simple. Recurrences are due not to the material used, but to patches which are too small or too tight.

A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo

OBJECTIVE

The purpose of this study was to determine the effectiveness of a new liberatory maneuver in the management of the geotropic variant of horizontal canal paroxysmal positional vertigo (HC-PPV).

STUDY DESIGN

Case review.

SETTING

Outpatient clinic.

PATIENTS

The diagnosis of HC-PPV was based on the history of recurrent sudden crisis of vertigo associated with bursts of horizontal geotropic paroxysmal nystagmus provoked by turning the head from the supine to either lateral position. The patients were 11 men and 21 women ranging in age from 30 to 85 years (average 55.43 years), and the average duration of symptoms was 7.68 days.

INTERVENTIONS

All patients were treated with a liberatory maneuver based on the hypothesis that the syndrome is caused by the presence of free-floating dense particles inside the endolymph of the posterior arm of the semicircular horizontal canal. The maneuver favors their outmigration into the utricle. Patients were reexamined immediately after the treatment and again 2 days later.

MAIN OUTCOME MEASURE

The treatment outcome was considered as responsive when, after one or more liberatory maneuvers, the clinical signs of PPV disappeared at the end of physical therapy.

RESULTS

The liberatory maneuver resulted in a complete remission of the positioning vertigo and nystagmus in all patients after the first session.

CONCLUSIONS

This approach represents a simple and effective approach to the management of the geotropic form of HC-PPV.

[Acute cholecystitis in patients over 80 years of age: indication for immediate surgical treatment]

The Authors analyse the results of very early surgical treatment in 43 patients over 80 years of age. The severity of morphological changes in the gallbladder and complicated course of the disease are the main factors causing an unfavorable effect on the results of a later treatment. Echography allows, in a high percentage of cases, to confirm the clinical doubt of acute cholecystitis. Cholecystectomy was carried out in all the patients within the first 6 hours (very early surgery-VES). The overall mortality rate was 7%; the morbility rate was 18%.

Long-term results after a low anterior resection with mucosectomy and colo-anal sleeve anastomosis for a diffuse cavernous haemangioma of the rectum

Diffuse cavernous hemangioma of the rectum is an unusual lesion. We reporting the case of an 18-year-old man with a rectal cavernous hemangioma in whom recurrent rectal bleeding and marked anemia were thought to be caused by his co-existing internal hemorrhoids. This resulted in a 2-year delay in reaching the correct diagnosis. Digital rectal examination revealed a walnut-sized, wide-based, elastic, soft mass 3 cm proximal to the anal verge. Colonoscopy revealed a bluish, submucosal lesion with superficial capillary dilatation at the same site. Arteriography demonstrated vascular tumours in the territory of the right hypogastric artery and the superior rectal artery. In 1972, Parks and co-workers described resection and colo-anal sleeve anastomosis as an alternative operation in the treatment of this rare malformation. We will describe the clinical presentation, diagnosis, and long-term results in a patient with this condition managed with this surgical technique. The patient has done well without any recurrence of rectal bleeding for over 10 years since his operation. Resection with a colo-anal sleeve anastomosis offers major advantages such as a lower risk of intraoperative bleeding, no risk of damaging the pelvic nerves, sparing of continence and avoidance of a permanent colostomy. It should therefore be considered the treatment of choice for this uncommon condition.

[Total versus subtotal thyroidectomy for multiple node goiter: experience with 350 surgically treated cases]

The surgical treatment of benign thyroid pathology and in particular the multinodular form is controversial. This controversy exists and one must choose either perform conservative surgical therapy such as lobectomy or sub-total thyroidectomy or total thyroidectomy. From January 1985 to July 1999, the Authors observed 534 cases of benign thyroid pathology. Of these 534, 330 were diagnosed with primitive goiter, and 20 with recurrent goiter; 13 cases of the primitive goiter type were found to have microfoci of carcinoma inside the goiter on the definitive histologic exam. There were 275 patients who underwent total thyroidectomy and the remaining 75 cases with ultrasound proven multinodular goiter were treated with lobectomy or sub-total thyroidectomy, depending on the appearance at the time of the operation as well as the macroscopic and microscopic exams of the integrity of the glandular parenchyma performed while in the operating room. The Authors demonstrated that in multinodular goiter there is a high percentage of cases with disease involving the entire gland. Many areas of apparently healthy tissue are found to be microscopically involved with a variable grade of chronic lymphocytic thyroiditis or follicular hyperplasia or even lobular dysplasia with the tendency to form nodules. These signs of disease of this organ tend to recur if not treated.

[Systemic neoadjuvant chemotherapy in locally advanced gastric carcinoma: phase II study with 5-fluorouracil, epirubicin and etoposide]

Locally advanced gastric adenocarcinomas have a poor prognosis, particularly when the tumours are bulky, located in the cardia or when they present local/regional lymph node involvement. Neoadjuvant chemotherapy for locally advanced gastric cancer is an experimental treatment strategy that may increase resectability and improve survival in patients suffering from an almost uniformly fatal neoplasm. At our institution 11 patients younger than 70 years of age in good physical and mental condition with non-resectable adenocarcinomas of the stomach as determined by endoscopy, computed tomography scans and pathology examinations, were treated with combination chemotherapy [5-fluorouracil (375 mg/m2 i.v. for 5 days, epirubicin (60 mg/m2 i.v. on day 1), etoposide 80 mg/m2 on days 1, 2 and 3, leucovorin 100 mg/m2 for 5 days] every 4 weeks as neoadjuvant chemotherapy. The response to chemotherapy was evaluated after three courses. After three courses, we had one complete response, 8 partial responses or stable disease, and no response in two cases. One patient was still alive 36 months postoperatively. These preliminary results suggest that this protocol is an effective form of neoadjuvant chemotherapy for locally advanced gastric carcinoma.

Microsurgical technique to improve the insertion of totally implantable arterial device (TIAD) in presence of hepatic artery anomalies

In order to achieve perfusion of both lobes of the liver for hepatic arterial infusion chemotherapy, several surgical techniques can be used when the right hepatic artery arises from the superior mesenteric artery. Three of these techniques (utilization of cystic artery, end-to-side anastomosis between the right hepatic artery and proper hepatic artery, and insertion of a fine-tipped special catheter in the right hepatic artery) often require microsurgery applications.

[Nephrogenic adenoma of the bladder. Morphological and immunophenotypic study with particular attention to differential diagnosis]

BACKGROUND

Nephrogenic Adenoma (NA) is a rare lesion of the urinary tract, considered a metaplastic response to chronic inflammation, trauma or immunosuppression.

METHODS AND RESULTS

We report two cases of NA arising in the urinary bladder of patients with previous history of recurrent urinary tract infections due to neuropsychiatric disease. Pathological examination of the lesions, resected by transurethral (TUR) management, revealed a papillary proliferation of tubules and cysts lined by cuboidal to low-columnar cells without atypia. Immunohistochemistry showed positivity for Cam 5.2, CK7 and EMA. MIB 1 count demonstrated a positivity in 12/200 cells in case 1 and < 2/200 in case 2. No expression of nuclear p53 was evident.

CONCLUSION

NA is a benign unusual neoplasm which might be misdiagnosed as clear cell adenocarcinoma of the bladder or prostatic adenocarcinoma. Its recognition is important because it is a benign lesion cured by a conservative resection and no additional therapy is generally required.