How does post COVID differ from other post-viral conditions in childhood and adolescence (0-20 years old)? A systematic review

Background

Post Coronavirus disease (COVID) and other post-viral infection syndromes present an overlap of pathogenesis, onset, progression, and symptom profile. We aimed to systematically describe studies on post-viral conditions and determine the entity of post COVID compared to other post-viral conditions in children.

Methods

We conducted a systematic search of the Embase, MEDLINE, Cochrane Library, and GoogleScholar databases (January 1946-3 November 2023), according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. The main outcomes were differences in condition duration, symptom type, and development of chronic symptoms. This systematic review was registered on PROSPERO (CRD42023401789).

Findings

35/5051 studies were included, with 42,934 children, adolescents and young adults (0-20 years old) overall. Twenty-eight studies focused on post COVID symptoms, followed by five papers on Respiratory Syncytial Virus (RSV) and Rhinovirus, one study on Epstein-Barr Virus (EBV), and one on gastrointestinal viruses. Studies on post COVID mainly reported data on older children/adolescents, describing long-lasting symptoms, including fatigue, neurologic, cardiorespiratory, musculoskeletal, mental health, and gastrointestinal symptoms. The maximum described symptoms duration was eighteen months, with an average follow-up of seven months. The development of chronic symptoms was reported by 30 studies (93.8%) for 10,473/28,474 patients (36.8%). Recovery was achieved in 18,001/28,474 cases (63.2%). The study on EBV reported persistent fatigue in adolescents for a similar duration (6 months, 46% chronic). Studies on RSV and Rhinovirus were mainly done in children under three years, with development of recurrent wheezing (up to 3 years).

Interpretation

Post-viral fatigue was a shared feature between post COVID and post EBV conditions. A better understanding of post COVID as a unique condition, sharing features with other post-viral syndromes, is needed. The healthcare burden and socio-economic consequences for children and their families warrant further investigation and development of appropriate healthcare management plans. The foremost requirement is the establishment of consistent and shareable definitions, as well as a consensus on outcomes, to effectively evaluate follow-up and quantify the burden of different viral infections.

Funding

EU Horizon, EDCTP, NIH.

Comparative study showed that children faced a 78% higher risk of new-onset conditions after they had COVID-19

AIM

Children have largely been unaffected by severe COVID-19 compared to adults, but data suggest that they may have experienced new conditions after developing the disease. We compared outcomes in children who had experienced COVID-19 and healthy controls.

METHODS

A retrospective nested cohort study assessed the incidence rate of new-onset conditions after COVID-19 in children aged 0-14 years. Data were retrieved from an Italian paediatric primary care database linked to Veneto Region registries. Exposed children with a positive nasopharyngeal swab were matched 1:1 with unexposed children who had tested negative. Conditional Cox regression was fitted to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CI) for the exposure and outcome associations after adjusting for covariates.

RESULTS

We compared 1656 exposed and 1656 unexposed children from 1 February 2020 to 30 November 2021. The overall excess risk for new-onset conditions after COVID-19 was 78% higher in the exposed than unexposed children. We found significantly higher risks for some new conditions in exposed children, including mental health issues (aHR 1.8, 95% CI 1.1-3.0) and neurological problems (aHR 2.4, 95% CI 1.4-4.1).

CONCLUSION

Exposed children had a 78% higher risk of developing new conditions of interest after COVID-19 than unexposed children.

Biomarkers in IBD: What to Utilize for the Diagnosis?

The role of biomarkers in the diagnosis of inflammatory bowel disease is not fully characterized. C-reactive protein has a short half-life and elevates quickly after the onset of an inflammatory process; the performance is better in Crohn's disease than in ulcerative colitis. Erythrocyte sedimentation rate is easy to determine, widely available, and cheap, but the long half-life, the influence of age, anemia, smoking, and drugs limit its usefulness. Fecal markers have good specificity, but suboptimal accuracy. Microbial antibodies and novel immunological markers show promise but need further evidence before entering clinical practice. Proteomic methods could represent the dawn of a new era of stool protein/peptide biomarker panels able to select patients at risk of inflammatory bowel disease.

Clinical features of COVID-19 in Italian outpatient children and adolescents during Parental, Delta, and Omicron waves: a prospective, observational, cohort study

Introduction

COVID-19 features changed with the Omicron variant of SARS-CoV-2 in adults. This study aims to describe COVID-19 symptoms in children and adolescents during the Parental, Delta, and Omicron eras.

Methods

A single-centre, prospective observational study was conducted on individuals aged 0-20 years attending the University Hospital of Padua (Italy) from April 2020 to December 2022. COVID-19 cases were defined by positive SARS-CoV-2 molecular detection and/or serology; patient/family symptoms and virological positivity were considered to determine the infection onset. Variables were summarized and compared using appropriate tests of descriptive statistics.

Results

A total of 509 cases [46% female, median age eight years (IQR: 4-12)] were studied. Three-hundred-eighty-seven (76%), 52 (10%), and 70 (14%) subjects experienced COVID-19 during the Parental, Delta, and Omicron waves, respectively. All subjects developed an asymptomatic/mild COVID-19. Overall, the most frequent symptoms were fever (47%) and rhinitis (21%), which showed a significant increasing incidence from the Parental to Omicron waves (p < 0.001). Conversely, diarrhea was most common during the pre-Omicron eras (p = 0.03). Stratifying symptoms according to the age group, fever, rhinitis, and skin rashes were observed more frequently among infants/toddlers; conversely, fatigue was more common in children older than five years. The duration of symptoms was similar across different SARS-CoV-2 variants of concern (VOCs); conversely, the number of symptoms varied according to the age group (p < 0.0001).

Discussion

This study showed differences in COVID-19 clinical presentation among infants, children, and adolescents and confirmed Omicron infection is more likely to be associated with upper respiratory symptoms. However, further population-based studies are needed to support these findings. In addition, active surveillance will play a crucial role in assessing the disease severity of future VOCs.

Impact of guidelines implementation on empiric antibiotic treatment for pediatric uncomplicated osteomyelitis and septic arthritis over a ten-year period: Results of the ELECTRIC study (ostEomyeLitis and sEptiC arThritis tReatment in children)

Background

Due to the growing evidence of the efficacy of intravenous (IV) cefazolin with an early switch to oral cefalexin in uncomplicated pediatric osteomyelitis (OM) and septic arthritis (SA) in children, we changed our guidelines for empiric antibiotic therapy in these conditions. This study aims at evaluating the impact of the guidelines' implementation in reducing broad-spectrum antibiotic prescriptions, duration of IV antibiotic treatment and hospital stay, treatment failure and recurrence.

Materials and methods

This is a retrospective, observational, quasi-experimental study. The four years pre-intervention were compared to the six years, ten months post-intervention (January 2012, through December 2015; January 2016, through October 31st, 2022). All patients aged 3 months to 18 years with OM or SA were evaluated for inclusion. Each population was divided into three groups: pre-intervention, post-intervention not following the guidelines, and post-intervention following the guidelines. Differences in antibiotic prescriptions such as Days of Therapy (DOT), activity spectrum and Length of Therapy (LOT), length of hospital stay (LOS), broad-spectrum antibiotics duration (bsDOT), treatment failure and relapse at six months were analyzed as outcomes.

Results

Of 87 included patients, 48 were diagnosed with OM (8 pre-intervention, 9 post-intervention not following the guidelines and 31 post-intervention following the guidelines) and 39 with SA (9 pre-intervention, 12 post-intervention not following the guidelines and 18 post-intervention following the guidelines). In OM patients, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group, with also the lowest proportion of patients discharged on IV treatment. Notably, significantly fewer cases required surgery in the post-intervention groups. Considering SA, LOS, IV DOT, DOT/LOT ratio, and bsDOT were significantly lower in the guidelines group. The treatment failure rate was comparable among all groups for both OM and SA. There were no relapse cases. The overall adherence was between 72 and 100%.

Conclusions

The implementation of guidelines was effective in decreasing the extensive use of broad-spectrum antibiotics and combination therapy for both OM and SA. Our results show the applicability, safety, and efficacy of a narrow-spectrum IV empirical antibiotic regimen with cefazolin, followed by oral monotherapy with first/second-generation cephalosporins, which was non-inferior to broad-spectrum regimens.

Long-term management of Fontan patients: The importance of a multidisciplinary approach

The Fontan operation is a palliative procedure that leads to increased survival of patients with a functional single ventricle (SV). Starting from 1967 when the first operation was performed by Francis Fontan, more and more patients have reached adulthood. Furthermore, it is expected that in the next 20 years, the population with Fontan circulation will reach 150,000 subjects. The absence of right ventricular propulsion and the inability to improve cardiac output because of the low cardiac reserve are the main issues with the Fontan circulation; however, potential complications may also involve multiple organ systems, such as the liver, lungs, brain, bones, and the lymphatic system. As these patients were initially managed mainly by pediatric cardiologists, it was important to assure the appropriate transition to adult care with the involvement of a multidisciplinary team, including adult congenital cardiologists and multiple subspecialists, many of whom are neither yet familiar with the pathophysiology nor the end-organ consequences of the Fontan circulation. Therefore, the aim of our work was to collect all the best available evidence on Fontan's complications management to provide "simple and immediate" information sources for practitioners looking for state of the art evidence to guide their decision-making and work practices. Moreover, we suggest a model of follow-up of patients with Fontan based on a patient-centered multidisciplinary approach.

Pancreatic pseudocyst: case report and short literature review

We report a case of pancreatic pseudocyst secondary to acute necrotizing pancreatitis treated with open cystogastrostomy. Following a literature review, we stress the enormous benefits offered by modern diagnostic techniques, and especially imaging techniques, for the diagnosis and monitoring of this disease. Treatment should be delayed for at least six weeks, following which the drainage by open surgery offers the best results and lowest morbidity and mortality, followed by laparoscopy and endoscopy, indicated in particular cases and in patients where open surgery is contraindicated.

Liver trauma. Diagnosis and treatment

The authors summarize the essential steps in liver surgery. Modern imaging techniques are of great help in establishing a circumstantiated diagnosis of post-traumatic lesions of the intra-abdominal parenchymatous organs, and especially the liver. Such diagnosis must always be based on the AAST (American Association for the Surgery of Trauma) classification, essential for a correct approach. Each therapeutic choice must be based on a careful clinical evaluation to establish whether emergency exploration of the abdomen or simple patient monitoring is indicated. Organ injuries and consequent hemoperitoneum must be found and quantified. In any case, diagnosis and treatment must only begin once all measures have been taken to ensure the maintenance of vital functions and the normalization of the main blood chemistry parameters.

Mucocele of the appendix. Two case reports

The authors present two cases of mucocele of the appendix and discuss them in relation to the literature and the clinical features of this disease. They clarify the definition of mucocele as an intraluminal accumulation of mucus in the appendix, and concentrate on the observable pathological processes, agreeing on the higher frequency of mucinous cystadenoma and the possibility that mucocele can develop into peritoneal pseudomyxoma or degenerate into cystadenocarcinoma. They also note that most diagnoses are made intra-operatively during appendectomy, and that, in cases suspected preoperatively, thorough investigation with imaging techniques is very important in order to plan the best treatment.

[Acute typhlitis associated with taxane-based chemotherapy]

A rare case of acute typhlitis is reported. The patient had undergone chemotherapy for a breast cancer. Clinical and diagnostic tools as well as general and topical care are examined.

[Prevalence of Staphylococcus aureus methicillin-resistant (MRSA) among health care workers]

Methicillin-resistant Staphylococcus Aureus (MRSA) is a type of Staphylococcus that is resistant to certain antibiotics. These antibiotics include methicillin and other more common antibiotics such as oxacillin, penicillin and amoxicillin. Staphylococcus infections, including MRSA, occur most frequently among persons in hospitals and healthcare facilities. The present study was performed to investigate the in vitro activity of oxacillin and other antimicrobial agents against S. aureus strains obtained from nursing personnel. The study included 56 hospital personnel of Universitary Policlinic of Messina. S. aureus strain was isolated in 14 samples (25%); resistent patterns have been studied and results have demonstrated: none methicillin resistant, while 14% oxacillin and tetraciclin resistant. The incidence of methicillin sensitive was 100%, while 86% proved to be sensitive to oxacillin and tetraciclin. In conclusion, the usually hygienic methods (disposable gowns, hygienic hand disinfection after each patients contact, masks use when is a risk of aerosolization of MRSA) are indicate for significantly reducing of these strains. Continuing education programmes can help to increase awareness among hospital staff.

An innovative percutaneous technique for the removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE) in the management of malignant billiary occlusions

PURPOSE

The purpose of this study was to assess the feasibility and clinical impact of the percutaneous removal and replacement of dysfunctioning plastic biliary endoprostheses (PBE).

MATERIALS AND METHODS

Over a period of 24 months, we observed eight patients (age 54-82 years; mean 65) with dysfunctioning PBE. After transhepatic cholangiography and bile duct catheterisation, the endoprostheses were grasped with a gooseneck snare and pushed into the duodenum using a long introducer sheath. Subsequently, we implanted six metallic stents in middle and distal occlusions and four plastic endoprostheses in two patients with proximal occlusion. Clinical and ultrasound followup was performed 1, 3 and 6 months after the procedure and then yearly.

RESULTS

The procedure was technically successful in all patients. No major complication occurred. All patients were discharged without biliary drainage catheters. During the follow-up period (mean: 7.1 months), four patients died and two occlusions of metallic stents were treated by implanting a further metallic stent.

CONCLUSIONS

Percutaneous removal of a dysfunctioning PBE is feasible and allows better quality of life owing to the absence of biliary drainage. Patency of metallic stents is higher than that of PBE. Larger studies are clearly required to validate this approach.

Human galectin-3 immunoexpression in thyroid follicular adenomas with cell atypia

Human galectin-3 (hgal-3) is a beta-galactoside binding protein involved in a number of physiological and pathological processes. Increasing hgal-3 immunoexpression has been reported in several human tumors, including thyroid carcinomas, but not in benign thyroid lesions. We analyzed the immunolocalization of hgal-3 in cell compartments of benign and malignant thyroid lesions. Hgal-3 immunoperoxidase reaction was carried out on 133 thyroid tissue samples obtained from 113 patients; 20 of these were normal (NT), 85 were benign thyroid lesions [20 colloid nodules (CN), 21 nodular hyperplasias (NH), 7 focal lymphocytic thyroiditis (FLT), 15 Hashimoto's thyroiditis (HT), 22 follicular adenomas (FA)], 25 differentiated carcinomas [15 papillary carcinomas (PC), 6 follicular carcinomas (FC) and 4 Hürthle cell carcinomas (HC)] and 3 anaplastic carcinomas (AC). Among the malignant thyroid lesions, hgal-3 was detected in 12/15 (80%) PC, 3/4 (75%) HC and in 4/6 (66.6%) FC, but in none of the 3 AC. Conversely, hgal-3 immunoexpression was absent in NT and in all benign thyroid lesions, but 1/15 HT and 10/22 (45.4%) FA. In the latter, hgal-3 was mostly expressed in microfollicular areas and in five of the six atypical FA. Hgal-3 cytoplasmic-perinuclear immunolocalization was observed in the majority of thyroid carcinomas and in more than half of the FA, theoretically suggesting an involvement of this protein in thyroid tumorigenesis throughout an antiapoptotic activity. Moreover, hgal-3 expression in FA might anticipate the likelihood of evolution of these benign lesions towards malignancy.

How do general practitioners rate their relationship with gastroenterologists?

BACKGROUND

Relations between general practitioners and the hospital consultants are often considered difficult, and occasionally generate conflicts, potentially affecting the patient management and healthcare system organisation. These views, however, have partly been contradicted by structured surveys and qualitative studies.

AIMS

We conducted a survey on the general practitioners' opinions regarding their relations with the gastroenterological-endoscopy services in order to explore current attitudes, any negative aspects and assess scope for improvement.

SUBJECTS AND METHODS

Structured questionnaires were sent to 221 general practitioners in the Veneto region of Italy; the questionnaire was based on 26 questions concerning their subjective relations with the gastroenterologists, expertise in the gastroenterological problems and perceived efficiency of gastroenterological services.

RESULTS

As many as 106 doctors answered the postal questionnaire (mean: 15 per province; range 5-20). Responses to the structured questions totalled to 2,339 items, out of which 1,234 (53%) presented positive responses, particularly with regard to admissions' management and the adequacy of referral reports. Many general practitioners reported of their participation in the meetings on gastroenterological problems. Homecare referrals were limited in number, even for the patients with tube feeding.

CONCLUSIONS

Relations between the general practitioners in Veneto and local gastroenterological services were generally good, possibly reflecting the well-developed outreach network. This liaison could be further improved via closer interrelations based not only on the patient referrals but also on the professional and information exchange to promote successful practice.

Hypocalcemia and hypoparathyroidism after total thyroidectomy: a clinical biological study and surgical considerations

BACKGROUND

Post-operative hypocalcemia is a common and most often transient event afterextensive thyroid surgery. It may be due to iatrogenic injury to the parathyroid glands.

AIMS

We carried out a study aimed to evaluate the incidence of hypocalcemia and hypoparathyroidism following extracapsular total thyroidectomy.

METHODS

The study was carried out in 312 patients (273 females and 39 males, whose age was between 23 and 76 years, median age 48.61 +/- 14.1) who had undergone total thyroidectomy (TT) in our department from 1995 to 1998 and in 100 patients (72 females and 28 males, whose age was between 24 and 75 years, median age 51.66 +/- 13.4) who had undergone other (non-thyroid) surgery.

RESULTS

Post-operative hypocalcemia was observed in 62 patients of the control group (62%) and the decrease of the serum calcium level lasted about 3 days, and went back to normal within the 5th day. In 2 patients undergoing total thyroidectomy, hypocalcemia was considered severe (confirmed for more than 7 days, symptomatic), these had been operated for large multinodular goitre with mediastinal extension. In these patients the symptoms arose acutely about 5 h after the operation. In both cases the clinical and biological aspects went back to normal within 10 days, after a treatment with calcium and vitamin D. Transient asymptomatic hypocalcemia was observed in 234 thyroidectomized patients (75%) and thus did not need any treatment for it.

CONCLUSION

The results obtained confirm that transient hypocalcemia can be observed after any operation; and particularly responsible is the decrease of the calcium concerning the proteins. We found that post-operative hypoparathyroidism is due to injury to the parathyroid glands (parathyroid ischaemia or surgical ablation of one or more glands). Here we see the delayed serum calcium level < or = 7.5 mg/dl or the delayed serum phosphorous level > 7.4 mg/dl. The results of our study, with 2 patients presenting transient post-operative hypoparathyroidism, contribute in confirming that the extracapsular total thyroidectomy aimed to reduce any injury to the parathyroid and to the recurrent nerves, represent the better operation also for the extended benignant thyroidopathies.

Amyand's hernia: case report and review of the literature

The authors report a case of gangrenous acute appendicitis in the sac of an inguinal hernia (Amyand's hernia). After a review of the literature, they emphasise the extreme rarity of the case reported, they underline how the clinical picture is highly similar to that of a strangulated inguinal hernia. They affirm that appendicectomy and hernioplasty may be performed at the same time, since the repair of the hernia should be performed without prosthesis implantation due to the contamination of the operating field.

Two mesalazine regimens in the prevention of the post-operative recurrence of Crohn's disease: a pragmatic, double-blind, randomized controlled trial

BACKGROUND

The role of mesalazine in preventing the clinical recurrence of Crohn's disease after surgery has been shown in a meta-analysis of all published studies. No clear relationship, however, has been shown between dosage and response.

AIM

To evaluate whether 4.0 g/day of mesalazine may offer therapeutic advantages over 2.4 g/day in the prevention of both endoscopic and clinical post-operative recurrence of Crohn's disease.

METHODS

The study was a double-blind, randomized, multi-centre, prospective, controlled clinical trial. Two hundred and six patients, submitted to first or second intestinal resection for Crohn's disease limited to the terminal ileum, with or without involvement of the caecum/ascending colon, were enrolled. Of these, 101 were randomly allocated to receive 4.0 g/day of mesalazine (Asacol, Giuliani SpA, Milan, Italy) and 105 to receive 2.4 g/day, starting 2 weeks after surgery. The primary outcome was endoscopic recurrence, at 12 months after surgery. Three different degrees of endoscopic recurrence were evaluated (endoscopic scores: > 0, > 1 and > 2). The secondary outcome was clinical recurrence, defined as a Crohn's disease activity index of more than 150 points or an increase in the Crohn's disease activity index of 100 points or more. For statistical analysis, chi-square, Wilcoxon and Cox regression model tests were used, when appropriate.

RESULTS

Eighty-four patients in the 4.0 g/day group and 81 patients in the 2.4 g/day group were evaluable by endoscopy. Endoscopic recurrence of > 0 was significantly higher in the 2.4 g/day group than in the 4.0 g/day group (62% vs. 46%; P < 0.04). No difference was observed between the two groups with regard to the other two endoscopic outcomes (> 1 and > 2) or clinical recurrence.

CONCLUSIONS

A 4.0 g/day regimen of mesalazine does not offer a clinically significant advantage over a 2.4 g/day regimen in the prevention of post-operative endoscopic and clinical recurrence of Crohn's disease at 1 year of follow-up.

[Surgery of inguinal hernia in the elderly]

The authors report their 14 years experiences with inguinal hernia repair in elderly. The result were compared with young (< 75 years old), and confirmed that there were no significant differences between the 2 groups. The study confirmed the safety and effectiveness of the "tension-free" technique under local anaesthesia, which is proposed as the treatment of choice in elderly.

Oral and topical 5-aminosalicylic acid (mesalazine) in inducing and maintaining remission in mild-moderate relapse of ulcerative colitis: one-year randomised multicentre trial

BACKGROUND

The association of oral 5-aminosalicylic acid (mesalazine) and enema is effective in treatment of mild-moderate forms of ulcerative colitis. However no study has been aimed at determining optimal duration of this association in active ulcerative colitis.

AIM

To determine whether longer duration of therapy: 1. increases the rate of patients achieving remission, and 2. reduces relapse rate during the maintenance period in patients in remission.

PATIENTS AND METHODS

A total of 149 patients, (89 male, 60 female), were randomly assigned to a regimen with 5-aminosalicylic acid tablets 2.4 g/day associated with 5-aminosalycilic enema 2 g/day for a 4-week (n = 73) or 8-week regimen (n = 76). After this acute therapy, patients were submitted to clinical, endoscopic and histological examinations and those in remission were assigned to a follow-up (maintenance) period with oral mesalazine alone at a dosage of 1.2 g/day. A clinical visit, including laboratory tests, at 6 months and an endoscopic-histological control at 12 months were carried out to exclude symptoms and endoscopic-histological signs of activity. Relapse of disease, i.e., presence of clinical symptoms or abnormal laboratory tests, was confirmed by endoscopy and histology.

RESULTS

At end of acute phase, clinical, endoscopic and histological remission was comparable in the two groups: 42/76 (55%), in the 4-week, and 47/73 patients (64%), in the 8-week regimen. No difference was found stratifying patients according to extension of disease. Of these 89 patients in remission, 75 (34 from 4-week regimen; 41 from 8-week regimen) completed 12 months' follow-up. At end of follow-up, a similar percentage of patients in the 4-week regimen (50%) and 8-week regimen (51%) were still in remission. No significant difference between cumulative relapse rates of the two groups was found. Stratifying patients according to extension of disease, in the 8-week regimen group, those with left-sided colitis showed a higher remission rate than that of patients with diffuse colitis (66% versus 35%, p < 0.05). All regimens were well tolerated by most patients during the entire study period.

CONCLUSIONS

An additional 4 weeks of topical treatment does not increase the remission rate in patients with mild-moderate active ulcerative colitis but seems to reduce the probability of relapse in patients with left-sided colitis.

[Indications for preventive tracheostomy in the surgical treatment of non-neoplastic thyroid disease]

In thyroid surgery, an emergency tracheostomy is mandatory, as is well known, in acute pre- and postoperative asphyxia due to obstruction of the upper airways, especially in cases of malignant tumours. In particular conditions, in the presence of benign thyroid disease and when there is no reduction in the laryngo-tracheal lumen, tracheostomy has an important precautionary function following total thyroidectomy. The authors describe their experience with 6 patients treated by precautionary tracheostomy after total thyroidectomy for benign thyroid disease, analysing the indications and the advantages of this method.

The umbilicus: a rare site for melanoma. Clinical considerations in two cases. Case reports

The umbilicus is a rare site for malignant melanoma. We report two cases of umbilical melanoma and analyse the mechanisms of diffusion of the neoplasm in relationship to the arterial, venous, and lymphatic anatomy of the region. Because of the peculiarity of these connections, we propose a revision of the concept of melanoma stage for the umbilical region.

The recurrent laryngeal nerve related to thyroid surgery

BACKGROUND

Iatrogenic injury of inferior laryngeal nerve is one of the most serious concerns in thyroid surgery. Paralysis of vocal cords is a common sequela of thyroidectomy. It represents a serious complication inducing, when bilateral, serious functional sequelae such as phonatory, respiratory and psychological problems that limit working capacities and social relationships of patients. We carried out an intraoperative study aimed to define anatomical relationships between the recurrent laryngeal nerve and the adjacent structures (the inferior thyroid artery in particular), intraoperative identification of which may allow prevention of iatrogenic injuries of the laryngeal nerve.

METHODS

One hundred ninety-two patients (165 females, 27 males whose age was between 18 and 90 years, median age 55) who had undergone thyroidectomy in our department in the last 3 years. Among them, 179 patients underwent total extracapsular thyroidectomy, and of the 13 remaining, 12 were completions of thyroidectomy in patients who had previously undergone a first thyroid surgical intervention and underwent istmo-lobectomy.

RESULTS

Despite a systematic intraoperative search, we identified the recurrent laryngeal nerve in 158 of 192 patients (82.3%), while in the remaining 34 (17.7%), the recurrent laryngeal nerve was not identified. In 122 out of the 158 patients (77.2%) in whom the recurrent laryngeal nerve had been detected, the nerve was identified bilaterally: in 19 of 158 (12%) only on the right side; in 17 of 158 (10.7%) only on the left. Concerning the postoperative results we noticed only one case (0.5%) of recurrent laryngeal nerve injury for neoplastic infiltration of its own branch, one case (0.5%) of monolateral cordal hypomotility, and two cases (1.04%) of bilateral cordal hypomotility with temporary disphonia, which regressed in 6 months of time.

CONCLUSION

The results of our study may confirm that iatrogenic injury to the recurrent laryngeal nerve, or to its branches, might be better avoided by searching, identifying, and exposing the nerve itself and by following its course with care. In our view, total extracapsular thyroidectomy, with systematic search for the nerve, is the best approach. We believe that deep knowledge of the thyroid region's surgical anatomy and the awareness of the extremely varying course of the recurrent laryngeal nerve and the inferior thyroid artery and their relations should be taken into account by surgeons.

Prevalence of upper gastrointestinal lesions and Helicobacter pylori infection in Crohn's disease

Crohn's disease can affect the upper gut with reported variable frequency, although concurrent Helicobacter pylori infection has been reported to be low. We prospectively investigated the prevalence of esophageal, gastric, and duodenal lesions and Helicobacter pylori infection in 67 Crohn's disease, 41 ulcerative colitis patients, and 43 controls. Symptoms, esophagogastroduodenoscopy, and multiple biopsies were performed on all patients consecutively. Endoscopic lesions were found in 63% of Crohn's disease patients, with a Helicobacter pylori prevalence of 28%. Granulomas were found in three patients. Twenty-two percent of the ulcerative colitis patients had lesions, with a 29% prevalence of Helicobacter pylori infection. Half of the controls had pathological endoscopy, and Helicobacter pylori was positive in 40% of the cases. Subjective symptoms did not predict the presence of endoscopic lesions or Helicobacter pylori infection in inflammatory bowel disease patients. Chronic gastritis and duodenitis are common in Crohn's disease patients, and the majority are not associated with Helicobacter pylori infection.

Prevalence of upper gastrointestinal lesions and Helicobacter pylori infection in Crohn's disease

Crohn's disease can affect the upper gut with reported variable frequency, although concurrent Helicobacter pylori infection has been reported to be low. We prospectively investigated the prevalence of esophageal, gastric, and duodenal lesions and Helicobacter pylori infection in 67 Crohn's disease, 41 ulcerative colitis patients, and 43 controls. Symptoms, esophagogastroduodenoscopy, and multiple biopsies were performed on all patients consecutively. Endoscopic lesions were found in 63% of Crohn's disease patients, with a Helicobacter pylori prevalence of 28%. Granulomas were found in three patients. Twenty-two percent of the ulcerative colitis patients had lesions, with a 29% prevalence of Helicobacter pylori infection. Half of the controls had pathological endoscopy, and Helicobacter pylori was positive in 40% of the cases. Subjective symptoms did not predict the presence of endoscopic lesions or Helicobacter pylori infection in inflammatory bowel disease patients. Chronic gastritis and duodenitis are common in Crohn's disease patients, and the majority are not associated with Helicobacter pylori infection.

[Intestinal recanalization 16 years after Hartmann's operation]

The authors report a case of a surgical intestinal recanalization after 16 years since a Hartmann's intervention. After some considerations on the results they obtained in similar cases, the Authors call attention on this specific clinical case. They come to the conclusion that a successful surgical recanalization--although the difficult availability of the remaining rectal stump--is possible even if a long period has passed since a Hartmann's intervention was performed. In fact the rectal stump and the sphincter apparatus, even if excluded from the fecal transit for a long while, retain largely their specific functional activities and show a marked ability for an effective sensitive-motor restoration.

[Presence and significance of anticardiolipin antibodies in infectious diseases]

IgG and IgM anti-cardiolipin antibodies were measured, by an ELISA technique, in the sera of patients with B hepatitis (28), infectious mononucleosis (10), chicken pox (12), HIV infection (20), acquired toxoplasmosis (41) and other infectious diseases [HBsAg+ chronic hepatitis (5), brucellosis (6), herpes zoster (4), boutonneuse fever (3), viral pneumonitis (4), rheumatic fever (2)]. Increased levels of anti-cardiolipin antibodies (aCL), at least in one immunoglobulin class, were detected in 37 out of 135 patients [27.4%; range: 7.3% (in the patients with toxoplasmosis) -80% (in the patients with HIV infection)]. Low or medium titer aCL were present in 28 patients, high titer in 9 (6 with HIV infection, 2 with chicken pox and I with lymphoadenopathic toxoplasmosis). None of the manifestations associated with aCL was present in the aCL-positive patients. Finally, positivity for aCL didn't seem to modify the clinical picture and the prognosis of the infectious disease.

Semi-selective immunoadsorption treatment in myasthenia gravis

We treated some patients with severe generalized myasthenia gravis (MG) with semi-selective adsorption by plasma perfusion(PP) on IM-T350 column. We studied efficiency and undesired effects of the employed material to verify the safety and effectiveness of methodology. Thus a treatment protocol has been prepared: 6 PP per treatment cycle; 3-7 days between PP sessions; plasma to treat per session 1,2 lt; only one adsorbent column for every cycle. Our experience, on 13 cycles of treatment, showed that PP in autoimmune MG has provided good clinical results without any improvement in genetic MG.

[Voluntary ingestion of packages containing narcotic drugs. Diagnosis and treatment in a clinical case]

A case of intracorporeal concealment of narcotics is reported. Cocaine mixed with marihuana were the ingested drugs. Surgical treatment is, in selected cases, the safest method to remove such packages from the gastrointestinal tract also in subjects without mechanical obstruction. In fact, rupture of a packet threatens the patient's life, because of cocaine's high toxicity and lack of antidote.

Cholestatic jaundice as the presenting symptom of small cell lung cancer

Small-cell lung cancer is an infrequent (10%) form of lung cancer which may rarely become apparent with signs of distant metastases. A case is presented where a cholestatic syndrome was the presenting feature of a small-cell lung cancer which was not suspected clinically. The misleading clinical picture, the inaccurate results of ultrasound, ERCP and chest x-ray did not allow the correct diagnosis to be made until post mortem examination. Even according to the published experience, which is reviewed here, this presentation and clinical course appear exceedingly rare.

A DIC-like picture on plasma and ascitic fluid of cirrhotic patients

Ascitic fluid reinfusion in severe cirrhosis has frequently been associated with intravascular coagulation (DIC). A low-grade DIC has been postulated to be present in liver cirrhosis. PT, APTT, fibrinogen, plasminogen, antiplasmin, fibrin degradation producers (FDP), euglobulin lysis time, tissue plasminogen activator, and fibrinopeptide A were investigated both in the plasma and ascitic fluid of cirrhotic patients before and after the concentration-reinfusion technique. Our results indicate that increased thrombin formation associated with hyperfibrinolysis is present in the plasma of cirrhotic patients. In ascitic fluid very high levels of thrombin and fibrinolysis activation were found. We conclude that (1) a DIC-like picture exists in ascites and (2) after ascites reinfusion procedures, ascitic fluid is the principal factor in the pathogenesis of DIC. During ascitic fluid reinfusion heparin treatment could be used successfully.

[Treatment of acute cholecystitis, yesterday and today: the role of diagnostic research]

To evaluate the influence of both ultrasonography and cholescintiscan on the choice of the treatment and prognosis of acute cholecystitis, the authors reviewed their series of 187 patients observed between 1974 and 1985. On the basis of diagnostic investigations employed, two distinct periods are considered, 1974-79 and 1980-85. In the I period, the exact diagnosis of the disease was obtained in 31 patients (26.3 percent) and the treatment was conservative in 81.3 percent of cases and surgical in 18.7 percent. In the II period, the disease was exactly diagnosed in 95.6 percent and all patients underwent surgery. The overall mortality and complication rate was respectively 5.1 percent and 11.8 percent in the I period and 1.1 percent and 5.8 percent in the II period. Authors conclude that ultrasonography and cholescintiscan, arising rapidly to the exact diagnosis of disease, influenced markedly the choice of surgical treatment, improving the prognosis of these patients.

[Changes in the levels of reverse triiodothyronine (rT3) during and after surgery of the thyroid gland]

The thyroid activity of twenty euthyroid patients, with single or multiple "cold" nodules was investigated, with determination of seric T3, T4, reverse-T3 (rT3) and TSH. The blood-drags were performed respectively, during (with seric samples from the inferior thyroid vein ipsilateral to the affected lobe) and after (1, 3 and 7 days) surgery. The results of this study--and particularly the significative decrease of T3 and the rapid rT3 increase, either during or after operation - suggests a condition similar to the described "Low T3 syndrome", as expression of both the stress determined by surgery and the correlated thyroid metabolic "adaptation". The clinical and biochemical euthyroidism, expressed by normal levels of TSH in all the samples, confirm the persistence of normal feed-back mechanism by the diencephalon-hypophysis-thyroid axis, even in stress conditions.

[Cytologic aspiration biopsy in the diagnosis and therapy of solitary cystic nodular thyropathies]

Between January and December 1983, 36 patients with single and benign cystic thyroid nodules underwent fine needle aspiration. They received, after fine needle aspiration, medical treatment (antiinflammatory drugs and L-T4). Clinical and ultrasonographic follow-up was performed either 6 and 18 months after FNA, to evaluate the lesion evolution. The six-month follow-up demonstrated no ultrasonographic signs of cystic lesion in 11 cases (30.6%); a decreased volume in 21 (58.3%) and four recurrences (11.1%), which underwent surgical treatment (lobectomy). In 21 patients with persistent lesions at 18 month follow-up, a cystic reduction in a 79.9% rate was documented. These data suggests the diagnostic importance of FNA and the safety of this method not only to surgical selection of patients, but also to the treatment of benign thyroid cysts.

[Current orientation in the surgical treatment of cancer of the thyroid]

The authors reviewed their series of thyroid cancers and analyzed possible factors of the low incidence of these neoplasms in their experience. They outline the importance of total thyroidectomy which must be performed as soon as possible. Cervical lymphadenectomy must be reserved only to papillary cancers in which intraoperative histologic examination give the evidence of multiple metastasis of cervical nodes.

[Acute appendicitis: clinico-diagnostic and therapeutic considerations]

Since january 1970-december 1982, 58 patients underwent emergently appendectomy for acute appendicitis. 31 (53,4 percent) where males; the average age was 21 +/- 2,3 years (M +/- SEM). The duration of symptoms ranged from 1-6 hours (10,3 percent of cases) to over 48 hours, before the hospital admission (15,4 percent of cases). 27 patients (46,5 percent) had a clinical examination at home by a physician. 21 patients (36,4 percent) came to hospital emergency unit without previous physical examination; 10 (17,2 percent) were transferred from other departments. In 6,9 percent of cases was present a perforated appendicitis with peritonitis. During operation, in 50 percent of patients was performed a therapeutic peritoneal lavage. In 63,7 percent of cases multiple drains were placed in peritoneal cavity. In all patients was effected postoperative antibiotic profilaxis. The mortality rate was 3,4 percent. General complications were observed more in patients with perforated appendicitis. This review suggests the following remarcable data: morbidity of this disease is still high; the physical examination is more important than laboratory work (especially in the elderly patients, which are often immunodepressed and in children, with leucocitosis-lack at hospital admission); early surgery is the most important factor to the improvement of prognosis in these cases and the results of surgical treatment are improved by large vertical incisions, peritoneal lavage and application of multiple intracavitary drains.

Study of retinol-binding protein in pancreatic cancer

Serum RBP, prealbumin, and zinc were evaluated in normal subjects and patients with pancreatic cancer and chronic pancreatitis. A significant decrease of RPB was found in pancreatic cancer patients compared with controls. A concomitant reduction of prealbumin and zinc was also observed. Multiple regression analysis suggested that the modification of RBP serum levels might be accounted for mainly by diminished prealbumin levels, while the direct role of zinc is negligible.

[Liver injuries. Clinico-diagnostic and therapeutic problems]

Out of 116 cases of abdominal trauma observed, 6 (23%) consisted of hepatic lesions. In 2 cases (33.3%) the hepatic lesion was isolated. In the other cases, it was associated with lesions to the diaphragm, duodenum, pancreas or thorax. After emphasis on the gravity of such lesions and the high mortality rate (33.3% in the cases observed) the factors contributing to the extremely gloomy prognosis are discussed and the basic therapeutic approach to injuries of varying gravity is outlined.

[Traumatic lesions of the diaphragm (personal experience)]

From 1971 to 1982, 126 blunt thoraco-abdominal trauma were seen: in 9 cases (7,1%), diaphragmatic rupture was present. Automobile accidents were the most frequent cause of diaphragmatic rupture and, in only one case, the injury was single. Diaphragmatic rupture was suspected preoperatively in two patients, who had positive physical and radiologic chest findings. The lesion was seen intraoperatively in the other patients, who underwent surgical operation because of severe intra-abdominal injuries. In the author's experience, roentgenologic examinations and adjuntive studies were not important for diagnosis of diaphragmatic injuries. Surgical treatment depended on entity of associated intra-abdominal and intrathoracic injuries, especially in patients observed during immediate post-traumatic period. Authors conclude that single diaphragmatic injury, generally, give no surgical or prognostic problems. High mortality rate seen in these patients is due to multiple organ involvement.