Search for Dark-Matter-Nucleon Interactions via Migdal Effect with DarkSide-50

Dark matter elastic scattering off nuclei can result in the excitation and ionization of the recoiling atom through the so-called Migdal effect. The energy deposition from the ionization electron adds to the energy deposited by the recoiling nuclear system and allows for the detection of interactions of sub-GeV/c^{2} mass dark matter. We present new constraints for sub-GeV/c^{2} dark matter using the dual-phase liquid argon time projection chamber of the DarkSide-50 experiment with an exposure of (12 306±184)  kg d. The analysis is based on the ionization signal alone and significantly enhances the sensitivity of DarkSide-50, enabling sensitivity to dark matter with masses down to 40  MeV/c^{2}. Furthermore, it sets the most stringent upper limit on the spin independent dark matter nucleon cross section for masses below 3.6  GeV/c^{2}.

Search for Dark Matter Particle Interactions with Electron Final States with DarkSide-50

We present a search for dark matter particles with sub-GeV/c^{2} masses whose interactions have final state electrons using the DarkSide-50 experiment's (12 306±184)  kg d low-radioactivity liquid argon exposure. By analyzing the ionization signals, we exclude new parameter space for the dark matter-electron cross section σ[over ¯]_{e}, the axioelectric coupling constant g_{Ae}, and the dark photon kinetic mixing parameter κ. We also set the first dark matter direct-detection constraints on the mixing angle |U_{e4}|^{2} for keV/c^{2} sterile neutrinos.

The novel Mechanical Ventilator Milano for the COVID-19 pandemic

This paper presents the Mechanical Ventilator Milano (MVM), a novel intensive therapy mechanical ventilator designed for rapid, large-scale, low-cost production for the COVID-19 pandemic. Free of moving mechanical parts and requiring only a source of compressed oxygen and medical air to operate, the MVM is designed to support the long-term invasive ventilation often required for COVID-19 patients and operates in pressure-regulated ventilation modes, which minimize the risk of furthering lung trauma. The MVM was extensively tested against ISO standards in the laboratory using a breathing simulator, with good agreement between input and measured breathing parameters and performing correctly in response to fault conditions and stability tests. The MVM has obtained Emergency Use Authorization by U.S. Food and Drug Administration (FDA) for use in healthcare settings during the COVID-19 pandemic and Health Canada Medical Device Authorization for Importation or Sale, under Interim Order for Use in Relation to COVID-19. Following these certifications, mass production is ongoing and distribution is under way in several countries. The MVM was designed, tested, prepared for certification, and mass produced in the space of a few months by a unique collaboration of respiratory healthcare professionals and experimental physicists, working with industrial partners, and is an excellent ventilator candidate for this pandemic anywhere in the world.

Enhanced recovery pathways in colorectal surgery: a consensus paper by the Associazione Chirurghi Ospedalieri Italiani (ACOI) and the PeriOperative Italian Society (POIS)

Enhanced Recovery After Surgery (ERAS) pathway is a multi-disciplinary, patient-centered protocol relying on the implementation of the best evidence-based perioperative practice. In the field of colorectal surgery, the application of ERAS programs is associated with up to 50% reduction of morbidity rates and up to 2.5 days reduction of postoperative hospital stay. However, widespread adoption of ERAS pathways is still yet to come, mainly because of the lack of proper information and communication. Purpose of this paper is to support the diffusion of ERAS pathways through a critical review of the existing evidence by members of the two national societies dealing with ERAS pathways in Italy, the PeriOperative Italian Society (POIS) and the Associazione Italiana Chirurghi Ospedalieri (ACOI), showing the results of a consensus development conference held at Matera, Italy, during the national ACOI Congress on June 10, 2019.

Constraints on Sub-GeV Dark-Matter-Electron Scattering from the DarkSide-50 Experiment

We present new constraints on sub-GeV dark-matter particles scattering off electrons based on 6780.0 kg d of data collected with the DarkSide-50 dual-phase argon time projection chamber. This analysis uses electroluminescence signals due to ionized electrons extracted from the liquid argon target. The detector has a very high trigger probability for these signals, allowing for an analysis threshold of three extracted electrons, or approximately 0.05 keVee. We calculate the expected recoil spectra for dark matter-electron scattering in argon and, under the assumption of momentum-independent scattering, improve upon existing limits from XENON10 for dark-matter particles with masses between 30 and 100  MeV/c^{2}.

Low-Mass Dark Matter Search with the DarkSide-50 Experiment

We present the results of a search for dark matter weakly interacting massive particles (WIMPs) in the mass range below 20  GeV/c^{2} using a target of low-radioactivity argon with a 6786.0 kg d exposure. The data were obtained using the DarkSide-50 apparatus at Laboratori Nazionali del Gran Sasso. The analysis is based on the ionization signal, for which the DarkSide-50 time projection chamber is fully efficient at 0.1  keVee. The observed rate in the detector at 0.5  keVee is about 1.5  event/keVee/kg/d and is almost entirely accounted for by known background sources. We obtain a 90% C.L. exclusion limit above 1.8  GeV/c^{2} for the spin-independent cross section of dark matter WIMPs on nucleons, extending the exclusion region for dark matter below previous limits in the range 1.8-6  GeV/c^{2}.

Prognostic value of Serum and Tumor Tissue CA 72-4 Content in Gastric Cancer

To date no general agreement has been reached regarding the prognostic significance of CEA, CA 19-9 and CA 72-4 as serum markers in gastric cancer, and only scattered information is available on the predictive value of marker expression in tumor tissue. Therefore, a longitudinal study was designed to analyze the presurgical serum and tumor tissue content of CA 72-4, CEA and CA 19-9 in 166 patients at different stages of gastric cancer, and to evaluate the possible correlation with clinicopathological features in respect to prognostic information on relapse-free survival. The results obtained showed that 48.4% of patients with tumor recurrence had positive presurgical CA 72-4 levels compared to approximately 24% of patients who remained free of disease. Furthermore, the median presurgical serum CA 72-4 levels were significantly elevated in relapsing patients. Serosa and lymph node involvement as well as positive presurgical serum CA 72-4 levels had independent prognostic value in predicting recurrence. A significant association between disease-free survival and lymph node involvement, depth of invasion and tumor tissue content of CA 72-4 was also demonstrated. We may therefore conclude that CA 72-4 antigen can be considered the marker of choice in the follow-up of gastric cancer patients and may be used as a prognostic indicator of relapse.

Recent Borexino results and perspectives of the SOX measurement

Borexino is a liquid scintillator detector sited underground in the Laboratori Nazionali del Gran Sasso (Italy). Its physics program, until the end of this year, is focussed on the study of solar neutrinos, in particular from the Beryllium, pp, pep and CNO fusion reactions. Knowing the reaction chains in the sun provides insights towards physics disciplines such as astrophysics (star physics, star formation, etc.), astroparticle and particle physics. Phase II started in 2011 and its aim is to improve the phase I results, in particular the measurements of the neutrino fluxes from the pep and CNO processes. By the end of this year, data taking from the sun will be over and a new project is scheduled to launch: Short distance Oscillation with boreXino (SOX), which uses a Cerium source for neutrinos (100÷150 kCi of activity) and aims to confirm or rule out the presence of sterile neutrinos. This particle is hypothesised to justify the reactor, Gallium and LSND anomalies found and can reject extensions to the standard model. The work presented is a summary of the solar neutrino results achieved so far, which lead not only to a precise study of the processes in the sun, but also to more Standard Model oriented measurements (such as the stability of the charge, i.e. the life time of the electron). Furthermore, the perspectives of the SOX program are discussed showing the experiment sensitivity to a fourth neutrino state covering almost entirely 3σ of the preferred region of the anomalous neutrino experiments, and additional applications of the detector such as the study of geo-neutrinos.

Enhanced recovery after surgery protocol in patients undergoing esophagectomy for cancer: a single center experience

This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.

Focus on the prophylaxis, epidemiology and therapy of methicillin-resistant Staphylococcus aureus surgical site infections and a position paper on associated risk factors: the perspective of an Italian group of surgeons

BACKGROUND

The aim of this research was to study the epidemiology, microbiology, prophylaxis, and antibiotic therapy of surgical site infections (SSIs), especially those caused by methicillin-resistant Staphylococcus aureus (MRSA), and identify the risk factors for these infections. In Italy SSIs occur in about 5 % of all surgical procedures. They are predominantly caused by staphylococci, and 30 % of them are diagnosed after discharge. In every surgical specialty there are specific procedures more associated with SSIs.

METHODS

The authors conducted a systematic review of the literature on SSIs, especially MRSA infections, and used the Delphi method to identify risk factors for these resistant infections.

RESULTS

Risk factors associated with MRSA SSIs identified by the Delphi method were: patients from long-term care facilities, recent hospitalization (within the preceding 30 days), Charlson score > 5 points, chronic obstructive pulmonary disease and thoracic surgery, antibiotic therapy with beta-lactams (especially cephalosporins and carbapenem) and/or quinolones in the preceding 30 days, age 75 years or older, current duration of hospitalization >16 days, and surgery with prothesis implantation. Protective factors were adequate antibiotic prophylaxis, laparoscopic surgery and the presence of an active, in-hospital surveillance program for the control of infections. MRSA therapy, especially with agents that enable the patient's rapid discharge from hospital is described.

CONCLUSION

The prevention, identification and treatment of SSIs, especially those caused by MRSA, should be implemented in surgical units in order to improve clinical and economic outcomes.

A survey on virtual environment applications to fear of public speaking

BACKGROUND

Social Anxiety Disorder (SAD) is one of the most prevalent anxiety disorders in Europe and comprises the fear of public speaking as its typical sub-type. Cognitive-Behavioural Therapy (CBT) is the intervention of choice for SAD, and it includes exposure to anxiety-provoking stimuli to induce systematic desensitization and reduce anxiety. Similarly, exposure therapy per se has been used and found effective, although it is not as specific as CBT for the treatment of SAD. Interestingly, exposure to anxiety-provoking situations can be achieved in Virtual Environments (VEs) through the simulation of social situations allowing individuals with public speaking anxiety to live and develop real exposure-like reactions. The Virtual Reality Exposure Therapy (VRET) is the treatment of anxiety disorders based on such VEs.

AIM

This article aims to provide an overview of the scientific literature related to the applications of Virtual Reality to the treatment of fear of public speaking.

MATERIALS AND METHODS

We conducted the literature review on PubMed and Google Scholar for studies including the fear-of-public-speaking VEs.

RESULTS AND CONCLUSIONS

Reviewed studies addressed two main aspects: the design parameters of the VEs for adequate reactions to synthetic social stimuli, and the efficacy of VEs for fear of public speaking treatment. VEs resulted effective for triggering as-if-real reactions in relation to public speaking. VE-based exposures reduced public speaking anxiety measurements, decreased scores and maintained them at 3 month follow-up. Studies comparing VRET to pharmacological therapy are lacking, and there are few randomized controlled trials that compare VRET to CBT, especially on fear of public speaking treatment.

Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT)

Acute kidney injury (AKI) is an independent risk factor for mortality in critically ill patients whose epidemiology has been made unclear in the past by the use of different definitions across various studies. The RIFLE consensus definition has provided a unifying definition for AKI leading to large retrospective studies in different countries. The present study is a prospective observational multicenter study designed to prospectively evaluate all incident admissions in 10 Intensive Care Units (ICUs) in Italy and the relevant epidemiology of AKI. A simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive patients into the study; 25 patients with End-Stage Renal Disease were excluded leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median SAPS II and APACHE II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 days (IQR 3, 14). Of 576 patients, 246 patients (42.7%) had AKI within 24 hours of ICU admission while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (P<0.001). 48 patients (8.3%) were treated with renal replacement therapy (RRT) in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. Among AKI patients, they were started on RRT a median of 1 (IQR 0-4) days after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) day. AKI patients had a higher crude ICU mortality (28.8% vs. non-AKI 8.1%, P<0.001) and longer ICU length of stay (median 7 days vs. 3 days [non-AKI], P<0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. Two hundred twenty five patients (59.4% of AKI patients) had complete recovery of renal function, with a SCr at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. Septic patients had more severe AKI, and were more likely to receive RRT with less frequency of renal function recovery. Patients with sepsis had higher ICU mortality and longer ICU stay. The study confirms previous analyses describing RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients where the level of severity correlated with mortality and length of stay. The tool developed for data collection resulted user friendly and easy to implement. Some of its features including a RIFLE class alert system, may help the treating physician to collect systematically AKI data in the ICU and possibly may guide specific decision on the institution of renal replacement therapy.

BDNF plasma levels in bipolar and unipolar depression

Introduction

There is increasing evidence that Brain-Derived Neurotrophic Factor (BDNF) may be involved in the pathophysiology of depression and the actions of antidepressants.

Aims

The aim of the present study was to analyze the relationship between the BDNF plasma levels and clinical variables in unipolar versus bipolar depressed patients.

Methods

Thirty-three outpatients (17 with unipolar and 16 with bipolar depression) and 15 healthy controls were included in the study. BDNF concentrations were measured with an ELISA assay method. Severity of depression was assessed by means of the 21-item Hamilton Rating Scale for Depression (HRSD) and the Clinical Global Impressions (CGI) Severity of Illness scale.

Results

The BDNF plasma levels were significantly reduced in patients with unipolar or bipolar depression, with no significant difference between the two groups. Significant and negative correlations were found in the total sample between BDNF levels and the HRSD total scores, the retardation factor scores and CGI “severity of illness” scores. When the same analyses were repeated in each group separately, these findings were confirmed only in patients with bipolar depression.

Conclusions

Our results show that lower BDNF levels may be related to both severity of depression and retardation symptoms in bipolar depression. Further studies need to ascertain whether and how the BDNF levels may be associated with any psychopathological dimensions of the depressive state and be used as a biological marker to differentiate bipolar from unipolar depression.

Manic spectrum symptoms are correlated to the severity of pain and the health-related quality of life in patients with fibromyalgia

OBJECTIVES

We aimed at investigating the impact of lifetime manic spectrum symptoms on the severity of pain and the health-related quality of life (HRQoL) in patients with fibromyalgia (FM).

METHODS

One hundred and sixty-seven patients with FM, assessed according to the ACR criteria, were consecutively enrolled. Psychiatric diagnoses were carried out following the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV-TR). The severity of pain and the HRQoL of FM patients was measured by means of the Fibromyalgia Impact Questionnaire (FIQ) and the Medical Outcomes Study Short Form-36 Health Survey (MOS SF-36); the mood spectrum symptomatology by means of the Mood Spectrum-Self Report (MOODS-SR).

RESULTS

A high rate of lifetime manic symptoms was detected and resulted as related to the Pain Visual Analogic Scale ("pain VAS") of the FIQ and the FIQ total scores as well as to the "bodily pain", and to the physical and mental component summary scores of the MOS SF-36, both in the whole sample (n=167) and in FM patients without bipolar disorder (n=160).

CONCLUSION

Our results highlight the need to pay more attention to manic spectrum symptoms and features in FM patients, because of their relationship with the severity of pain and with a worse HRQoL.

Long-term follow-up of patients with hyperthyroidism due to Graves' disease treated with methimazole. Comparison of usual treatment schedule with drug discontinuation vs continuous treatment with low methimazole doses: a retrospective study

Antithyroid drugs may be proposed as the firstline therapy for hyperthyroidism due to Graves' disease since some patients undergo prolonged remission after drug withdrawal. On the other hand, some studies, though controversial, indicated that methimazole (MMI) has some immunomodulating activity. We retrospectively analyzed 384 consecutive patients newly diagnosed with Graves' disease in the years 1990-2002 to ascertain whether long-term therapy with low doses of MMI may prevent relapse of thyrotoxicosis. Two hundred and forty-nine patients were included in our study. The date of reduction of MMI dose to 5 mg/day was considered time 0 for survival analysis. In 121 MMI was discontinued in less than 15 months after time 0 (group D), while in the remaining 128 a daily MMI 2.5-5 mg dose was maintained (group M). One hundred and thirty-five patients were excluded for inadequate response to MMI, relapse of thyrotoxicosis that could be related to an improper withdrawal or reduction of MMI, inadequate or too short followup, iodide contamination, steroid or interferon therapy, pregnancy or post-partum. D and M groups did not differ for clinical and hormonal parameters except age, which was lower in D (p=0.019). Age > vs < 35 yr was relevant in survival analysis; therefore patients were divided in 2 groups according to this age cut-off. In younger patients relapse of thyrotoxicosis occurred in 15 patients of group D 2.4-39.6 months (median 19.0) after time 0, and 8 M after 5.9-40.0 (21.3) months, while 14 D and 5 M maintained euthyroidism until the end of the observation after 31.8-95.3 (56.6) months and 30.4-62.1 (46.5) months, respectively. Survival analysis indicated that the risk of relapse was similar in group D and M. In older patients relapse of thyrotoxicosis occurred in 40 patients of group D after 8.2-65.8 (25.4) months and 29 M after 5.8-62.5 (22.4) months, while 52 D and 86 M maintained euthyroidism until the end of the observation, 20.1-168.0 (46.7) months and 24.1-117.4 (53.4) months respectively. Survival analysis indicated that the risk of relapse was increased in group D. Therefore long-term treatment with low doses of MMI seems to prevent relapse in Graves' disease in patients above 35 yr of age. This should be confirmed in a prospective study.

Anastomotic leaks after anterior resection for mid and low rectal cancer: survey of the Italian Society of Colorectal Surgery

BACKGROUND

The aim of the survey was to assess the incidence of anastomotic leaks (AL) and to identify risk factors predicting incidence and gravity of AL after low anterior resection (LAR) for rectal cancer performed by colorectal surgeons of the Italian Society of Colorectal Surgery (SICCR).

METHODS

Information about patients with rectal cancers less than 12 cm from the anal verge who underwent LAR during 2005 was collected retrospectively. AL was classified as grade I to IV according to gravity. Fifteen clinical variables were examined by univariate and multivariate analyses. Further analysis was conducted on patients with AL to identify factors correlated with gravity.

RESULTS

There were 520 patients representing 64% of LAR for rectal cancer performed by SICCR members. The overall rate of AL was 15.2%. Mortality was 2.7% including 0.6% from AL. The incidence of AL was correlated with higher age (p<0.05), lower (<20 per year) centre case volume (p<0.05), obesity (p<0.05), malnutrition (p<0.01) and intraoperative contamination (p<0.05), and was lower in patients with a colonic J-pouch reservoir (p<0.05). In the multivariate analysis age, malnutrition and intraoperative contamination were independent predictors. The only predictor of severe (grade III/IV) AL was alcohol/smoking habits (p<0.05) while the absence of a diverting stoma was borderline significant (p<0.07).

CONCLUSION

Our retrospective survey identified several risk factors for AL. This survey was a necessary step to construct prospective interventional studies and to establish benchmark standards for outcome studies.

The impact of thyroidectomy on psychiatric symptoms and quality of life

INTRODUCTION

Existing trials investigated the impact of medical treatment of thyroid disorders on health-related quality of life (QOL) and psychiatric symptoms. The aim of this prospective study is to analyze the impact of thyroid surgery on QOL and severity of psychiatric symptoms.

MATERIALS AND METHODS

Forty-seven patients undergoing thyroid surgery (TS) were assessed before thyroidectomy (T0) and 37 also after surgery, >or=6 months after euthyroidism was achieved (T1). QOL and psychiatric symptoms were evaluated at T0 and T1 using the Medical Outcomes Study Short Form Survey (SF-36) and the Symptom Checklist-90 (SCL-90-R). Scores at T0 were compared with those of patients undergoing surgery for non-thyroidal disease and the SF-36 scores were also compared with the normative Italian sample. Changes in QOL and psychiatric symptoms between T0 and T1 were also examined.

RESULTS

Health-related QOL in TS patients before surgery was poorer than in the comparison group on the SF-36 mental component summary measure and social functioning. Mental health improved significantly after surgery but social functioning remained markedly impaired. A significant reduction in the severity of psychiatric symptoms was observed.

DISCUSSION

Our results indicate that even long after euthyroidism is achieved after surgery, patients show a significant improvement of mental health and a reduction of psychiatric symptoms. Nevertheless, patients continue to have a poorer QOL compared to the Italian normative sample.

[Clinical guidelines for the management of gastrointestinal stromal tumors]

Treatment of gastrointestinal stromal tumors (GIST) has been revolutioned by the recently discovered molecular mechanism responsible for the oncogenesis of this disease. In addition, due to the rapid progress at molecular and clinical level observed in the last few years, there is a need to review the current state of the art in order to delineate appropriate guidelines for the optimal management of these tumors. A panel of experts from several specialities, including medical oncology, surgery, pathology, molecular biology and imaging, were invited to participate in a meeting to present and discuss a number of pre-selected questions, and to achieve a consensus according to the categories of the National Comprehensive Cancer Network (NCCN) and the Standard Options Recommandations (SOR) of the French Federation of Cancer Centers. Generally, consensus points were from categories 2A of the NCCN and B2 of the SOR. Conventional histologic examination with immunohistochemistry for CD117, CD34, SMA, S-100 and desmin is considered standard. Molecular analysis for the identification of KIT and PDGFRA mutation may be indicated in CD117-negative GIST. Complete tumor resection with negative margins is the optimal surgical treatment. Adjuvant imatinib should be considered an experimental approach. Neoadjuvant imatinib is also experimental, although its use may be justified in unresectable or marginally resectable GIST. Imatinib should be started in metastatic or recurrent disease, and should be continued until progressive disease or drug intolerance. In these cases, sunitinib can be used. The optimal criteria for the assessment and monitoring of GIST undergoing imatinib therapy are not well known, but they should include reduction in tumor size and disease stabilization, as well as reduction of tumor density on CT scan and metabolic activity on PET scan.

[G6PD phenotype and red blood cell sensitivity to the oxidising action of chlorites in drinking water]

Chlorine dioxide is widely used to replace sodium hypochlorite in the disinfection of surface waters for human consumption, in order to avoid or reduce the formation of organohalogenated compounds with mutagenic and carcinogenic activity. However, chlorine dioxide may lead to the formation of by-products, such as chlorites and chlorates, that have an oxidative effect on the blood corpuscled fraction. In this investigation, blood crasis was assessed in relation to the G6PD phenotype and the consumption of tap water, disinfected with chlorine dioxide, or bottled mineral water from non-disinfected underground sources. The results show that the effect of oxidative stress resulting from the uptake of chlorites with drinking water is not additive to the effect due to G6PD deficiency. The observed change in haematological parameters, including those related to the G6PD polymorphism, is always within the normal range. However, it is still possible that more relevant changes would follow exposure to chlorites concentrations greater than that observed in the present study.

High risk for microcarcinoma in thyroid benign diseases. Incidence in a one year period of total thyroidectomies

Over the last few years, incidental thyroid microcarcinoma (TMC) has become a frequent disease and its incidence in some reports is considerable. The discovery of new cases depends on the progress of the diagnostics (US scan, fine needle biopsy and cytology, CT, MRI), on the extended indications to thyroidectomy for benign disease and on the attention in pathologic examination of the specimen. The clinical evolution of this disease is not well known: in spite of a high incidence reported in some autoptic series, suggesting that this tumour could have a good prognosis, some authors report an overall incidence of up to 11% of local recurrence, metastasis and mortality. For these reasons the treatment of TMC is still controversial today. Aim of this study was to estimate the incidence and the clinico-pathological findings of TMC over a one year period of total thyroidectomies for diffuse benign thyroid diseases, and to evaluate, on the basis of the frequency of incidental microcarcinoma, if the surgical procedure of complete removal of the gland should be adopted in any case. In this series no patient had pre-operative diagnosis or tentative diagnosis of carcinoma and the incidence of TMC at the final histologic examination was 27.4%. Total thyroidectomy confirmed to be the treatment of choice for diffuse benign diseases and appeared necessary to obtain both, diagnosis and treatment of incidental TMC.

[Trihalomethanes and chlorites in finished drinking water in Sardinia (Italy) and possible health effects]

A five years monitoring was carried out in central and southern Sardinia (Italy) to assess the levels of two disinfection by-products (DBPs)--total thrialomethanes (TTHMs) and chlorites--in drinking water Between 1997 and 2002, about 1900 drinking water samples were analysed for both of them. The results showed that TTHMs exceeded very often the maximum admissible concentration. Chlorite concentration was found rising in all the distribution networks since the utilization of chlorine dioxide as disinfectant in 1999, exceeding the maximum contaminant level goals suggested by the World Health Organization. These results are relevant for epidemiological studies on health effects from DBPs exposure.

Prostaglandin E1 for treatment of erectile dysfunction

BACKGROUND

Erectile dysfunction (ED), the inability to achieve or maintain an erection sufficient for satisfactory sexual activity, is one of the most common sexual dysfunctions in men. ED may have a dramatic impact on the quality of life of many men and their partners.

OBJECTIVES

The aim of this systematic review was to evaluate and summarise the effectiveness and safety of PGE1 in the treatment of erectile dysfunction.

SEARCH STRATEGY

We searched the Cochrane MS Group Trials Register (June 2003), the Cochrane Central Register of Controlled Trials (issue 2, 2003), MEDLINE (January 1966 - June 2003), EMBASE (January 1988 - June 2003) and reference lists of articles. We also undertook handsearching and contacting trialists and pharmaceutical companies.

SELECTION CRITERIA

All unconfounded, double blind, randomised controlled trials comparing PGE1 and placebo treatment in participants with ED of different aetiology were considered. Primary outcomes were: (a) patient and partner satisfaction measured by means of a self-assessment; (b) quality of life and (c) safety assessment. Both parallel group and cross-over design trials were considered for inclusion.

DATA COLLECTION AND ANALYSIS

All the reviewers independently selected articles for inclusion, assessed the trials' quality and extracted the data. Study authors were contacted for additional information.

MAIN RESULTS

Four trials involving 1.873 people, heterogeneous with respect to aetiology of ED, were included. Study design was two cross-over and two parallel group trials. Only the latter provided adequate data for meta-analyses. PGE1 was effective during follow-up in the "at least one successful intercourse" outcome (Peto Odds Ratio, OR 7.22, 95% CI. 5.68-9.18) and "number of successful intercourse/number of PGE1 administrations" (Peto Odds Ratio, OR 6.46, 95% CI. 5.95-7.01). One cross-over study reported "at least one successful intercourse" in 63.6% of participants with at least one dose of PGE1 (P < 0.01 for each active dose versus placebo). In the other cross-over study, only one of three treatment groups conducted a self-evaluation (55.5%: "good" or "excellent" response). Adverse effects were most frequent in the treated groups and occurred more often and intensely as doses increased. Penile pain (Peto OR 7.39, 95% CI. 5.40-10.12) and minor urethral trauma (Peto OR 3.79, 95% CI. 1.88-7.65) were predominant.

REVIEWERS' CONCLUSIONS

PGE1 was beneficial for many participants with ED of different aetiology. Adverse effects were proportional to dosage, albeit never serious. The use of PGE1 in ED could have been better interpreted if its effectiveness were compared by aetiology and with different forms of administrations, a longer follow-up were considered and more emphasis given to patient/partner relationships and quality of life.

Bile duct injuries during laparoscopic cholecystectomy: a 1994-2001 audit on 13,718 operations in the area of Rome

BACKGROUND

Bile duct injuries (BDIs) during laparoscopic cholecystectomy (LC) still are reported with greater frequency than during open cholecystectomy (OC).

METHODS

In 1999, a retrospective study evaluating the incidence of BDIs during LC in the area of Rome from 1994 to 1998 (group A) was performed. In addition, a prospective audit was started, ending in December 2001 (group B).

RESULTS

In group A, 6,419 LCs were performed (222 were converted to OC; 3.4%). In group B, 7,299 LCs were performed (225 were converted to OC; 3.1%). Seventeen BDIs (0.26%) occurred in group A and 16 (0.22%) in group B. Overall, mortality and major morbidity rates were 12.1% and 30.3%, respectively, without significant differences between the two groups.

CONCLUSIONS

The incidence and clinical relevance of BDIs during LC in the area of Rome appeared to be stable over the past 8 years and were not influenced by the use of a prospective audit, as compared with a retrospective survey.

Gastrointestinal stromal tumors of the stomach. A ten-year surgical experience

Gastrointestinal stromal tumors show an increasing incidence. Immunohistochemistry is mandatory to make differential diagnosis with other mesenchimal tumors. We retrospectively reviewed 15 primary stomach GISTs operated during the last decade. Gastroscopy, Ultrasonography and CT scan were employed to obtain the diagnosis. Tumor size ranged from 1.5 to 30 cm in diameter. Treatment consisted of curative surgical resection without sistematic lymph node dissection. A wedge resection was sufficient in 8 cases. In 2 patients a distal subtotal gastrectomy was required and in 1 a total enlarged gastrectomy with pancreaticosplenectomy was performed. 4 GISTs were incidentally discovered and removed during surgical procedures for other gastrointestinal malignancies. In 4 cases a laparoscopic wedge resection was possible. In all cases postoperative course was uneventful. No adjuvant treatment was administered. Concerning the follow-up, two patients died for local and distant relapse while 13 are still alive (most of them operated during the last three years). GISTs show a very unpredictable clinical course and curative surgery is the only potential effective curative treatment.

[The modified "hanging maneuver" during orthotopic liver transplantation using a technique for conserving the inferior vena cava]

We describe a modification of Belghiti's "liver hanging maneuver" applied to the last phase of hepatectomy during OLT with IVC preservation. The proposed maneuver provides a better exposition of the suprahepatic veins allowing an ortogonal clamping of the suprahepatic confluence and avoiding caval clamping. It allows, moreover, an increase of venous surface available for the anastomosis that results wider and easier to perform. This provides a large outflow anastomotic cloaca and prevents outflow problems of the graft.

Adrenal glands metastases from malignant melanoma. Laparoscopic bilateral adrenalectomy

Adrenal metastases from Malignant Melanoma (MM) represent a debated therapeutical problem particularly in the case of disseminated disease. Surgical treatment, however, seems to be able to provide improvement on survival. Laparoscopic adrenalectomy is considered a gold standard procedure in benign adrenal disease but its value in malignancy, in terms of oncological effectiveness, is not known. A case of bilateral adrenal malignant melanoma metastases is reported. The patient, affected by superficial spreading melanoma of the right foot, eleven years after the primary developed a right adrenal metastasis. The relapse was treated by laparoscopic right adrenalectomy. One year later the patient had a new metastasis in the left adrenal gland and was submitted to laparoscopic left adrenalectomy. The two step laparoscopic bilateral adrenalectomy showed to be quite easy to perform, providing a complete removal of the whole glands, without adrenal tissue crushing and without neoplastic tissue dissemination in abdominal cavity. The postoperative course was excellent and the patient was discharged within about 72 hours after the two procedures. In literature only few reports indicate the feasibility of laparoscopic adrenalectomy for malignancy. In the reported case of malignant melanoma metastasis, minimally invasive adrenalectomy was very satisfactory and the good results obtained suggest its routine use.

Self-reported exercise and quality of life in young type 1 diabetic subjects

Evaluation of quality of life is important in treatment strategies of chronic illnesses, such as diabetes mellitus. The present study aimed at measuring the impact of self-reported exercise on quality of life in T1DM patients. Fifty-three young T1DM patients on intensive insulin-treatment regime who were regularly attending the Diabetes Clinic were selected. At the end of the scheduled clinic visit, they were asked to fill in an Italian version of the Diabetes Quality of Life (DQOL) questionnaire; 30 patients exercised regularly, whereas 23 were sedentary. Patients with clinical and laboratory evidence of major eye, renal and cardiovascular diseases were excluded. A significant difference in the scale of satisfaction (1.9 +/- 0.3 vs 2.2 +/- 0.5; p = 0.009), along with a better HbA1c level (7.0 +/- 1.0 vs 7.8 +/- 1.2; p = 0.014), was observed in physically active patients as compared to sedentary ones, whereas there were no differences between the 2 groups with respect to the impact and worry scale. Moreover, there were no significant correlations between glucose control parameters and the quality of life scores. In conclusion, we showed that self-reported exercise is associated with both a better quality of life and a better metabolic control in young T1DM patients. Further efforts should however be made to recognize all factors that can help motivate patients to exercise.

Sentinel node in gastric cancer surgery

Sentinel Node (SN) biopsy studies have been recently applied to gastric cancer. In this series, 40 selected patients operated for gastric adenocarcinoma located in the lesser curvature and/or anterior wall of the body and antrum, underwent an intraoperative dye lymphography. The lymphatic ducts and nodes were visualized and a SN was evidenced in all cases. This was removed and a frozen section examined. In all cases a radical D2-3 gastrectomy was performed and histology, molecular biology, RT-PCR research of micrometastases (CEA-mRNA), were determined on the specimens. Correlations between T and histological status of SN and regional nodes were done. In 16 cases the SN was negative and all the resected regional nodes were negative too. In 15 cases the SN node was positive and other nodes in other stations were found to be positive as well. In 2 cases the SN was negative but other nodes, in the same stations and in others, were positive (false negative = 5%). In 7 cases the SN was the only node in which metastases occurred, 3 demonstrated by conventional histology and 4 detected by RT-PCR. In these 7 cases the SN was the only involved node out of all resected nodes, thus demonstrating to be the real first node along the lymphatic routes from the tumour. This experience seems to confirm the existence of a Sentinel Node and that each gastric adenocarcinoma has its own lymphatic basin in which metastasis can occur. Although a prudent attitude towards the indications resulting from these observations is required, in selected cases a controlled and tailored lymphoadenectomy could be adopted.

Abdominal wall recurrences after colorectal resection for cancer: results of the Italian registry of laparoscopic colorectal surgery

PURPOSE

The purpose of the present study was to evaluate prospectively the abdominal wall recurrence rate after laparoscopic resection for colorectal cancer, to analyze the impact of the learning curve on abdominal wall recurrence, and to assess the outcome of those patients.

METHODS

The Italian Registry of Laparoscopic Colorectal Surgery database was analyzed to obtain data on cancer patients with abdominal wall recurrence, concomitant local or distant metastases, and interval between initial surgery and diagnosis of trocar site or minilaparotomy recurrences. The records of the initial procedures and the technique of specimen removal were reviewed.

RESULTS

From January 1992 to July 2000, 2,583 patients (1,753 cases of carcinomas and 830 cases of benign diseases) were recorded. The malignant lesions were located on the right colon in 19 percent, the left colon in 48.8 percent, and rectum in 32.2 percent. Sixteen patients with histologic evidence of colorectal adenocarcinoma recurrences at the abdominal wall were observed (0.9 percent). Ten patients presented an advanced stage (III for 7 patients and IV for 3 patients). Eleven cases occurred during the learning curve period (the first 50 consecutive cases). The median survival time after abdominal wall recurrence diagnosis was 16 (range, 12-60) months. By July 2000 only two patients were alive.

CONCLUSIONS

The results of the Italian prospective Registry of Laparoscopic Colorectal Surgery confirm that the incidence of abdominal wall recurrences is similar to that reported in open studies (<1 percent). Most abdominal wall recurrences occurred in the learning curve period, suggesting that surgical experience may play a role in the development of this outcome. The prognosis of these patients is very poor.

Transhiatal surgical resection for adenocarcinoma of the cardia

Aim of this study is to define feasibility and effectiveness of the transhiatal esophagogastric resection in cardia adenocarcinoma. From 1981 to 2001, we submitted to surgery 85 patients affected by cardia adenocarcinoma. Since 1994, 34 patients, in consideration of clinical, anatomosurgical (Siewert II-III) and pathologic (T1-3, cN mediastinal negative) findings, underwent transhiatal esophagogastric resection according to Pinotti's technique. This consisted in the midline opening of the central tendon of the diaphragm, ligature and section of the left inferior phrenic vessels, exposure and anterior retraction of the pericardium. The approach allowed in all cases a satisfactory esophageal mobilization and a good dissection of the inferior mediastinal structures avoiding thoracotomy. Postoperative complications were observed in 8 patients (24%). In 4 cases the complications were medical (11.8%) and in 4 cases surgical (11.8%). Death occurred in 4 cases (11.8%): in 3 patients (8.8%) for local complications (2 anastomotic leaks and 1 hemorrage) and in 1 (2.9%) for cardiac failure. The 26 non complicated cases had an uneventful postoperative course and were discharged 12 days after surgery. Middle and long term results were evaluated in terms of locoregional recurrence rate and actuarial survival. At 1 and 2 years locoregional recurrence occurred in 8.8% and 11.8% of cases respectively. Five-year overall survival was 22.5%. In selected cases (Siewert type II-III, T1-3 tumors with clinically negative mediastinal lymphnodes) the procedure in study appears technically feasible, it provides a satisfactory volume of esophageal exeresis and an adequate extension of mediastinal lymphadenectomy, representing a safe and effective alternative to thoracotomy in cardia cancer surgery.

Major and minor injuries during the creation of pneumoperitoneum. A multicenter study on 12,919 cases

BACKGROUND

Lap Group Roma was established in 1999 to promote and control the development of laparoscopic surgery in the area of Rome and its province. Complications during the creation of pneumoperitoneum were given a high priority of investigation, and a retrospective enquiry was immediately carried out.

METHODS

A questionnaire about all laparoscopic surgical practice performed from January 1994 to December 1998 was sent to the supervisors of 28 centers of general surgery in the area of Rome and its province participating to the Lap Group Roma, requesting demographics, type of procedure for the creation of pneumoperitoneum, type and timing of operation, and major vascular, visceral, and minor vascular injuries related to the creation of pneumoperitoneum.

RESULTS

The questionnaire was returned by 57% of the centers, for a total of 12,919 laparoscopic procedures. The type of procedure used to create the pneumoperitoneum involved a standard closed approach (Veress needle + first trocar) in 82% of the cases, an open (Hasson) approach in 9% of the cases, and the use of an optical trocar in 9% of the cases. There were seven major vascular injuries (0.05%), eight visceral lesions (0.06%), and nine minor vascular lesions (0.07%), for an overall morbility of 0.18%. There was no death related to these complications. The rate of complications differed significantly (p < 0.0001) depending on the type of approach used. It was 0.27% with the optical trocar (3 of 1,009 cases), 0.18% with the closed approach (20 of 10,664 cases), and 0.09% with the open approach (1 of 1,135 cases).

CONCLUSIONS

There is no foolproof technique for the creation of pneumoperitoneum, and this inquiry confirms the need of a constant search for prevention and early treatment of complications encountered during this obligatory phase of any laparoscopic approach. A well-conducted and prolonged prospective audit of clinical practice could help in identifying the risk factors that can make an alternative approach (open or video controlled) preferable to the widely used closed approach.

Prevalence of nasal colonization with methicillin-resistant Staphylococcus aureus in selected patient populations

Methicillin-resistant Staphylococcus aureus nasal colonization was investigated in patients arriving for elective cardiovascular surgery, renal patients admitted for arteriovenous graft surgery, and patients transferred to our hospital from other institutions. Renal patients were significantly more likely to be colonized and represent a potential source of MRSA to our institution.

[Liver metastasis of breast carcinoma. Results of surgical resection. Analysis of 15 operated cases]

AIM OF THE STUDY

The aim of the study was to define the efficacy of liver resection for metastases from operated breast cancer by means of analysis of the results of a single institution compared to the literature data.

MATERIALS AND METHODS

Over the period from 1990 to 1998, 15 patients with liver metastases from operated breast cancer were submitted to surgical resection. Thirteen patients were operated on for single metastases and two for multiple liver metastases. In the first group, a simple metastasectomy or wedge resection was sufficient, while in the second a bisegmentectomy and a right hepatectomy, respectively, were performed. Nine patients were subsequently submitted to adjuvant chemotherapy, two to chemo- and hormonotherapy, and two to hormonotherapy alone, while two other patients received no systemic treatment.

RESULTS

No major complications or postoperative mortality were observed. Median survival was 44 months. The actuarial 5-year survival rate was 38.3%. Eight patients are still alive, and 7 patients have died as a result of their liver and systemic metastases.

CONCLUSIONS

Hepatic metastasis from breast cancer is a good indication for surgical resection. Resection is capable of providing curative treatment and better results in terms of quality of life and survival rates, as compared to chemotherapy and hormonotherapy, especially in patients operated on for primary tumours more than three years earlier.

Pancreatic resections: early results and functional behaviour of the stapled pancreatic stump

Pancreaticoduodenectomy is the standard surgical treatment for patients with pancreatic head cancer. Morbidity and mortality rates following this procedure have constantly decreased over the past several years. Leakage of the pancreaticoenteric anastomosis is one of the most serious complications, often responsible for a fatal outcome. Several methods for the management of the pancreatic stump have been described in order to reduce the worrisome incidence of this complication, with variable results. In this series, the Authors review their experience of 75 pancreatic resections and analyze the early results and functional behaviour of 6 patients in which the pancreatic stump was stapled without pancreaticoenteric anastomosis.