Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients: the Italian Society of Emergency Surgery and Trauma (SICUT) guidelines

Dealing with acute cholecystitis in high-risk, critically ill, and unfit-for-surgery patients is frequent during daily practice and requires complex management. Several procedures exist to postpone and/or prevent surgical intervention in those patients who temporarily or definitively cannot undergo surgery. After a systematic review of the literature, an expert panel from the Italian Society of Emergency Surgery and Trauma (SICUT) discussed the different issues and statements in subsequent rounds. The final version of the statements was discussed during the annual meeting in Rome (September 2022). The present paper presents the definitive conclusions of the discussion. Fifteen statements based on the literature evidence were provided. The statements gave precise indications regarding the decisional process and the management of patients who cannot temporarily or definitively undergo cholecystectomy for acute cholecystitis. Acute cholecystitis management in high-risk, critically ill, and unfit-for-surgery patients should be multidisciplinary. The different gallbladder drainage methods must be tailored according to each patient and based on the expertise of the hospital. Percutaneous gallbladder drainage is recommended as the first choice as a bridge to surgery or in severely physiologically deranged patients. Endoscopic gallbladder drainage (cholecystoduodenostomy and cholecystogastrostomy) is suggested as a second-line alternative especially as a definitive procedure for those patients not amenable to surgical management. Trans-papillary gallbladder drainage is the last option to be reserved only to those unfit for other techniques. Delayed laparoscopic cholecystectomy in patients with percutaneous gallbladder drainage is suggested in all those patients recovering from the conditions that previously discouraged surgical intervention after at least 6 weeks from the gallbladder drainage.

Accuracy Of Imaging Software for 3d Rendering of Tooth Structures, Usable in Clinical Settings

AIM

The aim of this study was to evaluate the segmentation accuracy of dentition testing four free-source semi-automatic software.

MATERIALS AND METHODS

A total of 20 cone-beam computed tomography (CBCT) were selected to perform semi-automatic segmentation of maxillary and mandibular dentition. The software tested were Invesalius, ITK-Snap, 3D Slicer and Seg3D. Each tooth model was also manually segmented (Mimics software) and set as the gold standard (GS) reference of the investigation. A specific 3D imaging technology was used to perform the superimposition between the teeth models obtained with semi-automatic software and the GS model, and to perform the surface-to-surface matching analysis. The accuracy of semi-automatic segmentation was evaluated calculating the volumetric mean differences (mean bias and limits of agreement) and the percentage of matching of the tooth models compared to the manual segmentation (GS). Qualitative assessments were performed using color-coded maps. All data were statistically analysed to perform software comparisons.

RESULT

Statistically significant differences were found in the volumetric and matching percentage data (p < 0,05). Invesalius was the most accurate software for 3D rendering of the dentition with a volumetric bias (Mimics) ranging from 4,59 mm3 to 85,79 mm3; instead, ITK-SNAP showed the higher volumetric bias, ranging from 30,22 mm3 to 319,83 mm3. The dis-matched area was mainly located at the radicular region of the teeth. Volumetric data showed excellent inter-software reliability with coefficient values ranging from 0,951 to 0,997.

CONCLUSIO

Different semi-automatic software algorithms could generate different patterns of inaccuracy error in the segmentation of teeth.

Digital analysis of the occlusal changes and palatal morphology using elastodontic devices. A prospective clinical study including Class II subjects in mixed dentition

AIM

The aim of the present prospective study was to evaluate the effectiveness of elastodontic appliance (EAs) in the treatment of subjects presenting Class II sagittal discrepancy in mixed dentition, and to evaluate palatal morphological development during treatment.

MATERIALS

The study group, composed of 19 subjects, received treatment with EA for 1 year. The control group consisted of 17 untreated subjects.

INCLUSION CRITERIA

age between 6 and 11 years, mixed deciduous dentition and skeletal and/or dental Class II malocclusion.

EXCLUSION CRITERIA

previous orthodontic therapy, systemic diseases and signs of temporal dysfunction. Skeletal and dentoalveolar parameters were compared between T0 and T1. A 3D imaging technology was used to compare palatal morphology obtained from intra-oral digital scans between T0 (pre-treatment) and T1 (post-treatment).

CONCLUSION

EAs can successfully mitigate early signs of malocclusion in Class II subjects as well as contribute to the harmonious development of the palate.

The Smile Esthetic Index (SEI): A method to measure the esthetics of the smile. An intra-rater and inter-rater agreement study

PURPOSE

To propose a method to measure the esthetics of the smile and to report its validation by means of an intra-rater and inter-rater agreement analysis.

MATERIALS AND METHODS

Ten variables were chosen as determinants for the esthetics of a smile: smile line and facial midline, tooth alignment, tooth deformity, tooth dischromy, gingival dischromy, gingival recession, gingival excess, gingival scars and diastema/missing papillae. One examiner consecutively selected seventy smile pictures, which were in the frontal view. Ten examiners, with different levels of clinical experience and specialties, applied the proposed assessment method twice on the selected pictures, independently and blindly. Intraclass correlation coefficient (ICC) and Fleiss' kappa) statistics were performed to analyse the intra-rater and inter-rater agreement.

RESULTS

Considering the cumulative assessment of the Smile Esthetic Index (SEI), the ICC value for the inter-rater agreement of the 10 examiners was 0.62 (95% CI: 0.51 to 0.72), representing a substantial agreement. Intra-rater agreement ranged from 0.86 to 0.99. Inter-rater agreement (Fleiss' kappa statistics) calculated for each variable ranged from 0.17 to 0.75.

CONCLUSION

The SEI was a reproducible method, to assess the esthetic component of the smile, useful for the diagnostic phase and for setting appropriate treatment plans.

First Observation of an Hashimoto Thyroiditis-Like Disease in Horses from Eastern Europe: Histopathological and Immunological Findings

Among 622 slaughtered horses from eastern Europe, 156 thyroid glands were selected on the basis of macroscopic alterations (e.g., determination of volume and weight). In the 80% of these thyroids, microscopic alterations consistent with a diagnosis of Hashimoto thyroiditis-like disease were found. In particular, a subverted architecture of the thyroid gland with colloid rarefaction, lymphocytic infiltration, and fibrosis was noted. The confirmation of the histopathological diagnosis of an equine Hashimoto thyroiditis-like disease was provided by the increased serum concentration of thyroglobulin, of antithyroglobulin, and of antithyroid peroxidase autoantibodies. Despite evidence consistent with an Hashimoto thyroiditis-like disease in eastern European horses, the etiopathogenesis of this autoimmune disorder deserves further investigation. In this respect, in some horses histopathological alterations in the pituitary gland may suggest an as-yet-unidentified disorder within the hypothalamus-pituitary adrenal axis associated with Hashimoto thyroiditis.

Drug Targets in Colonoscopic Polypectomy: Biological Sealants with Special Reference to Fibrin-Glue (Tissucol)

The increasing outpatient use of colonoscopy in the diagnostic study and prophylaxis of colon diseases has allowed early identification of polypoid neoformations, thus indicating their increased incidence during the asymptomatic phase. In this respect, the application of biological sealants immediately before the polypectomy has represented a novel therapeutic strategy in the treatment of these preneoplastic lesions. The injection of biological sealants with needle under the polyp peduncle or sub-mucosa has demonstrated a protective action on the electrocoagulated area, an anti-haemorrhagic effect owing to the strengthened seal of the eschar that is formed, and a facilitated tissue regeneration, respectively. The author report his experience acquired over the past five years with regard to the use of biological sealant in colonoscopic polypectomy and conclude that biological sealants, a human fibrin glue, which utilises components of the human plasma, may allow a more generous removal of neoformations, the absence of post-polypectomy complications and, consequently, the dramatic reduction of time of patient's admission in the hospital. In fact, all patients were discharged after two hours from polypectomy, thus implying a better quality of life for patients, in the absence of post-operative complications and a reduction of non-medical costs.

Modifications of serum and cellular parameters in trotters after a race. Macrophage migration inhibitory activity reduction and serum beta-glucan elevation

Trotters are exposed to a chronic prolonged stress, such as daily training and frequent races during their active lifespans. There is evidence that trotters undergo very often lethal lung infections after a race, and therefore, is likely that modifications of certain physiologic cellular parameters could account for the increased susceptibility to microbial diseases. Here, we demonstrate that in 7 trotters after a race either serum values (e.g., glycaemia, triglycerides, transaminases, gamma-glutamyltransferase, cholinesterase, amylase, alkaline phosphatase, total proteins, serum albumin, sodium, blood urea nitrogen, lactic dehydrogenase, creatine phosphokinase, and creatinine) or hematological parameters (red blood cell count, hemoglobin, lymphocyte and monocyte count) were increased. At the same time, in the same animals after a race, macrophage migration inhibitory factor activity was depressed, thus indicating an impaired T-lymphocyte response. Finally, increased levels of circulating beta-glucans in some horses, after a race, may suggest a reduced clearance of fungal cell wall components. Taken together, these findings indicate a condition of multiple organ dysfunction, such as the liver, the kidney, the pancreas, and skeletal muscles, as well as a reduced cell-mediated immune response in trotters, after a race.

[Use of human fibrin glue in endoscopic polypectomy of the colon. Personal experience]

The authors report their experience acquired over the past three years with regard to the use of fibrin glue in colon endoscopic polypectomy. The increasingly routine use of colonoscopy in the prophylaxis and diagnostic study of colon disease has enabled the early identification of polypoid neoformations and thus justifies their increased incidence during the asymptomatic phase. The rationale underlying the use of fibrin glue immediately after polypectomy is defined by the authors as the protective action of fibrin glue on the electrocoagulated area, the anti-haemorrhagic effect owing to the strengthened seal of the eschar that is formed, and the facilitated regeneration of tissue. The authors affirm that if injected under the peduncle or polyp, when scissile, fibrin glue may allow a more generous removal of neoformations.