Cost-benefit of reflectance confocal microscopy in the diagnostic performance of melanoma

BACKGROUND

The sub-optimal diagnostic accuracy for melanoma leads to excise a high number of benign lesions, with consequent costs. Reflectance confocal microscopy (RCM) improves diagnostic specificity, thus possibly inducing a reduction in unnecessary excisions and related costs.

OBJECTIVE

To estimate the influence of RCM on number of benign lesions needed to excise (NNE) a melanoma, in term of clinical outcomes and costs per patient.

PATIENTS AND METHODS

Skin neoplasms excised by the dermatology public service in the Province of Modena were retrieved form centralized pathology database. Differences in NNE between the territorial service (using dermoscopy only) and the University Hospital (adding also RCM to the patients' workflow) were calculated and cost analysis was performed through a micro-costing approach.

RESULTS

A large reduction in benign lesions excised at University Hospital was evident, leading to NNE of 6.25 for University Hospital, compared to 19.41 for Territorial Dermatology. Since 4320 unnecessary excisions can be saved every million inhabitants, an overall yearly saving of over 280,000 Eur can be expected from the use of RCM.

CONCLUSIONS

The systematic use of RCM was dramatically affecting the number of benign lesions excised, and this can be translated in a significant cost-benefit advantage.

Risk of birth defects in a population exposed to environmental lead pollution

To investigate the relation between environmental lead and risk of birth defects in humans, we examined the prevalence at birth of congenital anomalies in an industrial area of northern Italy heavily polluted with lead. Through a population-based registry of birth defects, we identified anomalies diagnosed during three consecutive periods characterized by decreasing environmental lead exposure, 1982-1986, 1987-1990 and 1991-1995. In the lead-polluted area, we observed an excess risk of cardiovascular defects which decreased from 2.59 [95% confidence interval (CI) 1.68-3.82] in the first period to 1.18 (95% CI 0.62-2.06) and 0.97 (95% CI 0.57-1.54) in the subsequent periods. We also found an excess risk of oral clefts and musculoskeletal anomalies, with decreasing trends over time. We could not identify homogeneous patterns of temporal variation for other congenital anomalies, neither did we detect cases of neural tube defects. These results appear to support an association between severe parental lead exposure and specific birth defects.

Social context has differential effects on acquisition of nicotine self-administration in male and female rats

RATIONAL

Smoking typically begins during adolescence or early adulthood in a social context, yet the role of social context in animal models is poorly understood.

OBJECTIVES

The present study examined the effect of social context on acquisition of nicotine self-administration.

METHODS

Sixty-day-old male and female Sprague-Dawley rats were trained to press a lever for nicotine (0.015 mg/kg, IV) or saline infusions (males only) on a fixed ratio (FR1) schedule of reinforcement across nine sessions in duplex chambers that were conjoined with either a solid wall or a wall containing wire mesh creating a social context between rat dyads (social visual, auditory, and olfactory cues). In a subsequent experiment, sex differences and dose-dependent effects of nicotine [0 (saline), 0.015 or 0.03 mg/kg, IV] were directly compared in rats trained in the isolated or social context on a schedule progressing from FR1 to FR3. These rats were given 20 sessions followed by 3 extinction sessions.

RESULTS

We consistently found transient social facilitation of low-dose nicotine self-administration in males during the first session. However, across training overall, we found social suppression of nicotine intake that was most prominent in females during later sessions.

CONCLUSIONS

Collectively, these findings suggest that at the age of transition from adolescence to adulthood, a social context enhances the initial reinforcing effects of nicotine in males, but protects against nicotine intake during later sessions especially in females. These findings highlight the importance of sex and social context in studying neural mechanisms involved in initiation of nicotine use.

Children with medical complexity and paediatric palliative care: a retrospective cross-sectional survey of prevalence and needs

Background

Children with medical complexity (CMC) have been defined (Cohen et al., Pediatrics 127: 529–538, 2011.) as an emerging population potentially eligible for PPC. The current study investigated the prevalence of children with medical complexities eligible for a local palliative care network, including a paediatric hospice.

Methods

A retrospective cross-sectional survey has been conducted using children clinical charts from 14 local health authorities of our region (Emilia Romagna, Italy).

Results

The total number of children with life-limiting conditions was 601, with a mean age of 7.4 ± 4.8 years, a prevalence of 8.4/10.000 residents < 19 years of age and a heterogeneous presentation among the provinces in the region. Neurological diseases affect 51% of patients, followed by congenital diseases (21%) and pathologies originating in the perinatal period (6%), while only 4% of the patients had a cancer diagnosis. Patients are dependent from many devices and supports: 32% had a gastrostomy, 22% a respiratory support and 15% of patients had both of them.

Conclusions

Observed regional prevalence of complex needs is lower than that published from other European countries. More research is needed to raise awareness of palliative care for children with medical complexities in order to address specific needs.

Play with Mom: Insights into Regulatory Processes at Work during Baseline and Parent-infant Play

Frontal alpha asymmetry (FAA) is a neural correlate of approach and avoidance motivational processes. This study examined the shift in FAA from baseline to play, associations to parent-reported regulatory abilities, and parent and infant behaviors during play. Infants exhibited greater left frontal alpha activity (more approach) during baseline relative to play. Shifts in FAA toward greater left frontal alpha activity (more approach) from baseline to play were associated with parent ratings of infants' regulatory behaviors and object exploration exhibited during play. These results highlight ongoing regulatory processes involved in positively valenced tasks typical in infants' daily life.

Toxoplasma gondii pneumonitis in patients infected with the human immunodeficiency virus

Pulmonary toxoplasmosis is a rarely recognized opportunistic infection in immunocompromised patients. A few case reports have described pulmonary toxoplasmosis in human immunodeficiency virus-infected patients in association with Toxoplasma gondii central nervous system disease. We encountered six cases of pulmonary toxoplasmosis in human immunodeficiency virus-infected patients who presented with a protracted febrile illness, respiratory symptoms, and an abnormal chest roentgenogram in the absence of neurologic findings. No clinical or roentgenographic features distinguished T gondii pneumonitis from more common opportunistic pulmonary infections. As the acquired immunodeficiency syndrome epidemic progresses, the presenting illnesses have evolved. Toxoplasma gondii must be considered a potential cause of pulmonary disease during the evaluation of human immunodeficiency virus-infected patients with respiratory symptoms.

Associations between mothers' and fathers' depression and anxiety prior to birth and infant temperament trajectories over the first year of life: Evidence from diagnoses and symptom severity

BACKGROUND

Developmental shifts in infant temperament predict distal outcomes including emerging symptoms of psychopathology in childhood. Thus, it is critical to gain insight into factors that shape these developmental shifts. Although parental depression and anxiety represent strong predictors of infant temperament in cross-sectional research, few studies have examined how these factors influence temperament trajectories across infancy.

METHODS

We used latent growth curve modeling to examine whether mothers' and fathers' anxiety and depression, measured in two ways - as diagnostic status and symptom severity - serve as unique predictors of developmental shifts in infant temperament from 3 to 12 months. Participants included mothers (N = 234) and a subset of fathers (N = 142). Prior to or during pregnancy, both parents were assessed for lifetime diagnoses of depression and anxiety as well as current severity levels. Mothers rated their infants' temperament at 3, 6, and 12 months of age.

RESULTS

Mothers' depression and anxiety primarily predicted initial levels of temperament at 3 months. Controlling for mothers' symptoms, fathers' depression and anxiety largely related to temperament trajectories across infancy. Lifetime diagnoses and symptom severities were associated with distinct patterns.

LIMITATIONS

Infant temperament was assessed using a parent-report measure. Including an observational measure would provide a more comprehensive picture of the infants' functioning.

CONCLUSIONS

These results indicate that mothers' and fathers' mental health are uniquely associated with infant temperament development when measured using diagnostic status and/or symptom severity. Future studies should examine whether these temperament trajectories mediate intergenerational transmission of risk for depression and anxiety.

Alveolar epithelial barrier and acute lung injury

The central importance of the alveolar epithelial barrier in the pathogenesis and recovery from acute lung injury has only recently been appreciated. Both in vivo and in vitro studies have provided a new understanding of the mechanisms that regulate transport of sodium, water, and protein across the alveolar epithelial barrier. This new information regarding the normal function of the alveolar epithelial barrier in regulating lung fluid and protein balance has made it possible to study the function of the alveolar barrier both experimentally and clinically in the setting of acute lung injury. The alveolar epithelial barrier is much more resistant to injury than the nearby lung endothelium. The mechanisms that cause injury to the alveolar barrier are just beginning to be explored in different experimental models of acute lung injury. Some progress has been made in understanding how alveolar barrier injury occurs, especially in bacterial pneumonia. Finally, while it is recognized that alveolar epithelial type II cells play an important role in both ion transport and surfactant production, it is now possible to study in vitro the contribution of alveolar epithelial type II cells in repair of the denuded alveolar barrier.

Restructuring the surgical process after regional reform in Emilia-Romagna: an action-research project at Rizzoli Orthopedic Institute

BACKGROUND

Hospitals performing surgery in Italy underwent important transformations in recent years, with decreasing economic resources and higher expected standards of care. Regional authorities acted differently across the country to adapt to the new scenario, generating heterogeneous outcomes. The Rizzoli Orthopedic Institute (ROI) in the Emilia-Romagna region started its reorganization in 2017, after the issue of new regional regulations about surgical activity. Aim of this paper is to describe the actions taken at ROI and discuss their outcomes.

STUDY DESIGN

Action-research.

METHODS

From 2017 to 2019 an action-research project was developed to introduce organizational changes within ROI and close the existing gaps between regional requirements and actual features of the Institute. Four areas of intervention were identified: surgical scheduling, appropriateness of surgical setting, monitoring and management of the surgical path and accountability. Progress was monitored through the collection of performance indicators and qualitative investigation of the organizational culture.

RESULTS

Changes were implemented in all areas of intervention. Key features were the introduction of Operating Room Management (ORM) skills and the establishment of multiprofessional teams to drive the changes. Performance indicators showed a positive trend in the comparison between 2017 and 2018. Improvements were observed in terms of productivity, scheduling, and respect of standard waiting time, while case-mix did not significantly change.

CONCLUSIONS

Effective ORM and collaborative practices can successfully drive the change towards a more efficient surgical process without increasing resources consumption.

[Laparoscopic cholecystectomy. An analysis of the reasons for a conversion to conventional surgery in an elective surgery department]

BACKGROUND

To assess which factors determined conversion to laparotomy in patients undergoing laparoscopic elective cholecystectomy.

SETTING

department of General Surgery. University of Genoa. Italy.

METHODS

Two hundred sixty-four consecutive laparoscopic cholecystectomies were performed in our Department.

INTERVENTIONS

laparoscopic cholecystectomy was performed according to Dubois's technique. Duration of the procedure was not considered a reason for conversion.

RESULTS

121 patients showed "difficult intraoperative situations" with further conversion risk factor. Conversion to laparotomy was necessary in 11 patients (4.16%). Five patients underwent conversion in the first 50 cases (10%), while six in the last 214 (2.8%). We had to convert to open cholecystectomy only in eleven patients, despite the high rate of technical difficulties and anatomic anomalies even in cases which, in the past, represented a contraindication to this kind of technique. The use of new instruments and new surgical techniques has reduced to only factors of increased risk in those situations that in the past were considered as contraindications to laparoscopic cholecystectomy.

CONCLUSIONS

Conversion to open cholecystectomy is based on the surgeon's decision and the safety should be the main consideration in performing laparoscopic cholecystectomy. The use of a careful dissection could avoid the conversion in many patients.

[Medical-surgical integrated approach in the treatment of non-paraneoplasic hyperparathyroidism: our experience]

OBJECTIVE

Hyperparathyroidism is a generalized alteration of calcium, phosphorus and bone metabolism due to an increased secretion of parathyroid hormone (PTH). In addition to the paraneoplastic ectopic type, we can distinguish three eutopic types of hyperparathyroidism, i.e., the primary form, mostly due to a benign or malignant tumor of parathyroid gland, the secondary form, typical of kidney disease and tertiary form, due to the progression of secondary forms. There is not agreement, in medical literature, on the treatment of these patients. To establish the correct therapeutic approach in patients with hyperparathyroidism, we have followed a group of symptomatic subjects suffering from primary, secondary and tertiary hyperparathyroidism, taking into account the therapeutic needs.

METHODS

We followed for 12 months 155 patients suffering from primary, secondary and tertiary hyperparathyroidism; 82 were in end stage kidney disease, 93 were hypertensive. Subjects with primary forms has been treated, before parathyroidectomy, with hydration (physiological solution of NaCl), bisphosphonates i.v. (pamidronate 60-90 mg in 4-6h) and, if serum calcium was higher than 12 mg/dl, loop diuretics (furosemide 40 mg/day). Subjects with secondary forms has been treated with hypo-phosphoric diet, phosphate bindings (calcium carbonate 1 g/day) and oral calcitriol (1 microg/d) before subtotal parathyroidectomy. After surgery it was administered support therapy with calcium gluconate (40 ml/day) and vitamin D (2.5mg/d) until serum calcium normalization.

RESULTS

There were 55 cases of post surgery hypertensive attack treated with clonidine (300 microg/d); 8 months later there was not relapses but in all patients there was reduction of serum calcium concentration that required a substitutive treatment (calcium 1 g/day and calcitriol 1 microg/day). There was 1 case of heavy hypocalcemic state treated with calcium gluconate i.v. (40 ml/day).

CONCLUSIONS

A correct approach to a non-paraneoplastic hyper-parathyroid patient need of an integration of both current medical and surgical options. In primary forms the fi rst option is the surgical approach supported by medical treatment. In secondary forms medical approach is preferable to control renal and vascular complications, while surgical therapy is to prefer in non-responders to medical therapy forms.

Posterior tibial nerve stimulation: is the once-a-week protocol the best option?

AIM

Aim of our study was to compare the results of posterior tibial nerve stimulation (PTNS) performed weekly with those of PTNS performed 3 times per week in patients with overactive bladder syndrome.

METHODS

Thirty-five patients (28 females, 7 males) with overactive bladder syndrome not responding to antimuscarinic therapy were enrolled in a prospective study. A total of 17 out of 35 patients were randomly assigned to group A and treated with a PTNS protocol based on weekly stimulation sessions; 18 out of 35 patients were randomly assigned to group B and treated with a PTNS protocol based on stimulation sessions performed 3 times per week. All subjects were evaluated by means of 24 h bladder diaries, quality of life questionnaires (I-QoL, SF36) and urodynamic evaluation before and after treatment. Patients were asked after each stimulation session to give their opinion on the efficacy of the treatment. We have considered ''success'' those patients who presented a reduction >50% of the micturition episodes/24 h (ME/24) or (if incontinent) of the incontinence episodes/24 h (IE/24). Results before and after treatments in both groups were collected and statistically compared.

RESULTS

As a whole, 11/17 patients (63%) in group A and 12/18 patients (67%) in group B were considered ''success''; 4/11 (36%) incontinent patients in group A and 5/11 (45%) incontinent patients in group B were completely cured after treatment. In both groups, patients reported subjective improvement after 6-8 stimulation sessions.

CONCLUSIONS

Our findings seem to show that the periodicity of stimulation does not effect the results of PTNS treatment. The advantage of more frequent stimulation sessions is to achieve earlier a clinical improvement.

Understanding emerging regulation: The role of frontal electroencephalography asymmetry and negative affectivity

The present study examined frontal electroencephalography (EEG) asymmetry and negative affectivity (NA) as predictors of infant behaviors during the Still-Face Paradigm (SFP). It was hypothesized that infants with lower NA subscale scores who also demonstrate greater left frontal activation would exhibit more frequent social engagement and self-soothing behaviors during the SFP. Mothers reported infant temperament at 6-12 months of age (N = 62), and EEG was recorded during a baseline task and the SFP. Social engagement, distress, and self-soothing behaviors were coded during the SFP. A three-factor solution emerged based on exploratory factor analysis of eight infant behaviors. After considering bivariate relations, multiple regression analyses predicting the behavior factor labeled social engagement (containing vocalizations and handwaving; average factor loading = .56) were conducted separately for asymmetry and NA subscales, controlling for infant sex and age. The SFP asymmetry predicted social engagement after controlling for covariates and baseline asymmetry; however, NA subscales (falling reactivity and distress to limitations) did not uniquely explain significant variance. These findings highlight the importance of frontal EEG asymmetry in contributing to emerging social engagement and regulation in infancy. Implications include potentially utilizing asymmetry markers as screening and intervention targets in the first year of life.

Achieving RoutIne Screening for Emotional health (ARISE) in pediatric subspecialty clinics

OBJECTIVE

This study aims to describe the experience of implementing a psychosocial distress screening system for children with serious or chronic medical conditions.

METHODS

Achieving RoutIne Screening for Emotional health (ARISE) was developed to systematically evaluate psychosocial distress in children with serious medical or chronic medical illnesses, by integrating patient-reported outcome measures (PROM) into care delivery. ARISE was developed using a user-centered approach with extensive input from patients, families, and healthcare professionals to overcome barriers to routine PROM collection and integration into care as usual. It comprises a system to capture PROMs and then relay results to clinicians for changing care. We sought to implement ARISE at four subspecialty pediatric clinics caring for patients with cystic fibrosis, sickle cell disease, hemophilia, and neurological malignancy.

RESULTS

Problems with acceptability, appropriateness, and feasibility represented barriers to implementation which were overcome by modifying the intervention using stakeholder input during the planning phase, leading to broad program acceptance. ARISE was implemented in three of the four clinics, in which 79.8% of eligible children and their family completed PROMs.

CONCLUSION

The ARISE program demonstrated the feasibility and effectiveness of integrating psychosocial screenings into subspecialty pediatric clinics, thereby enhancing the identification and management of psychosocial issues in children with serious and chronic medical illnesses.