Maxillofacial Injuries in Padel Game

Background

Maxillofacial injuries are very frequent in the sports environment. Padel is a new sport of Mexican origin, very popular in Mexico, Spain, and Italy, but with a rapid spread in Europe and other continents.

Aims

The aim of this article is to report our experience of 16 patients with maxillofacial injuries that occurred during padel matches in 2021. All these injuries occurred due to the racket bouncing against the glass of the padel court. The bounce of the racquet is given either because the player was trying to hit the ball near the glass or by throwing the racket against the glass for an act of nervousness.

Methods

We carried out a literature review about sports traumas, and we calculated the possible force with which the racket, once bounced off the glass, hits the players' faces.

Results and Conclusions

The racket, bouncing off the glass wall, arrives with a specific force in the face of the player who threw the racket, being able to cause skin wounds, injuries, and fractures mainly at the level of the dentoalveolar junction.

POS1199 IS PSORIATIC ARTHRITIS A RISK FACTOR FOR SEVERE COVID -19 INFECTION? DATA FROM THE ARGENTINIAN REGISTRY SAR-COVID

Background

Comorbidities, particularly cardio-metabolic disorders, are highly prevalent in patients with psoriatic arthritis (PsA) and they were associated with an increased risk of atherosclerotic cardiovascular disease, which have been associated with higher morbidity and mortality. Whether PsA enhances the risk of SARS-CoV-2 infection or affects the disease outcome remains to be ascertained.

Objectives

To describe the sociodemographic, clinical and treatment characteristics of patients with PsA with confirmed SARS-CoV-2 infection from the SAR-COVID registry and to identify the variables associated with poor COVID-19 outcomes, comparing them with those with rheumatoid arthritis (RA).

Methods

Cross-sectional observational study including patients ≥18 years old, with diagnosis of PsA (CASPAR criteria) and RA (ACR / EULAR 2010 criteria), who had confirmed SARS-CoV-2 infection (RT-PCR or serology) from the SAR-COVID registry. Recruitment period was between August 13, 2020 and July 31, 2021. Sociodemographic variables, comorbidities, and treatments were analyzed. To assess the severity of the infection, the ordinal scale of the National Institute of Allergy and Infectious Diseases (NIAID)1 was used, and it was considered that a patient met the primary outcome, if they presented criteria of categories 5 or higher on the severity scale. For this analysis, Chi2 test, Fisher’s test, Student’s test or Wilcoxon test, and binomial logistic regression using NIAID>=5 as dependent variable were performed.

Results

A total of 129 PsA patients and 808 with RA were included. Clinical characteristics are shown in Table 1. Regarding PsA treatment, 12.4% of PsA were receiving IL-17 inhibitors, 5.4% IL12-23 inhibitors, one patient apremilast and one abatacept. The frequency of NIAID≥5 was comparable between groups (PsA 19.5% vs RA 20.1%; p=0.976). (Figure 1).

Table 1.

Characteristics of patients with PsA and RA who presented COVID-19 in the SAR-COVID registry.

Psoriatic arthritis (n=129)Rheumatoid arthritis (n=808)P valueTotal (n=937)Age (years), mean (SD)51.7 (12.7)53.1 (12.9)0.23952.9 (12.9)Female72 (55.8)684 (84.7)<0.001756 (80.7)Comorbidities65 (50.4)355 (43.9)0.203420 (44.8) Obesity (BMI ≥30)19 (15.2)102 (13.4)0.692121 (13.7) Morbid obesity (BMI ≥40)1 (0.8)10 (1.3)111 (1.25) Hypertension35 (28.5)205 (26.8)0.783240 (27.0) Diabetes16 (13.0)67 (8.8)0.18883 (9.39) Dyslipidemia24 (19.5)102 (13.5)0.106126 (14.4) Cardiovascular or cerebrovascular disease5 (11.4)32 (3.9)0.03337 (4.2)Two or more comorbidities55 (42.6)219 (27.1)<0.001274 (29.2)Current smoking4 (3.6)60 (8.4)0.7964 (7.7)High disease activity0 (0)29 (3.8)0.02729 (3.23)Glucocorticoids treatment5 (20.0)95 (60.1)<0.001100 (54.6)Conventional DMARDs47 (36.4)443 (54.8)<0.001490 (52.3)Biologic DMARDs60 (46.5)193 (23.9)<0.001253 (27.0)JAK inhibitors4 (3.10)72 (8.9)0.03876 (8.1)Full recovery of COVID-19105 (84.0)644 (81.7)0.127749 (82.0)COVID-19 complications16 (12.5)68 (8.7)0.22784 (9.2)Death due to COVID-191 (0.8)34 (4.3)0.07435 (3.8)

Notes=values n (%) unless otherwise indicated; BMI: Body Mass Index; DMARDs: disease-modifying antirheumatic drugs; JAK inhibitors: Janus kinase inhibitors.

PsA patients with NIAID≥5 in comparison with NIAID<5 were older (58.6±11.4 vs 50±12.5; p=0.002), had more frequently hypertension (52.2% vs 23%; p=0.011) and dyslipidemia (39.1% vs 15%; p=0.017). In the multivariate analysis, age (OR 1.06; 95% CI 1.02–1.11) was associated with a worse outcome of the COVID-19 (NIAID≥5) in patients with PsA, while those who received methotrexate (OR 0.34; 95% CI 0.11–0.92) and biological DMARDs (OR 0.28; 95% CI 0.09–0.78) had a better outcome.

Conclusion

Although PsA patients have a higher frequency of cardiovascular and metabolic comorbidities than those with RA, the COVID-19 severity was similar. Most of the patients had mild SARS-CoV-2 infection and a low death rate.

References

[1]Beigel JH, et al. Remdesivir for the Treatment of Covid-19 - Final Report. N Engl J Med. 2020 Nov 5;383(19):1813-1826.

Disclosure of Interests

None declared

POS1200 DIFFERENCES BETWEEN THE FIRST AND THE SECOND WAVE OF SARS-COV-2 INFECTION IN PATIENTS WITH IMMUNE-MEDIATED INFLAMMATORY DISEASES IN ARGENTINA: DATA FROM THE SAR-COVID REGISTRY

Background

In Argentina we have witnessed two COVID 19 waves between 2020 and 2021. The first wave occurred during the spring of 2020 and it was related to the wild type of the virus, the second occurred during the fall/winter of 2021 when the gamma variant showed a clear predominance. During the first wave, patient with rheumatic diseases showed a higher frequency of hospitalization and mortality (4% vs 0.26%) when compared to the general population1; at that time, however, vaccination was not yet available.

Objectives

To compare sociodemographic and disease characteristics, course and outcomes of SARS-CoV-2 infection in patients with immune-mediated/autoinflammatory diseases (IMADs) during the first and second waves in Argentina.

Methods

SAR-COVID is a national, multicenter, longitudinal and observational registry, in which patients ≥18 years of age, with a diagnosis of a rheumatic disease who had confirmed SARS-CoV-2 infection (RT-PCR or positive serology) were consecutively included since August 2020. For the purpose of this report, only patients with IMADs who had SARS-CoV-2 infection during the first wave (defined as cases occurred between March 2020 and March 2021) and the second wave (cases occurred between April and August 2021) were examined. Sociodemographic characteristics, disease diagnosis and activity, comorbidities, immunosuppressive treatment and COVID 19 clinical characteristics, complications and outcomes: hospitalization, intensive care unit (ICU) admission, use of mechanical ventilation and death were compared among groups. Descriptive statistical analysis was performed. Variables were compared with Chi squared test and Student T test or Mann Whitney test. Multivariable logistic regression models with forward and backward selection method, using hospitalization, ICU admission and death as dependent variables were carried out.

Results

A total of 1777 patients were included, 1342 from the first wave and 435 of the second one. Patients had a mean (SD) age of 50.7 (14.2) years and 81% were female. Both groups of patients were similar in terms of socio-demographic features, disease diagnosis, disease activity, the use of glucocorticoids ≥ 10 mg/day and the immunosuppressive drugs (Table 1 below). Patients infected during the first wave have higher frequency of comorbidities (49% vs 41%; p= 0.004). Hospitalizations due to COVID 19 (31% vs 20%; p <0.001) and ICU admissions (9% vs 5%; p= 0.009) were higher during the first wave. No differences in the use of mechanical ventilation (16% vs 16%; p= 0.97) nor in the mortality rate (5% vs 4%; p= 0.41) were observed. In the multivariable analysis, after adjusting for demographics, clinical features and immunosuppressive treatment, patients infected during the second wave were 40% less likely to be hospitalized (OR= 0.6, IC95% 0.4-0.8) and to be admitted to the ICU (OR= 0.6, IC95% 0.3-0.9).

Table 1.Variable (% or Mean – SD)First wave(n=1342)Second wave(n=435)p ValueFemale gender81800.7Age (years)51.0 (14.5)50.0 (13.3)0.2Disease diagnosis Rheumatoid arthritis46461 Ankylosing spondylitis10110.8 Systemic lupus erythematosus171850.9 Systemic Scleroderma551 Sjögren´s syndrome650.7 Inflammatory myopathies330.5 Vasculitis430.4Disease activity High430.5Use of immune modulatorsDMARDcs53560.2DMARDts460.1DMARDb82821Use of glucocorticoids ≥10 mg12120.9Comorbidities49410.004

Conclusion

The impact of COVID 19 in Argentina, in terms of mortality in patients with IMADs was still higher compared to the general population during the second wave. However, the frequency of hospitalizations and ICU admissions was lower. These findings could be explained by the introduction of the SARS COV 2 vaccination and, probably, by the cumulative knowledge and management improvement of this infection among physicians.

References

[1]Isnardi CA et al. Epidemiology and outcomes of patients with rheumatic diseases and SARS-COV-2 infection: data from the argentinean SAR-COVID Registry. Ann Rheum Dis, 2021, suppl 1, 887.

Disclosure of Interests

None declared

Ocular cicatricial pemphigoid: Methotrexate as an initial treatment?

OBJECTIVE

To analyse the clinical/epidemiological data, the management and the treatments established in patients with Ocular Cicatricial Pemphigoid (OCP) in a Rheumatology Service.

MATERIAL AND METHODS

Review of clinical histories of patients with OCP referred by ophthalmology between 2008 and 2019.

RESULTS

In our series of 27 patients, 67% were diagnosed and referred in the last 2 years. Most in Foster stage 1. Of the patients, 18.5% presented associated Sjogren's syndrome, with poor progression: 88.8% received Methotrexate, 74% used it as monotherapy and 66% continued with said treatment up to the end. Eighteen point five percent had to combine or rotate therapies, the drugs used were mycophenolate, azathioprine, cyclophosphamide, sirolimus, etanercept, rituximab: 29% used steroids. Only in 2 eyes was stage progression observed. There were no serious adverse events, and 37% had mild adverse events.

CONCLUSION

Starting immunosuppressive therapy early is essential, methotrexate being a good initial alternative in our experience, and treatment must be escalated in line with disease progression.

Ocular Cicatricial Pemphigoid: Methotrexate as an Initial Treatment?

OBJECTIVE

To analyse the clinical / epidemiological data, the management and the treatments established in patients with ocular cicatricial pemphigoid in a Rheumatology Service.

MATERIAL AND METHODS

Review of clinical histories of patients with ocular cicatricial pemphigoid referred by ophthalmology between 2008 and 2019.

RESULTS

In our series of 27 patients, 67% were diagnosed and referred in the last 2 years. Most in Foster stage 1. Of the patients, 18.5% presented associated Sjogren's syndrome, with poor progression: 88.8% received Methotrexate, 74% used it as monotherapy and 66% continued with said treatment up to the end. Eighteen point five percent had to combine or rotate therapies, the drugs used were mycophenolate, azathioprine, cyclophosphamide, sirolimus, etanercept, rituximab: 29% used steroids. Only in 2 eyes was stage progression observed. There were no serious adverse events, and 37% had mild adverse events.

CONCLUSION

Starting immunosuppressive therapy early is essential, methotrexate being a good initial alternative in our experience, and treatment must be escalated in line with disease progression.

PPHN and oxidative stress: a review of literature

Persistent pulmonary hypertension of the neonate is a multifactorial condition characterized by maladaptive pulmonary vascular remodeling and abnormal contractile reactivity. This review evaluates the role of oxidative stress and antioxidant treatment on the persistent pulmonary hypertension of the neonate.

Conservative management in congenital severe bilateral hydronephrosis related to uretero-pelvic junction obstruction

We report our experience in conservative management of patients with prenatal and neonatal diagnosis of severe bilateral ureteropelvic junction obstruction (UPJO), focusing on the actual predictors of renal function impairment or spontaneous resolution. Between 1996 and 2006, 20 patients with bilateral severe hydronephrosis related to UPJO were included in the study. Indications for surgery were an increased hydronephrosis, decreased renal function, onset of symptoms. Conservatively treated patients were followed up for 3 months to 10 years with renal ultrasound, DTPA diuretic, urine culture. At first renal scan, 22 out of 40 renal units had a poor, 10 an intermediary and 8 a good drainage. Pyeloplasty was required in 10 of the 40 kidneys, while 30 out of 40 kidneys were followed conservatively. At the end of follow up, sieric normalized creatinine and estimated glomerular filtration rate were normal in all patients. Our data showed that bilateral severe hydronephrosis related to UPJO can be safely managed in a similar manner of a unilateral case. A poor drainage could be considered a negative predictive factor in the feasibility of a conservative management.

A long-term follow-up in conservative management of unilateral ureteropelvic junction obstruction with poor drainage and good renal function

The aim of the study was to retrospectively review the outcome of neonatal ureteropelvic junction obstruction with a good renal function and a poor drainage at a first diuretic renal scan, in cases where surgery was recommended on the basis of a loss of renal function, worsening of hydronephrosis or occurrence of clinical symptoms. Hydronephrosis was graded from 1 to 4 or as ureteral tract dilatation (UTD) P1 to UTD P3. During follow-up, 15 out of 38 patients (34.2%) required surgery while 25 out of 38 (65.8%) could have been managed conservatively. In patients with grade 2, 3, and 4 hydronephrosis, the ureteropelvic junction obstruction resolved or improved spontaneously in 100%, 63%, and 33% of cases (in 100% of UTD P1, 67% of UTD P2, and 50% of UTD P3), respectively. The median of follow-up was 14 years. Chi-square test showed a significant relationship between initial grade of hydronephrosis or UTD and the possibility of an efficient conservative management (p = 0.0088 and p = 0.0460).Conclusion: Conservative management can be safely achieved in ureteropelvic junction obstruction with poor drainage. Scheduled controls are needed for early discovery of functional renal deterioration. High-grade hydronephrosis is unlikely to resolve spontaneously and is often accompanied by a loss of renal function during the first years of life. What is Known: • There is controversy about which management should be adopted in infants with unilateral ureteropelvic junction obstruction with poor drainage but good differential renal function. What is New: • Long-term follow-up suggests that conservative management can be safely achieved also in unilateral ureteropelvic junction obstruction with poor drainage in more than 60% of cases, even if high-grade hydronephrosis is unlikely to resolve spontaneously and it is often accompanied by a loss of renal function during the first years of life. In our experience, surgical intervention was required in more than 50% of cases before 1 year of life and in all cases before 3 years of life.

Are tree squirrels involved in the circulation of flaviviruses in Italy?

West Nile virus (WNV), Usutu virus (USUV) and tick-borne encephalitis virus (TBEV) are emerging zoonotic flaviviruses (family Flaviviridae), which have circulated in Europe in the past decade. A cross-sectional study was conducted to assess exposure to these antigenically related flaviviruses in eastern grey squirrels (Sciurus carolinensis) in Italy. Seventeen out of 158 (10.8%; CI_95% : 5.9-15.6) squirrels' sera tested through bELISA had antibodies against flaviviruses. Specific neutralizing antibodies to WNV, USUV and TBEV were detected by virus neutralization tests. Our results indicate that tree squirrels are exposed to Culex and tick-borne zoonotic flaviviruses in Italy. Moreover, this study shows for the first time USUV and TBEV exposure in grey squirrels, broadening the host range reported for these viruses. Even though further studies are needed to define the real role of tree squirrels in the epidemiology of flaviviruses in Europe, this study highlights that serology could be an effective approach for future investigations aimed at broadening our knowledge about the species exposed to these zoonotic infections.

A cross-sectional nationwide survey on esophageal atresia and tracheoesophageal fistula

BACKGROUND

Our study aims at disclosing epidemiology and most relevant clinical features of esophageal atresia (EA) pointing to a model of multicentre collaboration.

METHODS

A detailed questionnaire was sent to all Italian Units of pediatric surgery in order to collect data of patients born with EA between January and December 2012. The results were crosschecked by matching date and place of birth of the patients with those of diagnosis-related group provided by the Italian Ministry of Health (MOH).

RESULTS

A total of 146 questionnaires were returned plus a further 32 patients reported in the MOH database. Basing on a total of 178 patients with EA born in Italy in 2012, the incidence of EA was calculated in 3.33 per 10,000 live births. Antenatal diagnosis was suspected in 29.5% patients. 55.5% showed associated anomalies. The most common type of EA was Gross type C (89%). Postoperative complications occurred in 37% of type C EA and 100% of type A EA. A 9.5% mortality rate was reported.

CONCLUSIONS

This is the first Italian cross-sectional nationwide survey on EA. We can now develop shared guidelines and provide more reliable prognostic expectations for our patients.

Paediatric ulcerative colitis surgery: Italian survey

BACKGROUND AND AIMS

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons.

METHODS

This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected.

RESULTS

Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively.

CONCLUSIONS

This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

Colonic stenosis post-necrotizing enterocolitis in term newborn with acquired cytomegalovirus infection

Necrotizing enterocolitis is a gastrointestinal emergency typical of premature infants. Intestinal strictures infrequently complicate medical or surgical treatment of necrotizing enterocolitis. Postnatal cytomegalovirus infection with gastrointestinal linvolvement has occasionally been described in subjects with necrotizing enterocolitis. We report the case of a full term infant presenting necrotizing enterocolitis, acquired cytomegalovirus infection and post necrotizing enterocolitis colonic stricture.List of abbreviations: necrotizing enterocolitis = NEC,cytomegalovirus = CMV.

CO(2) pneumoperitoneum induces in vitro hypoxic response culminating in apoptosis of human neuroblastoma cells

The ablative role of minimally invasive surgery (MIS) in neuroblastoma (NB) is still controversial due to the possible CO₂ pneumoperitoneum side-effects on tumor aggressiveness. It is known that CO₂ produces hypoxic condition with changes in tumor microenvironment influencing cell functions. Here we investigated whether CO₂ exposure affects the transcription factor HIF-1α and the apoptotic signalling pathway in SH-SY5Y NB cells. SH-SY5Y cells were exposed to a pressure of 15 mmHg CO₂ (100%) for 4 h (T0) and then moved to normal condition for 24 h (T₂₄). In control and CO₂ -exposed cells, we analyzed the mRNA levels and DNA binding activity of HIF-1α. We also evaluated the proliferative activity and cell viability as well as caspase-9/3 cleavage and nuclear fragmentation. A significant increase in HIF- 1α activation was observed in SH-SY5Y cells exposed to CO₂ compared to control cells. CO₂ treatment also decreased the proliferation rate and the percentage of viable cells. In addition, the expression and cleavage of caspase-9 and -3 were significantly increased in NB cells exposed to CO₂. These data correlated with apoptotic feature observed in CO₂ -treated NB cells. Our findings show that CO₂ -induced hypoxic condition exerts cytotoxic effects on NB cells by eliciting mitochondrial apoptotic pathway and thereby improving the understanding of the possible clinical impact of CO₂ pneumoperitoneum on NB behaviour.

Effects of ischaemic post-conditioning on the early and late testicular damage after experimental testis ischaemia-reperfusion

Ischaemic post-conditioning (IPostC) might represent an innovative surgical approach to protect organs from ischaemia and reperfusion (I/R) injury. We investigated the molecular mechanisms underlying the contrasting effects of IPostC on the early and late damage induced by testicular I/R injury. Testis I/R was induced by occluding the right testicular vessels using a clip. Male rats were divided into the following groups: sham, I/R and I/R + IPostC. In the I/R group, the clip was removed after 60 min of ischaemia, and reperfusion was allowed for 30 min, 1 and 30 days. In the I/R + IPostC group, three cycles of 30-sec reperfusion and 30-sec ischaemia were performed after 60 min of ischaemia and then reperfusion followed up for 30 min, 1 and 30 days. Following 30-min reperfusion, there was an increase in mitogen-activated protein kinases (MAPKs) in I/R rats; after 1 day of reperfusion, interleukin-6, tumour necrosis factor-α and nuclear factor-κB (NF-κB) expression were significantly increased; IκB-α expression reduced; and a marked damage in both testes was observed. IPostC inhibited MAPKs, cytokines and NF-κB expression, augmented IκB-α expression and decreased histological damage in testes subjected to I/R. After 30 days of reperfusion, I/R injury activated the apoptosis machinery, caused severe histological damage and reduced spermatogenic activity. By contrast, IPostC did not modify the apoptotic markers, the histological alterations as well as spermatogenic activity following 30 days of reperfusion. Our data demonstrate that IPostC protects the testis from the early damage induced by I/R injury, but it does not protect against the late damage.

Feasibility of protein-sparing modified fast by tube (ProMoFasT) in obesity treatment: a phase II pilot trial on clinical safety and efficacy (appetite control, body composition, muscular strength, metabolic pattern, pulmonary function test)

Anecdotal data in the last few years suggest that protein-sparing modified diet (PSMF) delivered by naso-gastric tube enteral (with continuous feeding) could attain an significant weight loss and control of appetite oral feeding, but no phase II studies on safety and efficacy have been done up to now. To verify the safety and efficacy of a protein-sparing modified fast administered by naso-gastric tube (ProMoFasT) for 10 days followed by 20 days of a low-calorie diet, in patients with morbid obesity (appetite control, fat free mass maintenance, pulmonary function tests and metabolic pattern, side effects), 26 patients with a BMI ≥30 kg/m2 have been selected. The patients had to follow a protein-sparing fast by enteral nutrition (ProMoFasT) for 24 h/day, for 10 days followed by 20 days of low-calorie diet (LCD). The endpoint was represented by body weight, BMI, abdominal circumference, Haber's appetite test, body composition by body impedance assessment (BIA), handgrip strength test, metabolic pattern, pulmonary function test. Safety was assessed by evaluation of complications and side effects of PSMF and/or enteral nutrition. In this report the results on safety and efficacy are described after 10 and 30 days of treatment. After the recruiting phase, a total of 22 patients out of 26 enrolled [14 (63.6 %) females] were evaluated in this study. Globally almost all clinical parameters changed significantly during first 10 days. Total body weight significantly decreased after 10 days (∆-6.1 ± 2; p < 0.001) and this decrease is maintained in the following 20 days of LCD (∆ = -5.88 ± 1.79; p < 0.001). Also the abdominal circumference significantly decreased after 10 days [median (range): -4.5 (-30 to 0); p < 0.001] maintained then in the following 20 days of LCD [median (range) = -7 (-23.5 to -2); p < 0.001]. All BIA parameters significantly changed after 10 and 30 days from baseline. All parameters except BF had a significant change after 10 days of treatment while the difference at 30 days was lower than at 10 days for TBW, FFM and MM with no significant differences from baseline for the last two characteristics. For VAS appetite the difference was significant after 10 days and the decrease in appetite was maintained at 30 days with no significant difference (p = 0.83) between 10 and 30 days. No significant differences in the first 30 days were detected for PA and for both left and right hand grip strength. Particularly, a significant reduction of 1.82 kg in FFM after 10 days was detected, but not after 30 days. In contrast, a decrease of 3.8 kg of BF is observed after 30 days. As far as the respiratory functional tests (RFT) are concerned, a significant difference at 10 days was globally observed for functional residual capacity (p = 0.012) and expiratory reserve volume (p = 0.025). There are no reported major complications and side effects resulting from the enteral nutrition or PSMF. In particular, cardiac arrhythmias have not been reported. From the clinical point of view the PSMF with naso-gastric tube (ProMoFasT) method appears safe, it is associated with a significant weight loss related to decrease of FM and not to loss of FFM and appetite decreases. It is relevant that the RFT are significantly improved after only 10 days suggesting the efficacy of this regime in short period, too. These preliminary data underline the necessity to increase the number of RCT for this method, which could represent a possible alternative to other methodologies, such as the intragastric balloon, in particular when it is recommended to improve RFT before bariatric, gynecological, orthopedic and lymphatic surgery.

Natural history of non-operative treatment for renal injuries in children

AIM

Kidney is one of the solid organs injured in blunt abdominal traumas. Conservative management is well recognized in adults, but is still controversial in children. We performed a retrospective review regarding children with renal injuries observed at our Centre, analyzing the importance of a prompt diagnosis and the role of conservative treatment according to the degree of renal injury and natural history.

METHODS

We reviewed 15 cases of blunt abdominal trauma with renal injuries observed during a period of 11 years. The diagnosis was confirmed by abdominal computed tomography (CT) scan and ultrasonography (US). Conservative treatment started monitoring the hemodynamic stability, the hematocrit value, the hemoglobin, the red cell count, the urine analysis. If necessary blood transfusion was performed. A follow-up from 1 month to 2 years monitored the lesions healing.

RESULTS

Age of patients varied from 3 to 15 years (mean age = 6.3). Nine were males and six females. Two patients had an associated spleen lesion, thirteen had an isolated renal injury. Injury grades were classified as follows: grade I, 5 cases; grade II, 3 cases; grade III, 5 cases and grade IV, 2 cases. Non operative management was successful in 14 out of 15 cases; 1 patient with grade IV required a partial nephrectomy. At follow-up good healing of the lesions was observed.

CONCLUSION

Most of renal injury related to abdominal trauma can be successfully and safely managed conservatively. Hemodynamic stability, a prompt clinical and instrumental diagnosis and grading of lesions by CT are necessary to start an effective non operative treatment.

Molecular pathways involved in the early and late damage induced by testis ischemia: evidence for a rational pharmacological modulation

Testicular torsion or torsion of the spermatic cord is a surgical emergency in which misdiagnosis and inappropriate treatment can lead to male infertility. Events occurring during testicular torsion and detorsion are representative of an ischemia-reperfusion injury observed in other organs. The two most important factors determining testicular damage are the degree of twisting and the early onset of a surgical treatment to counter-rotate both testis and spermatic cord for inducing reperfusion. The damage from reperfusion is more severe than that induced by ischemia and several mechanisms are implicated in the development of testicular damage following torsion and detorsion. However, these mechanisms have not yet been fully clarified and, as a consequence, there is still a strong need to identify specific pharmacological treatment to limit the damage triggered by the reperfusion procedures. Ischemia and reperfusion of testis result in elevated production of reactive oxygen species (ROS), activate mitogen activated protein kinases (MAPKs) and PPARβ/δ receptor, induce transcription factors and growth factors including NF-κB and VEGF, trigger apoptotic machinery and induce several inflammatory cytokines, including TNF-α and IL-1β . This pathological cascade is responsible for the testicular atrophy, decreased blood flow and impaired spermatogenesis. Several pharmacological approaches have been characterized as promising therapeutic agents for the management of testicular torsion and may be useful to ameliorate the sequel of this disease.

Effects of polydeoxyribonucleotide on the histological damage and the altered spermatogenesis induced by testicular ischaemia and reperfusion in rats

The effects of polydeoxyribonucleotide (PDRN), an agonist of the A2A adenosine receptors which when activated positively influences sperm activity, were tested in an experimental testicular ischaemia/reperfusion injury model. Anaesthetized male Sprague-Dawley rats were subjected to testicular torsion-induced ischaemia, followed by reperfusion (TI/R). Immediately after detorsion, randomized animals, including SHAM, received intraperitoneal injections of: (i) vehicle (1 mL/kg 0.9% NaCl solution); (ii) PDRN (8 mg/kg); (iii) DMPX (3,7-dimethyl-1-propargilxanthine, 0.1 mg/kg); or (iv) PDRN (8 mg/kg) + DMPX (0.1 mg/kg). Animals were euthanized at 1, 7 and 30 days following reperfusion. Vascular endothelial growth factor (VEGF) expression is normally associated with adenosine A2A receptor stimulation. After treatment, VEGF mRNA/protein expression quantified by qPCR and Western blot, vascular endothelial growth factor receptor-1 (VEGFR1) and endothelial nitric oxide synthase (eNOS) mRNA measured by qPCR, VEGF and VEGFR1 assessed using immunohistochemical methods, histological staining and spermatogenic activity were all analysed. Testis ischaemia-reperfusion (TI/R) injury caused increases in VEGF mRNA and protein, VEGFR1 and eNOS mRNA, histological damage and reduced spermatogenic activity. Immunostaining showed a lower expression of VEGF in germinal epithelial cells and a strong expression of VEGFR1 in Leydig cells after TI/R. PDRN administration increased significantly VEGF message/protein, VEGFR1 and eNOS message, decreased histological damage and ameliorated spermatogenic activity. PDRN might be useful in the management of testicular torsion.

Anterior urethral valves in the fossa navicularis in a newborn: report of a case and review of the literature

Anterior urethral valves in the fossa navicularis is an exceptionally uncommon causes of lower urinary tract obstruction in newborn. The authors report a case of anterior urethral valves in thefossa navicularis in an 5 days-old boy, that observation of the voided stream revealed a filiform micturition and marked ballooing of the penile urethra. The meatus was located normally and of normal calibre. Voiding cystourethrography showed obstruction at the fossa navicularis, and a hyghly trabeculated bladder. Ultrasonography showed a severe bilateral hydroureteronephrosis. After a temporary soprapubic cystostomy, the urethroscopy revealed a valve on the floor of the fossa navicularis, excised with tenotomy scissor. Postoperatively ,urethral obstruction was relieved immediately by a good urinary stream. At 6 months follow-up the patient voided with a good stream and ultrasonography revealed complete disappearance of hydroureteronephrosis.

Neonatal intrathoracic gastric volvulus in Marfan's syndrome

Intrathoracic gastric volvulus is extremely rare in the newborn period. The authors describe the case of a newborn with unusual combination of intrathoracic gastric volvulus and Marfan's Syndrome and discuss its management.

Varicocele and infertility: why a prevention?

The varicocele is the abnormal dilation of the veins of the pampiniform plexus, resulting from an altered venous drainage, and it is considered one of the main causes of male infertility. In this paper we review the most recent observations on the histological, endocrinological, biochemical and clinical alterations reported in adolescents with left idiopathic varicocele. Data indicate that varicocele progressively impairs the reproductive function of the testis. Treatment could improve a number of such damages.

An uncommon case of associate intrinsic and extrinsic stenosis of the duodenum in newborn

The incidence of congenital combinations of extrinsic and intrinsic compression of duodenum is uncommon. The authors report a rare case of a neonate with a duodenal stenosis due to the contemporary presence of an annular pancreas and wind sock web. The diagnostic strategies and management will be discussed.

Case report of congenital fistula of the penile urethra

Isolated congenital fistula of the penile urethra is extremely rare. A case of congenital urethral fistula with an intact glandular urethra without chordee is reported with a discussion of the possible etiology and management.

C-kit positive interstitial cells of Cajal network in primary obstructive megaureter

AIM

Recent reports have shown an altered density of interstitial cells of Cajal (ICCs) and peripherin immunoreactive nerve fibres in uretopelvic junction obstruction. The aim was to investigate ICCs immunoexpression and ureteral innervation in primary obstructive megaureter (POM).

METHODS

Eight specimens of POM were obtained during tailoring. Restricted segments of ureters were divided from dilated segments. C-kit and peripherin immunohistochemistry were performed.

RESULTS

A normal distribution of ICCs was observed in both the circular and longitudinal muscle layers of the dilated segments. Marked muscle hypoplasia and sparse or no ICCs occurred in the longitudinal muscle layer of the restricted ureteral segments. A normal distribution of peripherin positive fibres was present in both the dilated and restricted segments.

CONCLUSIONS

Our data confirm defective muscularization in restricted aperistaltic POM. The lack of ICCs in the longitudinal muscular layer is probably due to the absence of c-kit positive muscle embryological precursors. No alteration in the peripherin immunoreactive nerve fibres network was observed in either the dilated or the restricted ureteral segments.

Interstitial cells of Cajal network in primary obstructive megaureter

OBJECTIVES

Recent reports showed an altered density of interstitial cells of Cajal (ICCs) and of peripherin immunoreactive nerve fibres in obstructed uretero-pelvic junction. Our aim was to investigate ICCs immunoexpression and ureteral innervation in primary obstructive megaureter (POM).

METHODS

8 specimens of POM were obtained during tailoring. Restricted segments of ureters were divided from the dilated ones. C-kit and peripherin immunohistochemistry were performed.

RESULTS

A normal distribution of ICCs was documented in both circular and longitudinal muscular layers of dilated segments. Marked muscular hypoplasia and a sparse or absent ICCs occurred in longitudinal muscular layer of restricted ureteral segments. A normal distribution of peripherin positive fibres was present in both dilated and restricted segments.

CONCLUSIONS

Our data confirmed a defective muscolarization in restricted, aperistaltic POM. The lacking of ICCs in the longitudinal muscular layer is, probably, due to the absence of c-kit positive muscular embryological precursors. No alteration of peripherin immunoreactive nerve fibres network was observed in both dilated and restricted ureteral segments.

Sarcoglycan immunoreactivity is lacking in infantile hypertrophic pyloric stenosis. A confocal laser scanning microscopic study

OBJECTIVES

The Dystrophin-Glycoprotein Complex (DGC) is a large multisubunit complex that plays a crucial role in maintaining the structural integrity and physiology of muscle fibers. Dystrophin has been reported to be absent in the pyloric muscle of infantile hypertrophic pyloric stenosis (IHPS) patients. The present study was designed to investigate the other two patterns of DGC (dystroglycan and sarcoglycan complexes) in normal pyloric muscle and their possible modifications in IHPS patients.

METHODS

Ten pyloric muscle biopsies were obtained from babies operated for IHPS and five control pylorus biopsy taken at autopsy from cases without gastrointestinal disease. The DGC sub-complexes (beta-dystroglican and beta, delta- sarcoglycans) were localized immunohistochemically using specific monoclonal antibodies. The results were evaluated using a confocal laser scanning microscope.

RESULTS

Positive immunolocalization of the two DGC sub complexes was demonstrated in the smooth muscle cells (SMCs) of the pyloric region of control patients. Similarly, a positive immune expression of beta-dystroglican was observed in the pyloric SMCs of IHPS patients. On the other hand a negative immunoreaction for sarcoglycans was recorded within the full thickness of the pyloric SMCs of these patients.

CONCLUSIONS

The absence of sarcoglycans within the hypertrophied pyloric muscle may be a predisposing factor in the pathogenesis of IHPS since it could alter the normal physiology of SMCs through the modifications of structural integrity of sarcolemma and signaling between the extracellular and intracellular compartment.

[Preputioplasty in the treatment of phimosis in pediatric age. Indications and results]

AIM

Phimosis is a common condition in the pediatric age. Circumcision has been the technique of choice for the surgical correction of this condition. As an alternative to circumcision different techniques of preputioplasty have been described in the last years. The aim of this paper was to report our experience with the preputioplasty technique in the treatment of phimosis in pediatric age.

METHODS

A preputioplasty is performed for phimosis correction in 109 patients aged between 4 and 16 years. Patients with a sclerotic phimosis were not treated with preputioplasty. All the patients underwent frenulotomy with dorsal preputial plasty using a single dorsal incision. Only in 3 patients a double lateral incision was necessary. Patients were operated under general anesthesia with an average time of 8 min.

RESULTS

Patients were followed-up at 8 days, 30 and 90 days postoperatively. The cosmetic result has been excellent in 90% of cases and good in 10%. The functional result has been excellent in all the patients. We observed 3 cases of infection and 8 cases of edema of the prepuce. These postoperative complications were all resolved with medical therapy. No recurrences have been observed.

CONCLUSIONS

Preputioplasty is a safe and rapid technique that allows to obtain excellent cosmetic and functional results. In our opinion, preputioplasty should be the first choice technique for the treatment of phimosis in pediatric and adolescent age.

Surgical correction of penoscrotal transposition associated with hypospadias and bifid scrotum: our experience of two-stage repair

OBJECTIVE

To assess the results of surgical correction of incomplete penoscrotal transposition and bifid scrotum using the Glenn-Anderson technique, and its impact on subsequent definitive urethroplasties and final outcome.

PATIENTS AND METHODS

We retrospectively reviewed 31 children that underwent two-stage repair for incomplete penoscrotal transposition with severe hypospadias and bifid scrotum. Patient age at stage 1 ranged from 12 to 24 months (average 16 months). The operative principle was based on achieving a normal anatomical position of the penis and scrotum using the Glenn-Anderson technique. In cases with associated scrotal or perineal hypospadias this was transformed into a penoscrotal hypospadias. Final stage urethroplasty was performed after a period of 6 months with a modified Thiersch-Duplay technique.

RESULTS

Cosmetic and functional results of the Glenn-Anderson operation were excellent. No major complications were observed. Of 31 patients, 12 (38%) had complications secondary to urethral repair.

CONCLUSION

The Glenn-Anderson technique for reconstruction of penoscrotal transposition and bifid scrotum is a simple technique, free of major complications. The purpose of this intervention is to improve the cosmetic appearance and function of the penis. A minimum period of 6 months between consecutive urethroplasties is important. The final stage guarantees good functional and cosmetic results preserving the prepuce.

Immunoexpression of aquaporin-1 in adolescent varicocele testes: Possible significance for fluid reabsorption

OBJECTIVES

To investigate the immunoexpression of aquaporin-1 (AQP-1), a major transmembrane water channel, in high-grade varicocele testes, which are known to imply an unbalanced transmembrane water flow, in both tubular and extratubular compartments.

METHODS

Light microscopy and AQP-1 immunohistologic examination were carried out on incisional testicular biopsies from 20 adolescent boys, aged 13 to 18 years, with grade 2 or 3 idiopathic varicocele. Testicular tissue from 4 autopsied subjects of matched age were also investigated as parallel controls.

RESULTS

At microscopic examination, the tubular lumina and extracellular matrix were expanded and venular profiles dilated. Cytoplasmic vacuoles were frequent in the Sertoli cells, spermatogonia, and spermatocytes, together with premature sloughing of germ cells and residual cytoplasmic droplets inside the spermatozoa, if present. Diffuse AQP-1 positivity occurred at venular endothelial cell membranes and, unexpectedly, at the cell membranes of the Sertoli cells, diploid germ cells, and haploid cells. In the control testes, focal AQP-1 immunolabeling was confined to the microvessel endothelial cells, without any positive reaction in the tubular or extratubular compartments.

CONCLUSIONS

This is the first report showing AQP-1 cell expression in adolescent varicocele testes in both tubular and extratubular compartments. It was associated with the main histologic features of unbalanced water flow in the tubular and interstitial compartments of the testis. Immunocytochemical patterns revealed AQP-1 as a possible critical reabsorption factor, acting to reduce abnormal fluid retention in endotubular cells and the extracellular matrix and, to a lesser extent, in Leydig cells.

Melatonin reduces oxidative stress in surgical neonates

BACKGROUND/PURPOSE

Cytokines are inflammatory mediators found in the circulation after surgery. Newborns have less protection against oxidation and are very susceptible to free radical oxidative damage. Melatonin has been reported recently to reduce oxidative stress in neonates with sepsis, asphyxia, and respiratory distress. The aim of this study has been to determine if melatonin would lower interleukin (IL)-6, IL-8, tumor necrosis factor alpha (TNF-alpha) and nitrite/nitrate (NOx) levels and modify serum inflammation parameters, improving the clinical course of surgical neonates.

METHODS

Ten newborns (group 1), 5 with surgical malformations and respiratory distress (group 1a) and 5 with isolated abdominal surgical malformations (group 1b) received a total of 10 doses of melatonin (10 mg/kg) at defined times interval for 72 hours. The treatment was started within 3 hours after the end of surgery. Ten surgical neonates (group 2), did not receive melatonin. Twenty healthy neonates (group 3) served as control. Blood samples were collected at the end of operation; before treatment with the antioxidant; and 24 hours 72 hours, and 7 days after start of treatment with melatonin or placebo, respectively.

RESULTS

Postoperative value of cytokines and NOx levels of groups 1 and 2 were significantly higher than group 3. Compared with group 1b, group 2 displayed significantly higher cytokines and NOx levels at 24 hours, 72 hours, and at 7 days. In group 1a the immediate postoperative values of cytokines were significantly higher than group 1b and group 2, but a significant improvement was observed after administration of melatonin with significantly lower levels of IL-6 and IL-8 with respect to group 2. An improvement of clinical outcome was observed by progressive reduction of clinical parameters of inflammation.

CONCLUSIONS

Melatonin reduces cytokines and NOx levels showing potent antioxidant properties with improvement in clinical outcome. Further studies are warranted to define, on larger numbers, the role of melatonin in surgical patients.

Varicocele and sport in the adolescent age. Preliminary report on the effects of physical training

The effect of physical training on the natural history of varicocele has received little attention. The aim of the present pilot study was to evaluate the prevalence of idiopathic varicocele in young athletes, in the attempt to find a correlation between the training workload and the clinical grade of varicocele. We evaluated 150 adolescents with an age of 10-16 yr (median age: 13 yr). All these subjects were athletes practicing different sport at agonistic level. One hundred and fifty non-athlete adolescents of matched age (median: 13.5 yr) were used as controls. All underwent physical examination, and if a varicocele was suspected, the diagnosis was confirmed or excluded by echo-color-Doppler examination. The young athletes were stratified into two groups according to the different time spent for training: Group 1-6 h training per week; Group 2-7 to 12 h per week. Statistical analysis was performed. A p<0.05 was considered significant. The physical examination revealed a clinical varicocele on the left side in 20 athletes. A significant positive correlation was observed between the Group 2 and the highest grade of varicocele (r2=0.9918, p=0.0041). In the adolescent group used as control we observed a varicocele in 16 cases. A positive correlation was observed between the number of athletes with varicocele and the highest grade of varicocele (r2=0.96, p=0.02). Sport training does not modify the prevalence of varicocele compared to the general population, but physical activity has to be considered as an aggravating factor in the natural history of varicocele. In countries where sport eligibility is necessary for agonistic sport practice, varicocele should be then considered as a conditioning factor.

The monitoring of tap waters in Milano: planning, methods and results

The radiometric monitoring of tap waters has been carried out, in Northern Italy, since late the 1980s as part of the activities headed by the National Surveillance Network on environmental radioactivity. Measurements were accomplished by gamma spectrometry over large samples of water that were drained in a single place and concentrated by ion exchange resin treatment. More recently a regular, periodical monitoring was started using liquid scintillation measurements. In this manner, gross alpha and beta activities, uranium, (226)Ra and (222)Rn concentrations are determined at present. Nevertheless, a single-point sampling may be not fully representative of the whole Milano aqueduct, significantly extended and fed by a number of wells. As a control, an extended monitoring of the aqueduct was planned and variations of water radioactivity in different Milano areas have been assessed.

[Preoperative staging of colorectal neoplasms: importance of the echo-endoscopy]

The A. A., after having confirmed how the timely diagnosis of cancer of the Sigma-Rectum section is the result a complicated and articulate diagnostic iter, describe the advantages of using the ultrasonography-endoscopy. Therefore they relate their experience, comparing the outcome of this research with that of the TC images and above all with the histo-pathological surveys on the removed sechions. They conclude affirming that a higher percentage of the diagnostic care is a clear evolution in the correct pre-operating stage of these neoplasias.

Bilateral neonatal adrenal abscess. Report of two cases and review of the literature

Neonatal adrenal abscess is an extremely rare condition. 32 cases, 4 bilateral, have been described in the world literature. We treated successfully other two bilateral cases. We report on this rare condition and review the world literature. In our Department we observed two patients in the neonatal period with abdominal distension, vomiting, irritability and fever. Abdominal ultrasound (US), plain x-ray of the abdomen, intravenous pyelography and computed tomography (CT) of the abdomen were performed. In both cases bilateral suprarenal cystic masses were identified. Vanilmandelic acid, Homovanillic acid and cathecolamines were normal. The two neonates underwent a surgical exploration. Abscesses were found and drained releasing a moderate amount of haemorrhagic and purulent materials from the adrenal glands. Post-operative histology on the surgical specimen showed in both cases an abscess in partial haemorrhagic adrenal glands. No neoplastic cells were observed. The recovery was uneventful and at six months follow-up both patients were well and without signs of adrenal insufficiency. Haematogenous bacteria seeding a normal gland or abscess formation in a previous haemorrhagic gland are the most accredited theories. Neuroblastoma, Wilm's tumor and renal duplication with dilatation of the upper segment must be considered in the differential diagnosis. Percutaneous drainage (+/- biopsy) under CT or US guide should be considered the treatment of choice, followed by surgical exploration when diagnosis is not clear.

[Acute urine retention: early clinical sign of a rhabdomyosarcoma of the bladder or prostate in children: report of three cases]

Acute urine retention can be the first clinical sign of a rabdomyosarcoma (RMS) of bladder and prostate. This is particularly evident in the age group comprised between 2 and 4 years. The Authors report their experience on three cases of 2 years old males admitted for acute urine retention. One case was diagnosed to have an prostate RMS, the other two a RMS of the bladder. The prostate RMS refused the operation dying 2 years after operation. Of the two cases of RMS of the bladder, one was treated successfully by polychemotherapy treatment, the second, after polychemotherapy underwent a partial cystectomy. The Authors conclude affirming the importance of a ultrasonography of the lower urinary tract in all patients with acute retention of urine, since this could be the first sign of a RMS of prostate or bladder.

Preliminary report on nitric oxide-mediated oxidative damage in adolescent varicocele

BACKGROUND

The current study was designed to characterize the process of nitric oxide (NO) and peroxynitrite generation through the determination of nitrotyrosine concentration in the dilated veins of varicoceles in adolescents.

METHODS

Ten adolescents with a median age of 13 years (range 12-17) affected by a left idiopathic varicocele (grade II and III) were studied. Whole blood samples were withdrawn from a peripheral vein at time of induction of anaesthesia, and from a dilated spermatic vein before ligation. Peripheral blood samples from five adolescents undergoing minor surgical procedures were used as controls. The nitrotyrosine concentration was evaluated by a sandwich enzyme-linked immunosorbent assay (ELISA), using a monoclonal anti-nitrotyrosine antibody and Western blot analysis.

RESULTS

Plasma nitrotyrosine concentrations were significantly greater in the spermatic vein when compared with the peripheral vein (P = 0.031). Nitrotyrosine in plasma of controls did not show any significant difference in comparison with peripheral samples from varicocele patients. Western blot analysis confirmed the above data.

CONCLUSIONS

In adolescents with a varicocele, there is an increase in nitrotyrosine concentration within the spermatic vein that can cause protein nitration and cytotoxicity via its reaction with various molecular targets. This could have repercussions on both sperm and testis function. We conclude that an oxidative stress status is present and should be considered as an indication for varicocele treatment in the adolescent.

Oestrogen-induced bone marrow aplasia in a dog with a Sertoli cell tumour

A 10-year-old male Drahthaar dog with unilateral cryptorchidism was examined because of feminisation and myelotoxicity. Radiography and ultrasonography revealed an abdominal mass which was surgically removed. The mass was identified as a Sertoli cell tumour on histological examination. Findings on bone marrow examination were compatible with aplasia due to the oestrogens secreted by the tumoral cells. Treatment with fluids, antibiotics, whole blood transfusions, corticosteroids and lithium carbonate was unsuccessful. Survival time was 22 days after surgery.

Utility of a scoring system in the diagnosis of acute appendicitis in pediatric age. A retrospective study

BACKGROUND

Acute appendicitis is the most frequent cause of surgical emergency in pediatric age. The aim of this study has been to evaluate the diagnostic accuracy of a scoring system, retrospectively applied, to the clinical and laboratory parameters in patients with acute appendicitis.

METHODS

A group of 156 patients admitted for acute abdominal pain and operated for appendectomy, in the last 3 years, has been included in the study. The mean age was 8.4 years. The modified Alvarado score has been used as scoring system: white count, neutrophil count, fibrinogen level, body temperature, resistance in the right iliac fossa, length of symptoms, nausea/vomiting. The score has been calculated for each patient. They were subdivided into 3 groups. Group I (score 1-4), no admission; Group II (5-6), admission and observation; Group III (7-10), surgery. This subdivision was then compared with the intraoperative notes.

RESULTS

Patients were divided into 3 groups. Group I, 24 patients (15%); Group II, 34 patients (22%); Group III, 98 patients (63%). On the basis of the intraoperative notes 61 patients had acute appendicitis and 95 complicated acute appendicitis. In this last subgroup the score gave a percentage of patients to operate of 90.5%.

CONCLUSIONS

With the present work we confirm the utility of a scoring system in the preoperative diagnosis of acute appendicitis and in our opinion it is a useful system for a first, rapid and economic evaluation in the pediatric emergency department.

Monocyte and neutrophil activity after minor surgical stress

BACKGROUND/PURPOSE

Surgical stress produces changes in the immune status of patients. In adults, major surgery causes immunosuppression, whereas minor operations stimulate immune responses. In children, the immunologic response to surgery has not been elucidated completely. The authors investigated the effects of minor surgery on immune response by analyzing neutrophil and monocyte phagocytosis and oxidative burst activity.

METHODS

Sixteen children undergoing elective minor surgery were enrolled. Blood samples were collected before the operation (at time of induction of anesthesia), at the end of operation, and 72 hours after surgery. Neutrophil and monocyte phagocytosis and oxidative burst activity were studied using a flow cytometric method.

RESULTS

Phagocytosis and oxidative burst increased significantly at the end of the operation, both in neutrophils (7.4% and 14.3%, respectively) and monocytes (11.6% and 27%, respectively). The increase was only significant for monocytes (17.5%) 72 hours after surgery. White cell count did not show any significant changes. There was no significant correlation between phagocytosis, oxidative burst activity, and white cell count or neutrophil and monocyte count.

CONCLUSIONS

This study shows that minor surgery in children induces immune activation by increasing neutrophil and monocyte phagocytosis and oxidative burst activity. Further studies are required to understand the molecular basis of these findings.

Nitric oxide synthase patterns in normal and varicocele testis in adolescents

OBJECTIVE

To determine if the testes of normal adolescents can produce nitric oxide (NO), by assessing NO synthase (NOS) activity, and whether this activity changes in adolescents with left idiopathic varicocele.

PATIENTS AND METHODS

After obtaining informed consent, testicular biopsies were obtained from eight adolescents (mean age 16.4 years; controls) who underwent surgery for inguinal hernia or hydrocele, and from 20 adolescents (mean age 16.2 years) operated for left idiopathic varicocele. Inducible and endothelial NOS (iNOS and eNOS) isoforms were investigated in the biopsy specimens by immunohistochemical localization and Western blot analysis using specific fluorescein-conjugated antibodies.

RESULTS

Both normal and pathological samples expressed eNOS at the level of vessels and Leydig cells. The iNOS was expressed in Leydig cells of normal testes and over-expressed in Leydig cells of varicocele testes.

CONCLUSION

Leydig cells of adolescent testes constitutively express iNOS. Under pathological conditions, e.g. varicocele, iNOS is up-regulated and is a possible source of NO overproduction. These results could be useful in explaining the pathogenesis of both testis and sperm dysfunction in varicocele.

Normal and varicocele testis in adolescents

The authors reviewed the results of their research on the structure and composition of normal and varicocele seminiferous tubules in adolescents. They give new evidences of normal structure of adolescent testis and demonstrate, for the first time, the ultrastructural and immunohistochemical modifications of the lamina propria and basal lamina in the adolescent varicocele patients, which are similar to those observed in adults, but less severe, and of the adherence junctions in seminiferous tubules. They also report the presence of oxidative stress in adolescents limited to testis and not generalised as in the adults. These data are well correlated to different clinical studies that support the hypothesis of a progressive course of varicocele and the need for surgical treatment in adolescent varicocele patients.