WHO air quality database: relevance, history and future developments

Air pollution is the second most important risk factor for noncommunicable diseases, but air quality monitoring is lacking in many low- and middle-income countries. The World Health Organization (WHO) recently released its 2022 updated air quality database status report. This report contains data from about 6743 human settlements, a sixfold increase from 1102 settlements in its first publication in 2011, which shows that air pollution is increasingly recognized as a health priority at global and national levels. However, progress varies across the world. More than 90% of the settlements in the database are in high- and middle-income countries and areas mainly in China, Europe, India and North America. The database is crucial for increasing awareness of air pollution, and for calculating global exposures and the corresponding burden of disease attributable to air pollution. This article describes the progress made and challenges in collecting air quality data. The database uses official data sources which can be difficult to access and assess, because air quality monitoring is done by different government bodies or uses varying monitoring methods. These air quality data can be used by the health sector to engage in discussions on monitoring air quality to protect public health, and facilitate multisectoral engagement of United Nations agencies to support countries to conform with the 2021 WHO air quality guidelines. Although air pollution levels in most countries are higher than those recommended in the guidelines, any action policy-makers take to reduce air pollution will help reduce the burden of air pollution on health.

Quantifying the Public Health Benefits of Reducing Air Pollution: Critically Assessing the Features and Capabilities of WHO's AirQ+ and U.S. EPA's Environmental Benefits Mapping and Analysis Program - Community Edition (BenMAP - CE)

Scientific evidence spanning experimental and epidemiologic studies has shown that air pollution exposures can lead to a range of health effects. Quantitative approaches that allow for the estimation of the adverse health impacts attributed to air pollution enable researchers and policy analysts to convey the public health impact of poor air quality. Multiple tools are currently available to conduct such analyses, which includes software packages designed by the World Health Organization (WHO): AirQ+, and the U.S. Environmental Protection Agency (U.S. EPA): Environmental Benefits Mapping and Analysis Program - Community Edition (BenMAP - CE), to quantify the number and economic value of air pollution-attributable premature deaths and illnesses. WHO's AirQ+ and U.S. EPA's BenMAP - CE are among the most popular tools to quantify these effects as reflected by the hundreds of peer-reviewed publications and technical reports over the past two decades that have employed these tools spanning many countries and multiple continents. Within this paper we conduct an analysis using common input parameters to compare AirQ+ and BenMAP - CE and show that the two software packages well align in the calculation of health impacts. Additionally, we detail the research questions best addressed by each tool.

Video-Assisted Anal Fistula Treatment (VAAFT) for complex anorectal fistula: efficacy and risk factors for failure at 3-year follow-up

BACKGROUND

The aim of this study was to assess the 3-year objective and subjective outcomes of patients with complex anorectal fistula treated with Video-Assisted Anal Fistula Treatment (VAAFT). Furthermore, we evaluated the risk factors associated with recurrence.

METHODS

All consecutive patients with complex anorectal fistula who underwent VAAFT in Beata Vergine Hospital of Mendrisio, Switzerland, from January 2013 to January 2016, were enrolled. Patients with suspicion or diagnosis of Crohn's disease, malignancy, previous history of radiotherapy or radical pelvic surgery were excluded. Preoperative clinical assessment based upon medical history, physical examination and endosonography, was performed in all patients. Data regarding subjective outcomes (the Patient Global Impression of Improvement, patient satisfaction scores and Wexner score), objective cure rate (absence of fistula at clinical examination), and adverse events were collected during follow-up. Uni and multivariate analysis were performed to investigate outcomes.

RESULTS

One hundred and four patients had VAAFT. At 3-year follow-up, 96 patients (92.3%) were available for the evaluation. At 3 years after surgery, 81 of 96 patients (84.4%) declared themselves cured (p = 0.60). Similarly, at 3-year evaluation, 80 of 96 patients (83.3%) were objectively cured (p = 0.52). No serious intraoperative or postoperative complications were reported. All recurrences were treated with a repeat VAAFT procedure resulting in a complete healing. Uni and multivariate analysis of variables potentially involved in the failure of VAAFT showed that age ≥ 50 years was the only factor associated at risk of recurrence.

CONCLUSIONS

VAAFT is a highly effective safe procedure for the treatment of anorectal fistula, with a low recurrence rate at 3-year follow-up. However, our study demonstrated that age ≥ 50 years is a risk factor for failure of VAAFT.

Electrospray Film Deposition for Solvent-Elimination Infrared Spectroscopy

The application of electrospray (ES) for quantitative transfer of analytes from solution to an internal reflection element for analysis by attenuated total reflection Fourier transform infrared (ATR FT-IR) spectroscopy has been developed in this work. The ES ATR FT-IR method is evaluated with non-volatile and semi-volatile organic and inorganic compounds dissolved in pure organic solvents or organics in a mixture with water. The technique demonstrates the capability for rapid solvent evaporation from dilute solutions, facilitating the creation of thin films that allow ATR FT-IR to generate transmission-mode-like spectra. Electrospray ATR FT-IR with multiple reflections displays a linear response ( R² = 0.95-0.99) in absorbance with the deposited mass and instrumental detection limit < 100 ng, which demonstrates potential for quantitative applications. The method is applicable when crystalline substances are present, even though the formation of particles restricts the upper limit of mass loadings relative to substances forming homogeneous films. In addition to the solvent, semi-volatile compounds can evaporate during the ES process; the magnitude of losses will depend on solution composition and temperature.

Immunological Reactivity of Serum Ferritin in Patients with Malignancy

Serum ferritin has been suggested as a tumor marker in the diagnosis of certain malignancies and for following the activity or dissemination of the malignant process. Since neoplastic tissues generally contain more acidic isoferritins than their normal tissue counterparts, it has also been suggested that the specific assay of such isoferritins in serum may be of particular value in the diagnosis of malignancy. In this work, we have evaluated ferritin concentration in the serum of normal subjects and patients with acute nonlymphocytic leukemia, Hodgkin's disease, breast cancer and lung cancer by simultaneously using three different immunoassays: an immunoradiometric assay based on polyclonal antibodies against human liver (basic, L-subunit rich) ferritin, a radioimmunoassay based on polyclonad antibodies against HeLa cell (acidic, H-subunit rich) ferritin, and an immunoradiometric assay based on the monoclonal antibody 2A4 raised against human heart (acidic, H-subunit rich) ferritin. Most of the patients studied had increased values for liver-type ferritin in the absence of increased iron stores. Binding of serum ferritin to concanavalin A did not prove to be useful in distinguishing a tumor-specific basic isoferritin. The HeLa ferritin assay was found to be less specific than the heart ferritin assay in the detection of acidic isoferritins, and did not provide any advantage over the liver assay in detecting the increased levels of serum ferritin associated with malignant disease. Heart-type ferritin was found in one-fifth of normal sera and 64% of sera from patients with malignancy. Values were very low compared with those for basic ferritin, ranging from less than 0.1 to 17% of total serum ferritin (geometric mean value 1.3%) in patients with malignancy. These findings indicate that at present there is little application for serum ferritin immunoassays based on antibodies to HeLa cell or heart ferritin in the diagnosis or monitoring of malignant disease. This seems to be due to the presence in human serum of biding factors which are responsible for the rapid clearance of acidic isoferritins from the circulation. The serum concentration of basic ferritin, however, can be useful in the diagnosis and management of some malignancies, and it is possible that studies on cell isoferritins can be important in biologic monitoring of neoplastic disorders. It should also be noted that the increased levels of serum ferritin found in patients with malignancy can exert adverse effects on the host immune response and perhaps an inhibitory effect on hematopoiesis.

Progesterone agonists and antagonists induce down– and up–regulation of estrogen receptors and estrogen inducible genes in human breast cancer cell lines

The effects of the synthetic progestin R5020 and the antiprogestin RU486 on the cellular content of estrogen receptors (ER) and on cell responsiveness to estrogens, have been investigated in the sex hormone-sensitive human breast cancer cell lines MCF-7 and T47D. When T47D cells were treated with R5020 (Promegestone) (10–8 M), ER was down-regulated to about 50% of the control level in a time-dependent manner. Maximum down-regulation was observed after 24 hours and remained at this level for the next 24 hours. Dihydrotestosterone (DHT) or dexamethasone (DEX) had no effect on ER sites. R5020 also down-regulated, although to a lesser extent, ER in the MCF-7 cells which contain fewer progesterone receptor (PR) sites.

When MCF-7 cells were transfected with a progesterone receptor expression vector (tMCF-7) to increase the number of PR sites, R5020 down-regulated the ER to a level similar to that reached in T47D cells. In both cell lines ER down-regulation was completely inhibited by a 10-fold molar excess of the antiprogestin RU486 (Mifepristone) (10–7 M). Surprisingly, when incubated with RU486 alone, T47D cells responded by up-regulating ER 2-4 fold.

The functional relevance of inhibition and up-regulation of ER for the estrogen responsiveness of hormone-sensitive human breast cancer cells was tested by assaying the synthesis of an estrogen-regulated product, the PS2 protein. Estrogen induction of this protein was inhibited by at least 70% in T47D cells exposed to R5020 for 24 hours before estrogen administration and by about 25% in MCF-7 cells under the same conditions. A 55% inhibition was observed in tMCF-7 cells. Up-regulation of ER by RU486 in T47D cells led to an increase in the estrogen induction of PS2 by about 18-20% compared to RU486 untreated cells.

These results indicate that the progestin and antiprogestin regulation of ER is functionally important for the estrogen responsiveness of breast cancer cells.

Regional Similarities and NOx-related Increases in Biogenic Secondary Organic Aerosol in Summertime Southeastern U.S

During the 2013 Southern Oxidant and Aerosol Study, Fourier Transform Infrared Spectroscopy (FTIR) and Aerosol Mass Spectrometer (AMS) measurements of submicron mass were collected at Look Rock (LRK), Tennessee, and Centreville (CTR), Alabama. Carbon monoxide and submicron sulfate and organic mass concentrations were 15-60% higher at CTR than at LRK but their time series had moderate correlations (r~0.5). However, NOx had no correlation (r=0.08) between the two sites with nighttime-to-early-morning peaks 3~10 times higher at CTR than at LRK. Organic mass (OM) sources identified by FTIR Positive Matrix Factorization (PMF) had three very similar factors at both sites: Fossil Fuel Combustion (FFC) related organic aerosols, Mixed Organic Aerosols (MOA), and Biogenic Organic Aerosols (BOA). The BOA spectrum from FTIR is similar (cosine similarity > 0.6) to that of lab-generated particle mass from the photochemical oxidation of both isoprene and monoterpenes under high NOx conditions from chamber experiments. The BOA mass fraction was highest during the night at CTR but in the afternoon at LRK. AMS PMF resulted in two similar pairs of factors at both sites and a third nighttime NOx-related factor (33% of OM) at CTR but a daytime nitrate-related factor (28% of OM) at LRK. NOx was correlated with BOA and LO-OOA for NOx concentrations higher than 1 ppb at both sites, producing 0.5 ± 0.1 μg m-3 for CTR-LO-OOA and 1.0 ± 0.3 μg m-3 for CTR-BOA above 1 ppb additional biogenic OM for each 1 ppb increase of NOx.

Practical and functional classification of the double urethra: A variable, complex and fascinating malformation observed in 20 patients

INTRODUCTION

Urethral duplication is a rare and variable malformation of the urinary tract, with non-univocal and complex management. In addition, different classification schemes have been proposed, but none have considered all the possible variants.

OBJECTIVE

To report experience with the management of 20 urethral duplication patients and propose a classification of this anomaly.

MATERIALS AND METHODS

A retrospective analysis collecting information regarding 20 patients (Table) with urethral duplication treated at a single institution over the past 40 years. Three females and 17 males were treated: two had vesico-urethral duplication, eight had urethral duplication with a single bladder, and eight had 'λ' duplication.

RESULTS

Immediate postoperative complications included urethral dehiescence (n = 1) and urethral stenosis (n = 2). The progressive augmentation by dilating the urethra (PADUA) technique was ineffective. During follow-up, the following were recorded: urinary incontinence (n = 2), urinary tract infection (n = 3), hypertension (n = 3) and erectile dysfunction (n = 1). All patients were satisfied with the aesthetic result.

DISCUSSION

Urethral duplication is a rare anomaly with male preponderance. Four types of duplication were described, on the basis of anatomy and management: vesical and urethral duplication (type 1), urethral duplication with single bladder (type 2), 'λ-type' duplication (type 3) and 'miscellanea' (multiple urethral channels, spindle urethra, other female forms, type 4). A full description of the malformation and surgical approach was given for each type. The advantages of the classification were compared with the literature.

CONCLUSIONS

The proposed classification should be a useful tool, based on the required surgical approach, even if surgery should be tailored to the patient. It is important to restore the anatomy and achieve urinary continence. Surgery can be challenging and a multi-step process, especially in cases of 'λ' duplications.

Long-term follow-up after esophageal replacement in children: 45-Year single-center experience

PURPOSE

We evaluated the results of esophagocoloplasty (ECP) in children by performing a 45-year retrospective cohort study in a single center.

MATERIALS AND METHODS

We collected all of the medical charts of patients who underwent ECP at our hospital from January 1969 to January 2014. We reviewed the medical history for each patient and then contacted the patients by phone to obtain responses to a questionnaire. The questionnaire evaluated the following four areas: overall general state, gastrointestinal function, dependence on the Health Sanitary System, and their aesthetic satisfaction.

RESULTS

We contacted 96 patients, and 72 completed our questionnaire. There were 45 males and 27 female respondents, with a mean age of 34.5 years. The mean Karnofsky performance status index was 96.4%. There were excellent scores obtained from 55 patients and fairly good scores from 16 patients. There was 1 patient with a low score, and there were no scores reported below 70%. Most patients (58/72) reported regular bowel habits, and no patients required drugs or other measures to facilitate defecation. Gastroesophageal reflux was present in 51 patients, and 62.8% have bothersome symptoms. Twenty-five patients used pharmacological therapies. Forty-eight patients (66.6%) were satisfied with the aesthetic result of surgery (mean score in a scale from 0 to 5, is 3).

CONCLUSIONS

ECP can be used in children who require esophageal substitution. The resulting long-term QoL is acceptable. However, the aesthetic outcomes remain a problem.

Effect of intravitreal bevacizumab on serum, aqueous, and vitreous humor levels of erythropoietin in patients with proliferative diabetic retinopathy

AIM

The aim of this study was to evaluate concentrations of erythropoietin (EPO) and vascular endothelial growth factor (VEGF) in serum, aqueous and vitreous humour of diabetic patients with proliferative retinopathy (PDR) and to verify their possible modifications induced by intravitreal injection of bevacizumab (IVB).

METHODS

This prospective observational study was performed on patients who underwent vitrectomy for proliferative diabetic retinopathy and macular hole or pucker. The study sample consisted of 33 patients with proliferative diabetic retinopathy and 20 non-diabetic patients with macular hole or pucker. EPO and VEGF levels in serum, aqueous and vitreous humour were measured in both groups. In diabetic patients measures were performed before and after IVB.

RESULTS

EPO and VEGF levels in aqueous and vitreous humour were markedly increased in diabetic patients with PDR as compared with those recorded in the control group (P<0.001); contrarily, EPO serum levels were similar in both groups (p=not significant). IVB did not affect EPO levels (aqueous 39.1 ± 29.2 vs. 38.6 ± 26.1; vitreous 179.3 ± 88.3 vs. 131.6 ± 67.8; serum 9.2 ± 5.8 vs. 6.9 ± 3.7 mUI/mL); conversely, VEGF concentration significantly decreased 15 days after IVB in serum and ocular fluids (aqueous 141.6 ± 12.3 vs. 81.4 ± 5.4; vitreous 180.4 ± 45.8 vs. 95.8 ± 23.6; serum 113.9 ± 52.8 vs. 73.2 ± 65.6 mUI/mL).

CONCLUSION

These findings demonstrate that the production of VEGF and EPO is regulated by different mechanisms. Intraocular levels of EPO in diabetic patients were significantly higher than those recorded in serum, suggesting a local production. In addition, bevacizumab does not influence intraocular levels of EPO.

Serum and intraocular concentrations of erythropoietin and vascular endothelial growth factor in patients with type 2 diabetes and proliferative retinopathy

AIM

This study compared systemic and intraocular concentrations of erythropoietin (EPO) and vascular endothelial growth factor (VEGF) in patients with type 2 diabetes (T2D) and proliferative diabetic retinopathy (PDR) with levels in patients without diabetes, and looked for possible correlations between the concentrations found and other variables analyzed.

METHODS

Concentrations of EPO and VEGF were measured in the aqueous and vitreous humours and serum of patients undergoing vitrectomy for PDR (33 patients) or for macular holes or puckers (20 control patients). EPO was assayed by radioimmunoassay, with a lower limit of detection (LOD) of 1.0 mIU/mL. VEGF was assayed using enzyme-linked immunosorbent assay (ELISA), with a lower LOD of 10.0 pg/mL.

RESULTS

EPO concentrations in serum did not differ significantly between the two groups, whereas EPO in vitreous and aqueous were higher in diabetic than in non-diabetic patients. VEGF in serum was lower in diabetic patients than in non-diabetics; conversely, VEGF concentrations in vitreous were significantly higher in diabetic patients. A direct correlation was found between vitreous and aqueous EPO concentrations, and between vitreous EPO and blood glucose concentrations. A significant, negative correlation between vitreous EPO concentration and age was also recorded.

CONCLUSION

High EPO concentrations in the vitreous of patients with PDR and its correlation with blood glucose suggest that EPO could play a role in the pathogenesis of PDR. All possible factors affecting serum and ocular concentrations of EPO and VEGF should be determined to identify compounds able to prevent and control this serious microvascular complication of diabetes.

Controlling the dynamics of a bidimensional gel above and below its percolation transition

The morphology and the microscopic internal dynamics of a bidimensional gel formed by spontaneous aggregation of gold nanoparticles confined at the water surface are investigated by a suite of techniques, including grazing-incidence x-ray photon correlation spectroscopy (GI-XPCS). The range of concentrations studied spans across the percolation transition for the formation of the gel. The dynamical features observed by GI-XPCS are interpreted in view of the results of microscopic imaging; an intrinsic link between the mechanical modulus and internal dynamics is demonstrated for all the concentrations. Our work presents an example of a transition from a stretched to a compressed correlation function actively controlled by quasistatically varying the relevant thermodynamic variable. Moreover, by applying a model proposed some time ago by Duri and Cipelletti [Europhys. Lett. 76, 972 (2006)] we are able to build a master curve for the shape parameter, whose scaling factor allows us to quantify a "long-time displacement length." This characteristic length is shown to converge, as the concentration is increased, to the "short-time localization length" determined by pseudo-Debye-Waller analysis of the initial contrast. Finally, the intrinsic dynamics of the system is then compared with that induced by means of a delicate mechanical perturbation applied to the interface.

Photochemical transformation of ibuprofen into harmful 4-isobutylacetophenone: pathways, kinetics, and significance for surface waters

The harmful compound 4-isobutylacetophenone (IBAP) can be formed photochemically from the anti-inflammatory drug ibuprofen (IBP), upon direct photolysis (yield 25 ± 7%, μ ± σ), reaction with ·OH (yield 2.3 ± 0.1%) and reaction with triplet states of chromophoric dissolved organic matter, (3)CDOM* (yield 31 ± 4%). In the latter case, anthraquinone-2-sulphonate was used as CDOM proxy. The three processes would account for most of the photochemical transformation of IBP and IBAP in surface waters. IBAP formation from IBP involves the propanoic acid chain, which is more reactive than the aromatic ring as shown by quantum mechanical calculations. IBAP is expected to undergo slightly faster photochemical transformation than IBP in surface waters, with a modelled pseudo-first order rate constant that is higher by 1.5-1.9 times compared to IBP. Due to fairly high formation yields and depending on IBP emission scenarios, photochemical modelling suggests that IBAP could reach concentration values up to ~15% of IBP in surface waters, thus being a potentially important transformation intermediate. This issue prompts for the need of field studies that provide information on IBAP environmental occurrence, which is virtually unknown at the present moment.

Role of mini-invasive surgery in the treatment of enteric duplications in paediatric age: a survey of 15 years

BACKGROUND

Gastrointestinal tract duplications (ATD) are rare malformations that occur with an incidence of 1 in 4000-5000 live births, with heterogeneous clinical pictures in relation to the different location and size. The purpose of this study was to analyze the role of minimally invasive surgery in the management of ATDs, through a critical analysys of 15 years of experience of the Department of Paediatric Surgery, University of Bologna.

METHODS

The medical records of 22 children diagnosed with ATDs were retrospectively reviewed (January 1995-August 2010). The study analyses: clinical presentation, preoperative diagnosis, site, anatomic type, treatment, and outcome.

RESULTS

Children were 16 males and 6 females, with age ranged from 1 day to 10 years. 20 ATDs (91%) were cystic type, while 2 cases (9%) were tubular one. During the first period of our experience, 10 (45.5%) cases were approached with an open surgery. Then subsequent 8 (36.4%) cases were treated with a diagnostic laparoscopy. This approach permitted also to perform a minilaparotomy, close to the site of the malformation, with a short length of the scar. In 2 cases (9%), we realized an ileal resection with end-to-end anastomosis with a trans-umbilical video-assisted procedure. In 2 cases (9%), we performed a complete removal of the lesions, after complete ligation of the vascular pedicle through a laparoscopic approach. 10 cases (45.5%) were located in the ileum, 6 cases (27.3%) were esophageal duplication, 3 cases (13.6%) were gastric duplications, 2 cases (9%) were located in the colon-rectum. The postoperative course was uneventful in all the cases.

DISCUSSIONS AND CONCLUSIONS

this study shows how, in the management of intestinal duplications, a mininvasive approach, is increasingly taking the field, along with increasing the "learning curve" with laparoscopy. In experienced hands, the laparoscopic approach allows an accurate definition of the exact site of duplication and a miniinvasive treatment with similar principles of open techniques.

Multiplex ligation-dependent probe amplification detection of an unknown large deletion of the CREB-binding protein gene in a patient with Rubinstein-Taybi syndrome

Rubinstein-Taybi syndrome is a rare autosomal dominant congenital disorder characterized by postnatal growth retardation, psychomotor developmental delay, skeletal anomalies, peculiar facial morphology, and tumorigenesis. Mutations in the gene encoding the cAMP response element-binding protein (CREB, also known as CREBBP or CBP) on chromosome 16p13.3 have been identified. In addition, some patients with low intelligence quotients and autistic features bear large deletions. Based on these observations, we used multiplex ligation-dependent probe amplification to search for large deletions affecting the CREBBP gene in a Rubinstein-Taybi syndrome patient. We identified a novel heterozygote deletion removing five exons (exons 17-21), encoding the histone acetyltransferase domain. We propose the use of multiplex ligation-dependent probe amplification as a fast, accurate and cheap test for detecting large deletions in the CREBBP gene in the sub-group of Rubinstein-Taybi syndrome patients with low intelligence quotients and autistic features.

Early ovarian pregnancy diagnosed by ultrasound and successfully treated with multidose methotrexate. A case report

A case report of a primary interstitial ovarian pregnancy is presented. A 37-year-old married woman with two children after two Cesarean sections and a spontaneous abortion, with a contraceptive intrauterine device (IUD) inserted three years before, presented at five weeks plus five days amenorrhea with a positive pregnancy test and lower abdominal pain but with no vaginal bleeding. Her previous menstrual cycles had been regular. She was hemodynamically stable. On bimanual examination, the uterus was of normal size, and there was an approximate four-cm tender right adnexal mass. Serum beta-human chorionic gonadotropin (b-hCG) was confirmed positive. Ultrasound revealed a well-positioned IUD in the uterus and a right adnexal mass with normal vascular flow on Doppler, that contained a well-defined gestational sac, well-distinct from the quiescent hemorrhagic corpus luteum. There was no fetal node or cardiac activity or free fluid. The patient received four injections of methotrexate intramuscularly using the multidose regimen that involves the administration of methotrexate calculated according to body weight, alternated with 0.1 mg/kg of leucovorin calcium per os after 30 hours until the values of 3-hCG had decreased by 15%. The patient's post-treatment period was uneventful with a full restoration of ovarian morphology and the complete absorption of the gestational sac. This case is the first where diagnosis was made by endovaginal sonography and treatment was made by multidose methotrexate. Spiegelberg criteria for the diagnosis of ovarian pregnancy are obsolete; new ultrasound and laboratory criteria are needed for a diagnosis as early as possible without the need of surgery.

Endometrial tuberculosis: a clinical case

Genital tuberculosis is a bacterial infection still frequent in less developed countries where lots of cases are not diagnosed nor treated. In this work we describe a rare case of primary endometrial tuberculosis in a woman of 50 years old. The diagnosis was confirmed by an ultrasonography of the pelvis and an endometrial biopsy followed by a histological examination. The patient after the diagnosis was put under antiturbecular treatment for six months with complete healing.

Thrombosed aneurysm of ductus arteriosus: a case report

Spontaneous aneurysms of the ductus arteriosus are rare complications of a patent ductus arteriosus. It is met at any age but it is most commonly seen in children under two months of age. Echocardiography is the best test to diagnose a ductus arteriosus, but actually the role of thoracoscopy is to help in differential diagnosis of mediastinal masses. Surgery should be recommended without delay, to avoid fatal complications, with the resection of the thrombosed aneurysm of the ductus arteriosus.

Minimally-invasive surgery in paediatric oncology: proposal of recommendations

The Authors report a proposal of recommendations concerning Minimally Invasive Surgery (MIS) in Paediatric Oncology. Since the exact role of MIS in Paediatric Oncology is still not completely defined, a restrict panel of Italian Paediatric Surgeons, some interested in Oncologic Surgery, others in MIS, prepared a schematic document, mainly founded on literature data, to provide Paediatric Surgeons with recommendations useful to approach paediatric tumours with MIS. The final draft was approved by the Italian Group of Paediatric Oncologic Surgeons. The Authors summarize the feasibility of MIS, when performed with different purposes (biopsy / resection) and timing (initial / delayed surgery) for the most common solid tumours in children. The oncologic criteria must be always followed with MIS as well as with "open" surgery.

X-ray magnetic circular dichroism and small angle neutron scattering studies of thiol capped gold nanoparticles

X-ray magnetic circular dichroism (XMCD) and Small Angle Neutron Scattering (SANS) measurements were performed on thiol capped Au nanoparticles (NPs) embedded into polyethylene. An XMCD signal of 0.8 x 10(-4) was found at the Au L3 edge of thiol capped Au NPs embedded in a polyethylene matrix for which Superconducting Quantum Interference Device (SQUID) magnetometry yielded a saturation magnetization, M(S), of 0.06 emu/g(Au). SANS measurements showed that the 3.2 nm average-diameter nanoparticles are 28% polydispersed, but no detectable SANS magnetic signal was found with the resolution and sensitivity accessible with the neutron experiment. A comparison with previous experiments carried out on Au NPs and multilayers, yield to different values between XMCD signals and magnetization measured by SQUID magnetometer. We discuss the origin of those differences.

Evolution of the surgical management of bowel atresia in newborn: laparoscopically assisted treatment

PURPOSE

The jejunal-ileal atresias are the most common cause of intestinal occlusion in neonatal period and the duodenal atresia is the most common cause of high bowel obstruction in newborn. The treatment classically used is performed by a transverse sovraumbilical laparotomy. The first "minimal-invasive" approach was performed at the end of the years '70. Nowadays three clusters of thought are delineated about of mini-invasive treatment of small bowel atresias: the intestinal continuity can be established with a circumbilical incision, a totally laparoscopic technique or a laparoscopically assisted approach. It's presented our initial experience of bowel atresia in newborn treated with laparoscopically assisted approach.

MATERIALS AND METHODS

Three newborns with prenatal diagnosis of suspected bowel obstruction and one with suspected duodenal atresia, confirmed the diagnosis after birth, underwent to laparoscopically-assisted surgery to correct these congenital anomalies. We have treated with this procedure a duodenal atresia, two jejunal atresias and an ileal form. Surgical management was consisted of an explorative laparoscopy that allowed to recognize and isolate the pathological portion. The second step was traditional open surgery: after the exteriorization of the pathological tract through the umbilical wound, we performed the intestinal anastomosis.

RESULTS

In all cases the operation was completed successfully, no conversion was necessary. Intraoperatively no complications occurred. The post-operative course was uneventful.

CONCLUSION

The video-assisted technique for the correction of small bowel atresia adds the advantages of the classic laparotomic procedure to the laparoscopic ones.

Congenital colonic stenosis: a case of late-onset

PURPOSE

Colonic atresia and stenosis are rare causes of intestinal obstruction in the infant. Only 1.8%-15% of intestinal atresias occur in the colon. Congenital colonic stenosis is even less common than colonic atresia. Only 10 cases have been reported in Literature since 1966 and only one late-onset case has been reported in Literature until now. We describe the case of a 4-month-old baby coming to our attention because of an intestinal subocclusion due to a congenital colonic stenosis of the ascending colon.

CASE REPORT

A 4-month-old baby came to our attention for persistent abdominal distension, reduction of bowl function and decaying of overall clinical conditions. A plain abdominal radiograph showed distended intestinal loops with air-fluid levels and no gas in the rectum. During the barium enema the contrast medium appeared to completely fill the lumen of the colon up to the ileo-cecal valve and Cecum appearing higher than normal. Beyond the ileo-cecal valve, the contrast medium showed an abnormal hypotonic dilatation of the small intestinal loops. Suspecting an organic intestinal obstruction, an explorative laparotomy was deemed necessary and at halfway in the ascending colon a stenosis was found.

RESULTS

The post-operative course was uneventful and the patient is currently in good clinical conditions, has a normal diet and is thriving.

CONCLUSION

Considering both the Literature and our own experience, it is wise to reckon the congenital colonic stenosis as a rare but possible cause of complete or partial intestinal obstruction not only in the newborn but also throughout the first year of life.

Clinical spectrum and management of congenital pulmonary cystic lesions

INTRODUCTION

Congenital cystic lesions of the lung in children are uncommon but potentially life-threatening and warrant an urgent diagnostic work-up. Pulmonary sequestration (PS), congenital cystic adenomatoid malformation (CCAM), congenital lobar emphysema (CLE), and bronchogenic cyst (BC) are the four major congenital cystic lesions, but they share similar embryologic and clinical characteristics. The purpose of this study is to review our institutional experience with congenital cystic lung disease emphasizing on diagnosis and management.

PATIENTS AND METHODS

Between January 1975 and October 2007, 109 patients have been treated, of which 57 males and 52 females, the age ranged from the birth to 13 years. 104 patients presented solitary lesions: CCAM (47), CLE (16), PS (22), BC (19). The remainders 5 patients presented two simultaneous lesions: intralobar PS and CCAM (2), CLE and CCAM (3).

RESULTS

All the lesions have been treated surgically: in the first cases, only symptomatic patients underwent surgery, while in the last years, patients have systematically been submitted operated.

CONCLUSIONS

A meaningful percentage of CCAM joins to PS and CLE; instead the BC are generally isolated, probably deriving by a more precocious embryogenetic defect. The treatment of these lesions is surgical: CCAM (type I-II) and CLE should be treated promptly in newborns for respiratory distress and pneumothorax; CCAM (type II) and BC generally become symptomatic gradually and expose to degenerative risk; intralobar PS generally becomes symptomatic and surgery prevents the risk of infections. Extralobar PS and the asymptomatic BC are not exempted by surgical approach whenever accidentally described as masses of uncertain nature. Asymptomatic cysts in children should be resected, to avoid later complications of the cysts, which could make operation more difficult. Conservative anatomic resections should be attempted to preserve functional lung tissue. Careful histologic examination of the resection specimen is mandatory to identify occult malignancy. In conclusion a correct embryogenetic organization and a clinical evaluation of the congenital cystic lung diseases allow a precocious and effective surgical timing.

Delayed-onset peripheral blood cytopenia after rituximab: frequency and risk factor assessment in a consecutive series of 77 treatments

The occurrence of unexplained peripheral blood cytopenia, particularly neutropenia, has been recently reported after rituximab. Its prevalence may be underestimated since it may occur late after treatment. This study analysed all cases of unexplained delayed-onset peripheral blood cytopenia of WHO grade II - IV occurring in an unselected series of patients treated with rituximab in order to evaluate its prevalence and clinical significance. Seventy-seven courses of rituximab (corresponding to 317 rituximab infusions) given to 72 consecutive patients affected by non-Hodgkin's Lymphoma and treated at a single Center with rituximab, alone (nine cases), associated with chemotherapy (50) or with chemotherapy and autologous stem cell transplantation (18) were evaluated. Twenty-three cases of cytopenia (29.8%) were observed. Neutropenia developed in 21 cases (27.3%), thrombocytopenia in eight (10.4%), anemia in four (5.2%). Multiple cytopenias were observed in nine cases. Neutropenia developed after a median of 10 weeks, anemia of 5 weeks and thrombocytopenia of 4 weeks after the last rituximab dose. Severe infections occurred in four of 21 neutropenic patients (19%), compared to two of 56 controls (3.6%) (p = 0.043). Cytopenia eventually resolved in nine of 18 evaluable cases after a median of 10 weeks (range 1 - 23). Age, sex, histology, bone marrow infiltration, hypogammaglobulinemia, previous chemotherapy, autologous stem cell transplant, rituximab schedule and timing, rituximab doses were analysed as predictors for cytopenia; by multivariate analysis only a previous treatment with chemotherapy and more than four rituximab doses were significantly associated with a higher risk of post-rituximab delayed cytopenia. Delayed-onset cytopenia, particularly neutropenia, is a clinically significant complication of rituximab treatment, which merits further investigation.

[Thoracoscopic treatment of oesophageal atresia]

BACKGROUND

Advancements in minimally invasive surgery in newborns have allowed even the most complex neonatal procedures to be approached using these techniques. Other authors have demonstrated its efficacy in the treatment of the esophageal atresia with distal fistula.

METHODS

We report our experience based on the thoracoscopic repair of esophageal atresia with distal fistula in two newborns. Birth weights were 2.800 g and 2.300 g respectively. The patients were intubated endotracheally and placed in a left prone position. Four trocars were inserted: the first one of 5 mm was positioned in the fifth intercostal space for the camera, the other two of 3 mm were positioned in the fourth intercostal space on the anterior and posterior axillary line respectively for the operative instruments. The last trocar of 3 mm was inserted in the third intercostal space on the anterior axillary line for the lung retractor. CO2 was insufflated at a pressure of 8 mm Hg and a flow of 0.5 L/min. The fistula was first isolated then ligated and cut with scissors. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 4-0 Vicryl sutures. A tube chest was placed through the lower trocar site with the tip near the anastomosis.

RESULTS

These two procedures were free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after a mean of 4 days. Barium swallow made on day 7 demonstrated no leakage and no stenosis of the anastomosis. Total oral feeding was possible after 8 days. Mean hospitalization was 14 days.

CONCLUSION

This initial report shows, as demonstrated by the experience since 1999 by other authors, that the thoracoscopic esophageal repair in the newborns is technically feasible and, thanks to a magnified vision, it allows to abtain a good isolation of the esophagus and of the tracheo-esophageal fistula respecting the anatomical structures. Moreover the advantages are in terms of exposure and esophageal length, avoiding the significant short and long-term morbidity associated with thoracotomy.

[Video-assisted treatment for biliary atresia]

BACKGROUND

The surgical treatment of biliary atresia is still a great challenge for pediatric surgeons. Kasai's operation usually needs a wide, painful, muscle-cutting laparotomies that quite often are followed by pain and peritoneal adhesion. These possible complications may disturb the post-operative course and humper liver transplantation. Advancements in minimally invasive surgery have allowed even the most complex procedures to be approached using these techniques.

METHODS

The authors present a case of successful Roux-en-Y laparoscopic portoenterostomy for the treatment of biliary atresia. We report a case of a 3-month-old patient with biliary atresia who weighted Kg 5,300 at the operation. The patient was placed in supine position. The procedure was performed with 4 trocars of 3 mm and 1 of 10 mm. The umbilical site was used for extracorporeal Roux-en-Y enteroenterostomy. CO2 was insufflated at a pressure of 8 mmHg and a flow of 0.5 L/min. A drain was placed through the lower trocar site with the tip near the anastomosis.

RESULTS

The procedure was free of neither intraoperative nor post-operative complications. Feeding by nasogastric tube was started after 2 days. Total oral feeding was possible after 8 days.

CONCLUSION

Laparoscopic approach to perform Kasai's operation is technically feasible and thanks to a magnified vision, it allows to abtain a good visualization of the portal structures with an adequate retraction of the liver. This procedure can avoid or decrease the post-operative complications such as pain, breathing difficulty, adhesions and resulting in very small scars. Anyway laparoscopic Kasaiportoenterostomy should be done by a surgeon with a good experience in laparoscopic hand-suturing and neonatal experience and with the support of an experienced in neonatal and infantile videosurgery anaesthesiologist.

CXCR4/SDF-1 expression in early breast cancer (BC) is not influenced by circulating estrogens serum levels

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Background: The chemokine SDF-1 and its receptor CXCR4 have been found to enhance the metastatic potential of BC cells and correlate with a poorer prognosis of BC patients. Estradiol is a known mitogenic factor for BC cells. SDF-1 has been reported to be an estradiol (E2)-inducible autocrine growth factor that supports the growth of breast cancer cell lines in vitro. The aim of this study was to verify whether estrogens serum levels may influence SDF-1 and CXCR4 expression in vivo, in a series of patients with early stage BC. Methods: 68 patients sequentially observed at the Spedali Civili di Brescia from 2001 to 2002, with a diagnosis of T1a,b,c, N0 breast cancer were retrospectively analysed. CXCR4 and SDF-1 expression was determined by immunohistochemistry with anti-human CXCR4 (Clone 44716) and anti-human SDF-1 (Clone 79018) monoclonal antibodies (R&D Systems, Minneapolis, USA) followed by incubation with the EnVision peroxidase kit (Dakocytomation, Glostrup, Denmark). A serum sample was obtained from all patients at baseline before surgery. Serum estrone (E1) and estradiol (E2) were measured by radioimmunoassay by using commercial kits (Alifax, Padua, IT and Ortho-Clinical Diagnostics, Amersham, UK, respectively). Results: Estrogens serum levels analysis revealed elevated levels of E1 in 9/54 (16%) post-menopausal patients, while E2 levels were in the normal ranges. SDF-1 was expressed in 68/68 (100%) patients with a diffuse and intense cytoplasmatic pattern of staining and CXCR4 was coexpressed in 15/68 (22%) patients with a predominant faint nuclear distibution (p 0,06). No significant correlations were found between CXCR4, SDF-1 and E1 or E2, respectively, as well as with other clinico-pathological characteristics. After a median follow-up of 48 months, 3/68 (4%) patients which all resulted CXC4/SDF1-positive, relapsed and are dead for metastatic disease. Conclusions: This study demonstrates that in T1N0 BC patients: 1) SDF-1 is high levels in the majority of cases; 2) CXCR4 is expressed in approximately 20% of cases with restriction to the nucleus and 3) serum levels of circulating E2 and E1 in pre- or post-menopausal patients, respectively, do not influence CXCR4/SDF-1 expression on breast cancer cells.

No significant financial relationships to disclose.

One trocar assisted pyeloplasty (OTAP): initial experience and codification of a technique

BACKGROUND

The Anderson-Hynes pyeloplasty is still the gold standard for the surgical treatment of the ureteropelvic junction obstruction (UPJO) in children. To reduce the surgical invasivity, laparoscopic (RPSc) and retroperitoneoscopic (RPSc) pyeloplasty have been proposed but concerns have been expressed. In the RPSc approach, the small operative space and the technical difficulties have limited the application and diffusion of this techinique while in case of laparoscopy, a transperitoneal technique is used to treat a retroperitoneal disease. We report our initial experience with the "one trocar assisted pyeloplasty" (OTAP) in the treatment of UPJO in children.

METHODS

From January 2005 to December 2006 sixteen children (13 males--3 females) from 2 to 18 months of age (mean age 5.6 months), with impaired monolateral renal function underwent surgical treatment for UPJO. In 11 cases the obstruction was on the left side and in one case a crossing vessel was found. The renal pelvis was anteriorly reached using a 10 mm operative telescope via a flank 12 mm incision. The UPJ was exteriorized and a dismembered pyeloplasty performed also for the crossing vessel. In two cases a 6 Fr uretero-pyelo-nephrostomy catheter was used.

RESULTS

The patients were discharged after four days without complications. The cosmetic results are excellent. In one case, a small perianastomotic leakage was seen. The ultrasonographic follow-up demonstrated the spontaneous resolution of the leakage. The post operative US follow-up showed the reduction of the dilatation in all cases.

DISCUSSION

This is an initial experience and a longer follow-up is needed. However, in our opinion the OTAP could be considered as a safe and feasible alternative to the laparoscopic or retroperitoneoscopic pyeloplasty, especially in very small children and also in presence of crossing vessels.

[Laparoscopic surgery in Hirschsprung's disease]

The laparoscopic treatment of benign conditions of the colon represents only one of the numerous application fields of the modern laparoscopic techniques in pediatric surgery. Until the half of the 1990's, the surgical treatment of choice for Hirschsprung's disease has been the procedure ideated by Soave in the early 1960's. Nowadays, the optimal treatment in the classic forms of aganglionic megacolon consists in performing, in neonatal age or in the first months of life, a transanal extramucous pull-through. This approach can be integrated by a laparoscopic step. From September 2000, at the Department of Pediatric Surgery, Bologna University, we have operated 21 cases of congenital aganglionic megacolon with this technique.

Molecular adsorbent recirculating system (MARS) application in liver failure: clinical and hemodepurative results in 22 patients

PURPOSE

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) still show a poor prognosis. MARS was used in 22 patients with ALF or ACLF to prolong patient survival for liver function recovery or as a bridge to transplantation.

DESIGN

Evaluation of depurative efficiency, biocompatibility, hemodynamics, encephalopathy (HE) and clinical outcome.

PROCEDURES

During 71 five-hour sessions we evaluated (0', 60', 120', 180', 240', 300'): bilirubin, ammonia, cholic acid (CCA), chenodeoxycholic acid (CCDCA), leukocytes, platelets, hemoglobin and mean arterial pressure (MAP). Serum creatinine, electrolytes, cardiac output, cardiac index (bioimpedence) and HE (West Haven Criteria score) were evaluated at 0' and 300'. STATISTICAL METHODS AND OUTCOME MEASURES: Student's t-test for pre- vs. end-session values was used. For bilirubin and ammonia the correlation test was made between pre- and end-session values and between pre-session values and removal rates (RRS).

MAIN FINDINGS

Survival was 90.9% at 7 days, 40.9% at 30 days. Pre- vs. end-session: bilirubin from 37.2 +/- 12.5 mg/dL to 24.9 +/- 8.9 mg/dL (p < 0.01), ammonia from 88.0 +/- 60.4 micromol/L to 43.6 +/- 32.9 micromol/L (p < 0.01), CCA from 42.8 +/- 21.0 micromol/L 18.2 +/- 9.8 micromol/L (p < 0.01), CCDCA from 26.3 +/- 6.3 micromol/L to 15.7+/-7.6 micromol/L (p<0.01). The correlation test between pre-session values of bilirubin and ammonia vs. RR S was respectively 0.32 (p = 0.01) and 0.30 (p = 0.04). Leukocytes, platelets and hemoglobin remained stable. MAP increased from 82.0 +/- 12.0 mmHg to 87.0 +/- 13.0 mmHg (p < 0.05), West Haven Criteria score decreased from 2.7 +/- 0.7 to 0.7 +/- 0.7 (p < 0.001).

CONCLUSION

MARS treatment led in all patients to an improvement of clinical, hemodynamic and neurological conditions, with significant reduction in the hepatic toxins blood level. Treatment biocompatibility and tolerance were satisfactory.

[Psychopathology in epilepsy and pseudoepilepsy: preliminary results in our experience]

PURPOSE

Pseudoseizures or nonepileptic seizures (NES) are termed "nonepileptic psychogenic seizures" and account for approximately 20% of all intractable seizure disorders. These seizures are often misdiagnosed as true epilepsy, resulting in inappropriate, ineffective and costly treatment of many patients. Nowadays video-EEG monitoring have greatly improved the ability of specialists to correctly distinguish NES from epilepsy. Nevertheless, patients with NES do not always demonstrate obvious psychopathology. The aim of this study is to examine the complexity and severity of psychopathological features of patients with NES, in order to optimize strategies of intervention and appropriate long-term psychological and psychopharmacological treatment for these patients.

MATERIALS AND METHODS

We evaluated three samples: patients with NES, patients with epilepsy and a control sample. Subjects with pseudoseizures and epileptic seizures have been randomly recruited from the Epilepsy Centre at the Neurology Institute of Catholic University of Sacred Heart of Rome. Seizures have been documented by the recording of spontaneous events with video-EEG, EEG, clinical observation and ictal examination. Each sample of patients has been tested using the Hamilton Rating Scale for Depression (HDRS), Dissociative Experience Scale (DES), Minnesota Multiphasic Personality Inventory-2 (MMPI-2) and Short Form Health Survey 36 (SF-36).

RESULTS

17 (4 M; 13 F) patients with NES, 13 (3 M; 10 F) patients with epilepsy and 16 (4 M; 12 F) control subjects were recruited. Our preliminary results confirm previous researches showing that NES typically manifest between 20 and 30 years of age and that approximately a three-quarters of all patients are women. Besides, they confirm that psychosocial, environmental and intrapsychic mechanisms interact in the aetiology of NES: in particular, our preliminary results are consistent with the hypothesis that traumatic experiences are important precursors to the development and expression of NES.

CONCLUSIONS

This study has yielded promising results and confirm the necessity to improve our knowledge about psychopathology of patients with NES. Psychiatrists and neurologists should work in equipe to guarantee an adequate treatment for a pathology too long set aside and almost ignored from clinical research.

[Laparoscopic surgical treatment of anorectal malformations]

Anorectal Malformations (ARM) include a wide spectrum of anomalies, ranging from anal and rectal agenesis (usually associated with a recto-urethral, rectovaginal or recto-vestibular fistula) to ano-cutaneous fistula. On the basis of studies on the anatomy of the muscular structures contained in the pelvic cavity and on the physiology of the mechanisms which regulate the continence, many different techniques have been performed to allow a surgical treatment for the ARMs and to obtain post-operative results as nearer as possible to normality, that is to an adequate colic motility and a defecation control. In 2000, a new surgical technique for high and intermediate ARMs has been introduced, the laparoscopically assisted ano-rectal pull-through (LAARP) according to Georgeson. At the Department of Pediatric Surgery, Bologna University, from 2000 to nowadays, we have treated with LAARP 7 cases of high ARMs, all male patients and with colostomy. The average age at operation was between 2 and 10 months.