Impact of the COVID-19 pandemic on neuromuscular rehabilitation setting. Part 2: patients and families' views on the received health care during the pandemic

This study explored views of users with muscular dystrophies and their caregivers on staff-user relationships and the treatments provided by a Rehabilitation Centre during the pandemic. Patients and relatives were asked to anonymously complete an open-ended questionnaire exploring their views on these aspects. Fifty-four patients and 40 caregivers gave their informed consent and participated in the survey. Fifty-three patients were adults, 28% suffering from Duchenne/Becker muscular dystrophy. Patients reported 269 comments on health care services provided during the pandemic, 132 (49%) concerning positive aspects and 137 (51%) negative aspects. The prompt restart of the rehabilitation therapies and the staff closeness over the pandemic were the practical aspects most frequently appreciated (46.9%), while closer family contacts and the perception of being able to rely on the Centre's constant support were the most cited psychological aspects (53.1%). Architectural barriers, difficulties in accessing public health services, economic difficulties, and lack of support from welfare and other agencies were the practical critical points most frequently reported (89%). In addition, social isolation, and loneliness due to fear of contagion were the most negative psychological aspects (10.1%). As regard the caregivers' views, participants reported 151 comments. Of these, 86 (56.9%) were positive and 65 (43.1%) were negative. Among the positive aspects, the psychological ones - such as closer family contacts, not feeling abandoned and counting on the constant Centre's professional support prevailed (53.5%). As for the negative aspects, most caregivers (92.6%) believe that the pandemic exacerbated their financial and bureaucratic difficulties, particularly in poorer families.

Laser Ablation Treatment of Recurrent Lymph Node Metastases from Papillary Thyroid Carcinoma

(1) Background: The incidence of papillary thyroid cancers is increasing. Papillary neoplasm metastasizes to the central and lateral lymph nodes of the neck. The recurrence rate is less than 30%. The gold standard of treatment for lymph node recurrences is surgery, but surgery is burdened by a high rate of complications. Therefore, laser ablation of recurrent lymph nodes has been recognized as an alternative treatment with minimal invasiveness, a low complication rate and a curative effect. (2) Methods: We analyzed 10 patients who underwent a total thyroidectomy and metabolic radiotherapy and who developed a lymph node recurrence in the laterocervical compartment in the following 12-18 months. (3) Results: Patients developed lymph node recurrence at IV and Vb levels in 70% and 30% of cases, respectively. All patients were treated with a single laser ablative session. Hydrodissection was performed in all patients. The energy delivered was 1120 ± 159.3 Joules and 3-4 Watts in 362 ± 45.7 s. No complications were reported. All patients underwent a 6-month follow-up. A volumetric reduction of 40.12 ± 2.2%, 49.1 ± 2.13% and 59.8 ± 3.05%, respectively at 1-, 3- and 6-months of follow-up was reported. (4) Conclusions: At 6 months, a fine needle aspiration was performed, which was negative for malignant cells and negative for a dosage of Thyroglobulin in eluate. The laser ablation is an effective alternative to surgical treatment.

Impact of the COVID-19 pandemic on rehabilitation setting. Part 1: professionals' views on the changes in routine care provided by a rehabilitation centre for patients with muscle diseases

The outbreak of COVID-19 has forced the health care system to undergo profound rearrangements in services and facilities, especially during the periods of lockdown. In this context, inpatient and outpatient services had to rethink and reorganize their activities to meet the needs of severely disabled patients, as those affected by Muscular Dystrophies (MDs).

We present the preliminary results of a survey aiming to explore the staff views on the changes in the care provided by the Gaetano Torre Rehabilitation Centre, and, the impact of these changes on professionals, patients and their families.

The survey was carried out using an open-ended questionnaire including six-items, on the practical and psychological aspects emerged during the pandemic in relation to the healthcare services provided by the Centre and to the patients/caregivers conditions. The participants, most of them physiotherapists, highlighted 169 aspects emerging in the pandemic, 48.5% referring to the resources used to cope with critical issues and 51.5% concerning the difficulties encountered. Emotional aspects prevailed on practical aspects both in resources (52.4 vs 47.6%) and in difficulties (57.5 vs 42.5%) categories. In particular, with regard to patients’ resources, psychological benefits, despite the burden, were greater than practical ones (87 vs 13%), in the form of improved intra-family relationships, feeling more cared for, and satisfaction for the received care. As for the patients’ relatives, the staff indicated more resources than difficulties (72.8 vs 17.2%). Among the former, 75% concerned the emotional sphere, such as the perception of having a point of reference even in such a difficult time.

Peripheral Arterial Tonometry (EndoPAT)-measured Endothelial Dysfunction in Migraine with Aura children

BACKGROUND

The association between Migraine with Aura (MA) and vascular disease has been previously reported. We investigated whether pre-clinical vascular alterations, such as Endothelial Dysfunction, are already present in children and adolescents with Migraine with Aura.

METHODS

We retrospectively enrolled 27 patients having Migraine with Aura, aged9 -18 years, and 31 age matched healthy control subjects to evaluateEndothelial Function by Peripheral Arterial Tonometry. This technique measures finger pulse wave amplitude, before and during reactive hyperaemia, and calculates the Augmentation Index (AI) and the Reactive Hyperaemia Index (RHI). We also set-up an Aura Severity Scale to assess disease severity and its relationship with AI and RHI alterations.

RESULTS

Also if the case-control study resulted only partially as significant, we found there is an inversely proportional relationship between the severity of the migraine measured with Aura Severity Scale and the values of the endoscore (a significantly reduced levels of AI (p-value <0,03) and a marginal reduction of RHI levels (p-value <0,07).

CONCLUSION

Further studies should explore the impact of pre-clinical vascular alterations in children and adolescents with Migraine with Aura.

The Ablation of Thyroid Nodule's Afferent Arteries Before Radiofrequency Ablation: Preliminary Data

Induced radiofrequency thermal ablation is the cytoreductive treatment of symptomatic benign thyroid nodules, metastatic and recurrent thyroid tumors and papillary thyroid microcarcinomas. It is a safe and effective alternative to surgery and it allows to obtain satisfactory results in terms of volumetric reduction of the nodule with significant improvement in the quality of life. The trans-isthmic approach and the moving shot technique are the two basic techniques; however, an advanced technique, artery-first feeding radiofrequency ablation, has been developed and validated. We have prospectively included 29 consecutive patients who have undergone radiofrequency ablation (Group A) or artery- first vRFA (Group B). All included patients had a diagnosis of benign nodular goiter and they underwent a single session of radiofrequency ablation. All patients followed a follow-up program at 1 month, 3 months, and 6 months. Continuous variables (age, TSH value, basal volume of nodule, used Joule, time in second of the procedure, nodules' volume at 1-, 3-, and 6- months of follow-up and percentage of volume reduction at 1-, 3-, and 6- months of follow-up) were described as mean, standard deviation and range, while categorical variables (gender, nodule structure and nodule vascularization) were described as number of cases and percentage. Independent samples t-test were performed to compare the continuous variables. A Test of Proportions was applied to the categorical variables. The Fisher's exact test was used to analyze the gender. Statistical significance was considered in case of p-value <0.05. Solid structure and spongiform structure showed statistic differences with p-values of 0.022 and 0.023 respectively between two groups. The percentage of reduction at 1 month did not show a significant difference between two groups; instead, the percentage of volume reduction was decreased mostly in the Group B at 3 months and 6 months of follow-up with a p-value of 0.003 and 0.013, respectively. The Joules/energy used showed a statistically significant difference (p-value=0.05), more energy must be used in vascular radiofrequency ablation. These data allow us to hypothesize that vRFA may improve the effectiveness of the procedure, allowing for a reduction in volume more quickly. They were preliminary but promising results, clearly a larger series of cases and prolonged follow-up are needed to clarify and confirm our observations.

Efficacy and tolerability of mycophenolate mofetil in a pediatric Rasmussen syndrome

Rasmussen syndrome (RS) is a chronic encephalopathy with uncertain etiology and immune-mediated pathogenesis. The only definitive treatment is represented by functional hemispherectomy. We describe the case of a 6.5-year-old female patient who developed several episodes of focal, unilateral clonic seizures. Following laboratory and instrumental investigations, the patient was diagnosed as having RS. A treatment with corticosteroids, intravenous immunoglobulin, and the antiseizure medication (carbamazepine and levetiracetam) did not completely control the seizures. Therefore, the patient was treated with mycophenolate mofetil (MMF), showing a good clinical response, with reduction of the seizures, and stability of the radiological findings. This case suggests the potential utility of MMF in the immune approach to RS.

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Rasmussen encephalitis (RE) is an immune-mediated disease of unknown etiology.

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Current definitive treatment for RE is represented by hemispherectomy.

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The immune approach of RE has been performed with several agents.

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In this case, mycophenolate mofetil was successfully used in a patient with RE.

Effects of low-carbohydrate diet therapy in overweight subjects with autoimmune thyroiditis: possible synergism with ChREBP

The thyroid is one of the metabolism regulating glands. Its function is to determine the amount of calories that the body has to burn to maintain normal weight. Thyroiditides are inflammatory processes that mainly result in autoimmune diseases. We have conducted the present study in order to have a clear picture of both autoimmune status and the control of body weight. We have evaluated the amount of either thyroid hormones, or antithyroid, or anti-microsomal, or anti-peroxidase antibodies (Abs) in patients with high amounts of Abs. In a diet devoid of carbohydrates (bread, pasta, fruit, and rice), free from goitrogenic food, and based on body mass index, the distribution of body mass and intracellular and extracellular water conducted for 3 weeks gives the following results: patients treated as above showed a significant reduction of antithyroid (−40%, P<0.013), anti-microsomal (−57%, P<0.003), and anti-peroxidase (−44%, P<0,029) Abs. Untreated patients had a significant increase in antithyroid (+9%, P<0.017) and anti-microsomal (+30%, P<0.028) Abs. Even the level of anti-peroxidase Abs increased without reaching statistical significance (+16%, P>0064). With regard to the body parameters measured in patients who followed this diet, reduction in body weight (−5%, P<0.000) and body mass index (−4%, P<0.000) were observed. Since 83% of patients with high levels of autoantibodies are breath test positive to lactase with a lactase deficit higher than 50%, this fact led us to hypothesize a correlation with carbohydrate-responsive element-binding protein and therefore a possible role of carbohydrate metabolism in the development and maintenance of autoimmune thyroiditis associated with body weight increase and slower basic metabolism.

A Rapid and Sensitive Assay for the Detection of Benzylpenicillin (PenG) in Milk

Antibiotics, such as benzyl-penicillin (PenG) and cephalosporin, are the most common compounds used in animal therapy. Their massive and illegal use in animal therapy and prophylaxis inevitably causes the presence of traces in foods of animal origin (milk and meat), which creates several problems for human health. With the aim to prevent the negative impact of β-lactam and, in particular, PenG residues present in the milk on customer health, many countries have established maximum residue limits (MRLs). To cope with this problem here, we propose an effective alternative, compared to the analytical methods actually employed, to quantify the presence of penicillin G using the surface plasmon resonance (SPR) method. In particular, the PenG molecule was conjugated to a protein carrier to immunize a rabbit and produce polyclonal antibodies (anti-PenG). The produced antibodies were used as molecular recognition elements for the design of a competitive immune-assay for the detection of PenG by SPR experiments. The detection limit of the developed assay was found to be 8.0 pM, a value much lower than the MRL of the EU regulation limit that is fixed at 12 nM. Thus, our results clearly show that this system could be successfully suitable for the accurate and easy determination of PenG.

A near-infrared fluorescence assay method to detect patulin in food

Patulin (PAT) is a toxic secondary metabolite (mycotoxin) of different fungal species belonging to the genera Penicillium, Aspergillus, and Byssochlamys. They can grow on a large variety of food, including fruits, grains, and cheese. The amount of PAT in apple derivative products is a crucial issue because it is the measure of the quality of both the used raw products and the performed production process. Actually, all current methodologies used for the quantification of PAT are time-consuming and require skilled personnel beyond the sample pretreatment methods (e.g., high-performance liquid chromatography, mass spectrometry, and electrophoresis techniques). In this work, we present a novel fluorescence polarization approach based on the use of emergent near-infrared (NIR) fluorescence probes. The use of these fluorophores coupled to anti-PAT antibodies makes possible the detection of PAT directly in apple juice without any sample pretreatment. This methodology is based on the increase of fluorescence polarization emission of a fluorescence-labeled PAT derivative on binding to specific antibodies. A competition between PAT and the fluorescence-labeled PAT derivative allowed detecting PAT. The limit of detection of the method is 0.06 μg/L, a value that is lower than maximum residue limit of PAT fixed at 50 μg/L from European Union regulation.

Laparoscopic cholecystectomy: consensus conference-based guidelines

INTRODUCTION

Laparoscopic cholecystectomy (LC) is the gold standard technique for gallbladder diseases in both acute and elective surgery. Nevertheless, reports from national surveys still seem to represent some doubts regarding its diffusion. There is neither a wide consensus on its indications nor on its possible related morbidity. On the other hand, more than 25 years have passed since the introduction of LC, and we have all witnessed the exponential growth of knowledge, skill and technology that has followed it. In 1995, the EAES published its consensus statement on laparoscopic cholecystectomy in which seven main questions were answered, according to the available evidence. During the following 20 years, there have been several additional guidelines on LC, mainly focused on some particular aspect, such as emergency or concomitant biliary tract surgery.

METHODS

In 2012, several Italian surgical societies decided to revisit the clinical recommendations for the role of laparoscopy in the treatment of gallbladder diseases in adults, to update and supplement the existing guidelines with recommendations that reflect what is known and what constitutes good practice concerning LC.

Haptoglobin increases with age in rat hippocampus and modulates Apolipoprotein E mediated cholesterol trafficking in neuroblastoma cell lines

Alteration in cholesterol metabolism has been implicated in the pathogenesis of several neurodegenerative disorders. Apolipoprotein E (ApoE) is the major component of brain lipoproteins supporting cholesterol transport. We previously reported that the acute-phase protein Haptoglobin (Hpt) binds ApoE, and influences its function in blood cholesterol homeostasis. Major aim of this study was to investigate whether Hpt influences the mechanisms by which cholesterol is shuttled from astrocytes to neurons. In detail it was studied Hpt effect on ApoE-dependent cholesterol efflux from astrocytes and ApoE-mediated cholesterol incorporation in neurons. We report here that Hpt impairs ApoE-mediated cholesterol uptake in human neuroblastoma cell line SH-SY5Y, and limits the toxicity of a massive concentration of cholesterol for these cells, while it does not affect cholesterol efflux from the human glioblastoma-astrocytoma cell line U-87 MG. As aging is the most important non-genetic risk factor for various neurodegenerative disorders, and our results suggest that Hpt modulates ApoE functions, we evaluated the Hpt and ApoE expression profiles in cerebral cortex and hippocampus of adolescent (2 months), adult (5 and 8 months), and middle-aged (16 months) rats. Hpt mRNA level was higher in hippocampus of 8 and 16 month-old than in 2-month old rats (p < 0.05), and Hpt concentration increased with the age from adolescence to middle-age (p < 0.001). ApoE concentration, in hippocampus, was higher (p < 0.001) in 5 month-old rats compared to 2 month but did not further change with aging. No age-related changes of Hpt (protein and mRNA) were found in the cortex. Our results suggest that aging is associated with changes, particularly in the hippocampus, in the Hpt/ApoE ratio. Age-related changes in the concentration of Hpt were also found in human cerebrospinal fluids. The age-related changes might affect neuronal function and survival in brain, and have important implications in brain pathophysiology.

Evaluation of cadmium, lead and metallothionein contents in the tissues of mussels (Mytilus galloprovincialis) from the Campania coast (Italy): levels and seasonal trends

The biological effect of seasonality on cadmium, lead and metallothionein contents was assessed in mussels Mytilus galloprovincialis from natural banks located along the coastline of the Gulf of Naples (Campania, Italy). Heavy metals and metallothionein concentrations were measured in digestive and reproductive glands. The results showed a clear correlation between metallothionein content and the reproductive gland status determined during the seasons; on the contrary, no correlation was found between metallothionein and metal contents. Data allow us to hypothesize that metallothionein functions go beyond metal detoxification, thus opening new scenarios for these proteins in invertebrates. The effect of seasons on metals concentration in mussel tissues showed similar seasonal patterns between the sites, regardless of their anthropogenic impacts. Cadmium content was not strictly related to seasonal periods, whereas lead content was significantly lower in summer. The results also indicate that the metal contents in mussels from the Gulf of Naples do not represent a risk to human health, even in the period of their maximum accumulation, and that the relaying of mussels before marketing could improve the animal stress conditions, but having a slight effect on metal excretion.

Early outcomes of colon laparoscopic resection in the elderly patients compared with the younger

BACKGROUND

The aim of this study was to define any benefits in terms of early outcome for laparoscopic colectomy in patients over 75 years old (OP) compared with the outcomes of a younger populations (YP).

METHODS

Forty elderly patients undergoing laparoscopic colectomy for colorectal cancer between 2007-2011 were studied, the patients are divided for gender, age, year of surgery, site of cancer, and comorbidity on admission and compared with 40 younger patients.

RESULTS AND DISCUSSION

Mean (standard deviation) age was 81.3 in OP and 68.3 YP Conversion rate was the same between the two groups. There was no difference in operative mean time . The overall mortality rate was 0% percent. The surgical morbidity rate was the same but there was an increased in cardiologic e bronchopneumonia complications in older population. Patients treated with laparoscopic approach had a faster recovery of bowel function and a significant reduction of the mean length of hospital stay not age related. Laparoscopy allowed a better preservation of postoperative independence status.

CONCLUSIONS

Laparoscopic colectomy for cancer in elderly patients is safe and beneficial including preservation of postoperative independence and a reduction of length of hospital stay.

[Lymphectomy in differentiated thyroid carcinoma]

Papillary and follicular thyroid carcinoma are still characterised by unclear biological and clinical behaviour with an autoptic incidence higher than the clinical incidence. Lymph-node involvement represents a prognostic factor that may increase the rate of local relapse, reducing long-term survival only in high risk patients--age > 45 years, M+, T > 3 cm, extra thyroidal extension, follicular histotype. The authors analyse the role of lymph-node cervical dissection. Routine or selective, extended or conservative lymphectomy are described in the literature. Prognostic factors are useful to determine the most appropriate surgical procedure. An elective cervical central dissection may be indicated in patients at high risk, while in cases of monolateral lymph-node metastases, in patients at low risk, a selective lymph node dissection of levels VI-III-IV is associated with lower morbidity. Modified radical neck dissection is reserved for patients at high risk or in cases of multiple lymph-node metastases (> 5) to reduce the incidence of local relapse. In the treatment of differentiated thyroid carcinoma an elective total thyroidectomy must be performed in combination with adjuvant radioiodine ablation.

Parathyroidectomy improves the quality of sleep in maintenance hemodialysis patients with severe hyperparathyroidism

Sleeping disorders are very common in patients with chronic kidney disease on dialysis (CKD5D) and are an emerging risk factor able to predict mortality. Parathyroid hormone (PTH) although considered a pivotal uremic toxin has rarely been associated with sleep disorders in uremia. In a study from our laboratory PTH concentrations failed to distinguish patients with sleep disorders from those without. In a study performed by Chou et al a 97% prevalence of insomnia was found in patients undergoing hemodialysis requiring parathyroidectomy. Surgery reduced PTH and increased sleeping hours within 3 months. The aim of this study was to study the effects of parathyroidectomy on the sleep disorders of insomniacs on maintenance hemodialysis. The study was performed in 16 insomniac patients on maintenance hemodialysis who successfully underwent surgery with autotransplantation of autologous parathyroid tissue (40 mg) under the skin of the forearm. Patients (5 F and 11 M) were studied from 1 month before surgery to 1 year after. Sleep disorders were assessed by means of a 27-item questionnaire--Sleep Disorder questionnaire (SDQ)--that identified sleeping disorders according to Diagnostic and Statistical Manual of Mental Disorders - IV Edition (DSM-IV) criteria. The Charlson Comorbidity Index (CCI) was also measured along with systolic and diastolic blood pressure, Hb, PTH, Ca, P. A 95.5% prevalence of sleep disorders was found pre operatively. Patients slept 4.90+/-1.2 hours, Ca averaged 10.09+/-0.54 mg/dL, Phosphate 5.5+/-1.93, CCI 9.8+/-1.1, PTH 1498+/-498 ng/mL. After 1 year follow-up 2 out 16 patients had normal sleep, 6 out 16 patients had subclinical sleep disorders and 8 remained insomniacs (p=0.008, Mc Nemar Test for paired data, insomniacs vs. no disturbance + subclinical disorders). Sleeping hours increased up to 6.0+/-1.24 (p<0.05), PTH was normalized, the Charlson Comorbidity Index was reduced (p<0.05) as were plasma calcium and phosphate (p<0.01). The study indicates that insomnia in patients with severe hyperparathyroidism on maintenance hemodialysis is ameliorated by parathyroidectomy.

Hepaticojejunostomy in the treatment of iatrogenic biliary lesions following laparoscopic cholecystectomy. A retrospective study on 51 cases

BACKGROUND/AIMS

Laparoscopic cholecystectomy is characterized by a higher incidence of iatrogenic biliary lesions. The Authors evaluate the role of hepaticojejunostomy in the treatment of iatrogenic biliary lesions following laparoscopic cholecystectomy in 51 patients observed in the Campania region, Italy from 1991 to 2003.

METHODOLOGY

The Authors report the data of a retrospective multicentric study of 51 patients -39 women (76.47%), 12 men (13.53%)-reoperated on for major biliary lesions following laparoscopic cholecystectomy. Hepaticojejunostomy in 20 cases (39.21%) and T-Tube plasty in 20 cases (39.21%) were performed.

RESULTS

The mean follow-up was 25.01 months. The mean hospital stay was 25.7 days. 1/51 patients (1.9%) died from intraoperative incontrollable hemorrhage while cumulative postoperative mortality was 9.8% (5/51 patients). Therapeutic success rate of hepaticojejunostomy was 70% with a T-Tube plasty success rate of 65%. 9/51 patients (17.64%) were reoperated while in 4/51 (7.84%) a biliary stent was positioned. In 1/51 patients (1.9%) a biliary cirrhosis and in 3/51 (5.7%) a bioumoral cholestasis was observed.

CONCLUSIONS

Laparoscopic cholecystectomy causes a higher incidence of iatrogenic biliary lesions. Hepaticojejunostomy gives better long-term results and lower morbidity compared to T-Tube plasty. Management of septic complications in patients with iatrogenic biliary lesions represents the first therapeutic step.

[Surgical treatment of fecal incontinence secondary to obstetric trauma]

Fecal incontinence (FI) is associated to elevated costs related to diagnostic work-up, surgical treatment and instrumental follow-up. The real incidence is unknown and prevalence is higher after 45 years with a ratio F:M ratio of 8:1. Frequently FI is due to pelvic damage secondary to obstetric trauma. The Authors analyze surgical treatment results of FI secondary to obstetric trauma evaluating pathogenesis and instrumental diagnostic preoperative work-up. In case of muscular injury, "overlapping" of external sphincter represents the treatment of choice allowing a good medium long term results. In the treatment of patients with more complex injures or after overlapping failures, direct sphincteroplasty are indicated. After multiple surgical failures, or in case of pure neural damage, sacral nerve stimulation, graciloplasty or artificial anal sphincter may be offered by referral centers.

[Surgical treatment of iatrogenic bile duct injuries following laparoscopic cholecystectomy: analysis of long-term results. Retrospective clinical study in 51 patients operated in the Campania region from 1991 to 2003]

An higher incidence rate of iatrogenic bile duct injuries is reported in cholecystectomy performed with the laparoscopy than with the laparotomy approach. The aim of this study was to provide a multicentre report on surgical treatment and the outcome of biliary complications during and following laparoscopic cholecystectomy. A questionnaire was mailed to all surgeons with experience in laparoscopic cholecystectomy in the Campania region. Data were collected from January 1991 to December 2003. Each patient was requested to indicate age, gender, associated diseases, site and type of lesion, surgical experience, diagnosis, treatment and complications. Twenty-six surgeons answered the questionnaire. Fifty-one patients (36 F/15 M; mean age: 42.5 +/- 11.9, range 13-91 years) with bile duct injuries following laparoscopic cholecystectomy were reported. The most frequent lesions were main bile duct partial or total transection. The intraoperative mortality rate was 1/51 (1.9%) due to a complex biliary and vascular injury. The postoperative mortality rate of revision surgery was 5/50 (10%). T-tube positioning (n = 20) and Roux-en-Y hepato-jejunostomy (n = 20) were the procedures most frequently performed. The complication rate in patients treated with the T-tube was significantly higher than in those treated with hepatico-jejunostomy. Surgical treatment of biliary injuries following laparoscopic cholecystectomy was characterized by unusually high mortality and morbidity for a non-neoplastic disease. Roux-en-Y hepato-jejunostomy remains the procedure of choice for these injuries.

Laparoscopic Treatment of an Omental Cyst

The authors evaluated the role of a laparoscopic approach on a complete resection of an omental cyst. A young female patient (25 years of age) underwent a complete resection of a 12-cm omental cyst via a laparoscopic approach. The patient presented with vomiting, nausea, and pain in the periduodenal area. The lesion was diagnosed via CT and MRI. The authors used four trocars (2 x 10 mm, 2 x 5 mm). After complete resection and aspiration, the cyst was removed in a bag. The postoperative period was uneventful, and the patient was discharged after 48 hours. There was no sign of relapse after 30 months of follow-up. Mesenteric and omental cysts are congenital abdominal lesions. Therefore, a complete resection is mandatory because of the high incidence of relapse. A laparoscopic operation proves a suitable approach because of the advantages of lower costs and comparable results to open surgery.

[Stapled hemorrhoidopexy in the treatment of hemorroidal prolapse]

In the treatment of hemorroidal prolapse, stapled hemorrhoidopexy, according to the Longo's technique, represents an innovative and interesting procedure. The Authors consider own experience in the years 2001-2002, estimating preliminary results in the treatment of 50 patients affected by hemorrhoidal disease classified as III-IV grade, associated with mucosal prolapse, rectocystocele in 5 cases, anal fissures in 6 and hyperplastic polyp in 1. The patients were submitted to mucosal prolapsectomy with mechanical stapler (PPH 01-33 Ethicon), applying haemostatic stitch on suture line, apart from intraoperative bleeding, associated to closed anal sphincterotomy in 6 cases, and resection of anal hyperplasic polyp in 1. In 5 cases of rectocystocele a Burch's culposuspension was associated to a stapled transanal rectal resection (STARR). After 3 and 12 months the Authors performed ano-rectoscopy, anal manometry and defecography. Mean operative time was 45 minutes (range 20'-130') and mean hospital stay was 3 days (range 2-6 days). In the early postoperative course urinary ritention in 4 cases, treated with temporary catheterization in 3 and permanent for 72 hours in 1, was observed. Only 1 patient, was reoperated in day-surgery and with loco-regional anesthesia for residual fibrous hemorroid. Bleeding, severe pain, anal stenosis, impairment of continence were not observed. According to the Literature data, our experience confirm that mucoprolapsectomy represents an innovative, safe, simple and definitive operation in the treatment of hemorrhoids disease. In case of rectal prolapse associated to external fibrous hemorroids, a combined surgical treatment is requested in order to achieve better results.

[Treatment for microcarcinoma of the thyroid. Clinical experience]

According to WHO, small papillary cancer represents a papillary carcinoma < or = 1 cm in greatest dimension. The autoptic incidence is more elevated showing a low aggressivity. In fact lower mortality and local relapse have been reported. The AA report their results of 17 pt operated on for benign thyroid pathology in last three years. The diagnosis has been "incidental cancer" with 7 mm of mean diameter. Surgical treatment consisted of 9 total thyroidectomy, 3 near total thyroidectomy, 3 subtotal thyroidectomy, 2 lobo-isthmusectomy, with completion on the fifteenth day. Radioiodine therapy was administered in the case of uptake > 3.5%. There were no significant complications. Only in parathyroidectomy for secondary hyperparathyroidism, we have definitive hypoparathyroidism. Age, capsular infiltration, multifocality and lymphonodal dissemination represent main prognostic factors. In the treatment of SPC we recommend a total thyroidectomy or a near total in association with iodine-131 radioiodine therapy.

Total parathyroidectomy with or without autoimplantion in the therapy of secondary hyperparathyroidism

BACKGROUND

Secondary hyperparathyroidism (HPTs) in patients with chronic renal failure is related to a reduction of absorption of calcium with hyperplasia of main cells and an increase of PTH levels: this often leads to complications in dialysis.

METHODS

Data from 10 patients (mean age 55 years) with HPTs who underwent total parathyroidectomy from November 1999 to November 2001 were retrospectively collected. Surgical indications included: persistent hypercalcemia, bone fractures, fatigue, joint pain and itching. Median preoperative PTH level was 800 pg/ml. Presurgical work-up included: serum PTH, calcium and alkaline phospha-tases. Thyroid ultrasound and scintigraphy, 99Tc sestamibi scintigraphy, CBM, FNB were also performed. In 5 patients 2 hours prior to the operation 2 MCu of sestamibi 99Tc had been injected. Patients underwent cervical exploration radioguided in 5 cases under general anesthesia. The operation consisted in the removal of all glands with subcutaneous forearm implant in 4 cases. PTH dosage at starting time of operation (time 0) was performed; it was repeated after the removal of each parathyroid gland and postoperatively on days 1 and 3 and then every month for 6 months.

RESULTS

Twenty-four hours postoperatively 9 patients showed a great reduction of PTH levels with improved symptoms already on day 1 postoperative. In the patient with persistent HPT an autoimplant had been performed.

CONCLUSIONS

Secondary HPT still shows unclear aspects. Parathyroidectomy determines an immediate improvement in symptoms. In all observed patients PTH was significantly reduced, serum calcium returned to normal and in any case hypoparathyroidism was detected.

Evaluation of cardiac and respiratory involvement in sarcoglycanopathies

Sarcoglycanopathies constitute a subgroup of limb-girdle recessive muscular dystrophies due to defects in sarcoglycan complex that comprises five distinct transmembrane proteins called alpha-, beta-, gamma-, delta-and epsilon-sarcoglycans. As it is well known that sarcoglycans are expressed both in heart and in skeletal muscles and a complete deficiency in delta-sarcoglycan is the cause of the Syrian hamster BIO.14 cardiomyopathy, we studied cardiac and respiratory involvement in 20 patients with sarcoglycanopathies by clinical, electrocardiographic, echocardiographic, scintigraphic and spirometric assessments. A normal heart function was found in 31.3% of all patients; a preclinical cardiomyopathy in 43.7%; an arrhythmogenic cardiomyopathy in 6.3% and initial signs of dilated cardiomyopathy in 18.7%. In one patient the data were examined retrospectively. No correlation was found between cardiac and skeletal muscle involvement. With reference to the type of sarcoglycanopathy, signs of hypoxic myocardial damage occurred in beta-, gamma- and delta-sarcoglycanopathies, while initial signs of a dilated cardiomyopathy in gamma- and delta-sarcoglycanopathies were found. A normal respiratory function was observed in 23.5% of all patients, a mild impairment in 35.4%, a moderate impairment in 29.4%, and a severe impairment in 11.7%.

Identification of a novel sarcoglycan gene at 5q33 encoding a sarcolemmal 35 kDa glycoprotein

Mutations in any of the genes encoding the alpha, beta or gamma-sarcoglycan components of dystrophin-associated glycoproteins result in both sporadic and familial cases of either limb-girdle muscular dystrophy or severe childhood autosomal recessive muscular dystrophy. The collective name 'sarcoglycanopathies' has been proposed for these forms. We report the identification of a fourth member of the human sarcoglycan family. We named this novel cDNA delta-sarcoglycan. Its mRNA expression is abundant in striated and smooth muscles, with a main 8 kb transcript, encoding a predicted basic transmembrane glycoprotein of 290 amino acids. Antibodies specifically raised against this protein recognized a single band at 35 kDa on western blots of human and mouse muscle. Immunohistochemical staining revealed a unique sarcolemmal localization. FISH, radiation hybrid and YAC mapping concordantly linked the delta-sarcoglycan gene to 5q33, close to D5S487 and D5S1439. The gene spans at least 100 kb and is composed of eight exons. The identification of a novel sarcoglycan component modifies the current model of the dystrophin-glycoprotein complex.

A report on 528 intragenic deletions detected in DMD and BMD patients by an Italian collaborative study

The results of a collaborative study involving about one third of the total DMD and BMD cases living in the Italian territory are reported. The analysis of the breakpoint frequency by intron revealed significant differences among regional groups of DMD patients (for introns 2, 11 and 50 in Sardinia and for introns 9 and 45 in northeastern Italy), whereas no regional differences were observed among regional groups of BMD patients. These differences involve the same Italian regions which previous studies, performed by different markers, identified as "genetically differentiated". The data support the possibility of a differential distribution among populations of some intronic sequences, facilitating the origin of deletion breakpoints within the dystrophin gene.