Fausto Fama

Inguinal hernioplasty improves the quality of life in patients with cirrhosis

BACKGROUND The optimal management of symptomatic inguinal hernia (SIH) in cirrhotics is still undefined. Both hernia and cirrhosis impair quality of life (QOL). The aim of this study was to evaluate QOL by a Short Form-36 (SF-36) questionnaire in cirrhotic patients undergoing inguinal hernioplasty. METHODS Thirty-two cirrhotic patients undergoing inguinal hernioplasty were evaluated. They were classified according to Childs class and to the absence or presence of refractory ascites. The SF-36 questionnaire was administered the day before and 6 months after surgery. Global analyses of the 8 domains of SF-36 and of 2 comprehensive indexes of SF-36, Physical Component Summary (PCS) and Mental Component Summary (MCS), were performed. RESULTS Lichtenstein hernioplasty for SIH originated no major complications. All 8 domains of SF-36 and MCS and PCS scores improved remarkably after hernioplasty especially in patients in Childs class C and/or with refractory ascites. CONCLUSIONS Inguinal hernioplasty for SIH in patients with cirrhosis is a safe procedure. The improvement of QOL represents a clear cut indication for elective hernia repair.

Fissurectomy and anal advancement flap for anterior chronic anal fissure without hypertonia of the internal anal sphincter in females

Aim  Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy.

FEM and Von Mises Analysis on Prosthetic Crowns Structural Elements: Evaluation of Different Applied Materials

The aim of this paper is to underline the mechanical properties of dental single crown prosthodontics materials in order to differentiate the possibility of using each material for typical clinical condition and masticatory load. Objective of the investigation is to highlight the stress distribution over different common dental crowns by using computer-aided design software and a three-dimensional virtual model. By using engineering systems of analyses like FEM and Von Mises investigations it has been highlighted the strength over simulated lower first premolar crowns made by chrome cobalt alloy, golden alloy, dental resin, and zirconia. The prosthodontics crown models have been created and put on simulated chewing stresses. The three-dimensional models were subjected to axial and oblique forces and both guaranteed expected results over simulated masticatory cycle. Dental resin presented the low value of fracture while high values have been recorded for the metal alloy and zirconia. Clinicians should choose the better prosthetic solution for the teeth they want to restore and replace. Both prosthetic dental crowns offer long-term success if applied following the manufacture guide limitations and suggestions.

Prognostic value of HMGB1 and oxidative stress markers in multiple trauma patients: A single-centre prospective study

Serious multiple traumatic injuries may rapidly become fatal or be complicated by a life-threatening sequelae leading to a significant increase of the mortality rate. Trauma scoring systems are used to evaluate the critical status of the patient and recently many different biomarkers have been taken into account to better estimate the potential clinical outcome. The aim of the present study is to analyse the expression pattern of high-mobility group box-1 (HMGB1), oxidative stress markers and nuclear factor erythroid 2-related (Nrf2) in critically ill traumatic patients (at hospital admittance and after 6 and 24 h), in order to find out their potential role as early post-traumatic predictors markers. Forty-seven patients admitted for multiple trauma and 15 healthy participants were prospectively recruited. Eight patients (17%) died within 92 h of admission; this subgroup of patients presented the highest severity scores and their HMGB1 expression levels were significantly correlated with ISS, whereas patients with higher ISS exhibited higher levels of HMGB1 (P <0.001). Our study suggests the role of HMGB1 as a predictive biomarker of outcome in injured patients and hypothesizes the protective role of Nrf2 in bringing down the oxidative stress and HMGB1 release; measuring HMGB1 in combination with Nrf2 might represent a potentially useful tool in the early detection of post-trauma complications.

Prevalence of Ectopic Breast Tissue and Tumor: A 20-Year Single Center Experience.

BACKGROUND Ectopic breast tissue, which includes both supernumerary breast and aberrant breast tissue, is the most common congenital breast abnormality. Ectopic breast cancers are rare neoplasms that occur in 0.3% to 0.6% of all cases of breast cancer. PATIENTS AND METHODS We retrospectively report, using a large series of breast abnormalities diagnosed and treated, our clinical experience on the management of the ectopic breast cancer. In 2 decades, we observed 327 (2.7%) patients with ectopic breast tissue out of a total of 12,177 subjects undergoing a breast visit for lesions. All patients were classified into 8 classes, according to the classification of Kajava, and assessed by a physician examination, ultrasounds, and, when appropriate, further studies with fine needle aspiration cytology and mammography. All specimens were submitted to the anatomo-pathologist. The most frequent benign histological diagnosis was fibrocystic disease. A rare granulosa cell tumor was also found in the right anterior thoracic wall of 1 patient. Four malignancies were also diagnosed in 4 women: an infiltrating lobular cancer in 1 patient with a lesion classified as class I, and an infiltrating apocrine carcinoma, an infiltrating ductal cancer, and an infiltrating ductal cancer with tubular pattern, occurring in 3 patients with lesions classified as class IV. Only 1 recurrence was observed. We recommend an earlier surgical approach for patients with lesions from class I to IV.

Influence of needle diameter on spinal anaesthesia puncture failures for caesarean section: A prospective, randomised, experimental study

OBJECTIVES Spinal anaesthesia represents the technique of choice for elective caesarean section. The purpose of this study was to compare the puncture failure rates with 25, 26 or 27 gauge (G) pencil-point, Whitacre type (with introducer) needles during spinal anaesthesia for caesarean section. STUDY DESIGN Prospective, randomised, experimental study in healthy subjects. PATIENTS AND METHODS We recruited 330 adults, consecutively scheduled parturients, randomised into three groups. The subarachnoid puncture procedure was standardised. The flexibility of the three needle types was assessed in vitro, and a force was applied using a dynamometer. The occurrence of postdural puncture headache was also evaluated. RESULTS The number of spinal puncture failures was significantly higher in the 27G group, than in the 25G (P=0.006) group and the 26G (P<0.001) group, but did not differ between the 25G and 26G groups (P=0.606). Ten postdural puncture headaches were observed without significant differences among the groups. CONCLUSIONS This prospective study showed that puncture failures occur less frequently with the use of 25G or 26G pencil-point needles as compared to 27G needles, probably due to the higher flexibility of the latter. This characteristic was demonstrated in vitro, in a reproducible model. This experiment suggests that a 26G pencil-point needle is the optimal gauge for performing spinal anaesthesia for scheduled caesarean sections.

Epidemiology and outcome of multiple trauma in the elderly population in a tertiary care hospital in southern Italy

Background It is estimated that, in Italy, by 2050 almost 35% of the population will be older than 65 years and 14% will be older than 80 years. As the elderly population grows, the fraction of geriatric trauma patients seen in trauma centers is rapidly increasing. Traumatic injuries in the elderly often represent a major medical and surgical challenge. Even a condition as simple as an isolated fracture can be life threatening in the geriatric population. Aim of the study is to identify incidence and pattern of distribution of injuries in the geriatric trauma patients, as well as shortterm prognosis.

Multiple sclerosis and amyotrophic lateral sclerosis: a human leukocyte antigen challenge

Multiple sclerosis (MS) and amyotrophic lateral sclerosis (ALS) are two different central nervous system pathology that, according to the most accredited hypotheses, recognize a different etiopathogenesis. The simultaneous occurrence of MS and ALS is quite unusual. To our knowledge, only three cases have been so far described by clinical, laboratory, and post-mortem studies. We report four new cases of this peculiar combination that have been observed and are herein described, included their human leukocyte antigen (HLA) profile studies. On the basis that three out of four patients in our case series presented HLA-B*18:01A, we may hypothesize that this antigen could play a role in developing both diseases.

Multicentric Castleman Disease: An Unusual Breast Lump

An 80-year-old male presented with painless lump in the left breast, presenting over 2 months. On examination, he had a mobile mass in the superolateral quadrant approximately 10 mm in diameter with associated axillary lymphadenopathy. He had no other systemic symptoms or abnormal clinical findings, specifically neither peripheral adenopathy nor hepatosplenomegaly. His past medical history included hypertension, hyperlipidemia, hepatitis B, and a previous right cervical lymph node dissection for tonsillar cancer. Ultrasound scan showed mild bilateral gynaecomastia with an hypoechoic mass (8 5 mm) in the left superolateral breast (Fig 1A) and confirmed the ipsilateral lymphadenopathy. The mass had an unclear lymph-like morpholgy, with an irregular vascular pattern by color Doppler. Mammography revealed a nodular area (8 6 mm) with irregular margins without microcalcifications. Ultrasound-guided fine-needle aspiration cytology was not helpful. Laboratory investigations were normal apart from an elevated gammaglutamyltranspeptidase of 108 U/L (normal range, 8 to 78 U/L) and nonconjugated bilirubin of 1.0 mg/dL (normal range, 0.1 to 0.9 mg/dL). There was neither lymphocytosis (51.9% lymphocytes) nor serological positivity for active hepatitis C virus, HIV, and human herpes virus-8 (HHV8). Tumor markers (ie, carcinoembryonic antigen, alpha-fetoprotein, CA15-3, CA19-9, CA125) were all normal. The patient underwent a superolateral quadrantectomy. Frozen section evaluation showed an intramammary lymph node, with lymphoid proliferation associated with germinal center hyalinisation. Axillary dissection was performed and all lymph nodes were formalin-fixed (10%; pH, 7.0) and routinely processed: 5 m thick slices were cut and hematoxylin and eosin (H&E) stained. Histopathological examination of the single breast and sixteen harvested axillary lymph nodes demonstrated germinal center hyalinisation with marked vascular proliferation. Many dysplastic dendritic cells were readily identifiable in hyaline centers. There was a tight concentric layering of lymphocytes at the follicular periphery resulting in an onion-skin appearance (Fig 1B, H&E stain, 180) and the interfollicular stroma was replete with multiple hyperplastic vessels (Fig 1C, H&E stain, 400). No other mammary cytoarchitectural alterations were found. According to these histological findings, B-cell lymphoma was excluded, and the diagnosis of hyaline-vascular type was made. The patient’s postoperative course was uneventful, and he was discharged after 4 days. In consideration of both his advanced age and the absence of malignancy, no complementary treatment was administered. At 18 months follow-up, the patient was well and free of local or distant lymphadenopathy. Castleman disease (CD), or angiofollicular lymphoid hyperplasia, is a rare lymphoproliferative disorder firstly described in 1956. It is an unusual condition in which the primary etiology and pathogenesis, which may be either reactive or neoplastic, remain incompletely elucidated. Clinically, CD may be unicentric if confined to a single lymph node or multicentric when there are numerous involved nodes associated with concomitant systemic symptoms. CD is equally distributed between the sexes, and unicentric disease, corresponding to the disorder originally described, accounts for approximately 90% of CD cases. While unicentric CD typically follows a benign course and is simply treated by surgical excision, multicentric disease is generally associated with a poorer clinical outcome, and adjuvant therapies are generally required. This type tends to be associated with AIDSand human herpesvirus 8 –related infections, and the most common symptoms include fever, weight loss, hemolytic anemia, night sweats, and the POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal proteinaemia and skin changes) syndrome. Keller et al classified three histological subtypes of CD: hyaline-vascular, plasma-cell, and mixed. Histologically, the hyaline-vascular type, usually found in unicentric CD, is characterized by small hyaline-vascular follicles and interfollicular stroma with capillary proliferation. Plasma-cell type, typical of multicentric CD, present large follicles with intervening sheets of plasma cells. Additionally, a mixed variety has been described. Lymph node

Colonic acute malignant obstructions: effectiveness of self-expanding metallic stent as bridge to surgery

BACKGROUND/AIMS Bowel obstruction is a frequent event in patients with adenocarcinoma, affecting, in some series, almost one-third of the patients. In the last decades, in addition to surgery, self-expanding metallic stents (SEMSs) are available both as a bridge to surgery (BTS) or palliation. The aim of our study was to demonstrate the safety and efficacy of the use of SEMSs as BTS in selected patients with acute colonic malignant obstructions. MATERIALS AND METHODS In total, 125 patients with malignant colonic obstruction who underwent emergency surgery or stent insertion were retrospectively enrolled in our study; 62 patients underwent surgery initially, whereas 62 were subjected to stenting as BTS. The 6-month and 1-year survival rates after the procedure (stenting or surgery) and short-term and long-term complication rates were considered as primary endpoints; the recanalization rate after Hartmanns procedure and the length of hospitalization were considered as secondary endpoints. RESULTS On comparing the surgery group (SG) and the BTS group (BG), we observed a lower short-term complication rate (p<0.05) and a reduction in the mean hospital stay (16.1±7.7 vs. 13.5±3.0, p<0.05) in the latter. No differences in long-term complications were found. The recanalization rate after Hartmanns procedure was higher in BG than in SG, although this was not statistically significant. CONCLUSION Our experience shows that SEMS insertion is a safe and effective technique in selected patients with colonic malignant obstruction; the reduction in hospital stay and short-term complications in BG is an important cost-saving aim.