Primary Subcutaneous Umbilical Endometriosis: Case Report and Review of the Literature.

We report the case of a patient diagnosed with primary umbilical endometriosis intending to discuss the diagnostic and therapeutic management of this rare disease. A 45-year-old woman suffering from a painful swelling located in the umbilical region, with intact and normal cutaneous aspect, came to our attention. Ultrasonography of the umbilical region showed a nodule with a nonhomogeneous echotexture pattern. Partial omphalectomy was performed under local anesthesia in day care setting surgery. Histology confirmed the diagnosis of umbilical endometriosis. Pre- and postoperative clinical controls showed no evidence for other endometriosis localization. No medical treatment was administered. No signs of recurrence were observed after 5 years from surgery. A review of the literature of the last 10 years was generated based on MEDLINE research, selecting some specific keywords. Several lesions can occur in the umbilical region, and endometriosis has to be ruled out even in patients without any surgery in their medical history. Surgery is the gold standard treatment for this condition: partial and radical omphalectomy are the two treatment options. We believe that given the significant psychological and aesthetical value of the umbilicus, surgical treatment has to be tailored and in case of a small endometrial umbilical nodule, partial omphalectomy (local excision of the umbilical endometrial nodule) with a 3 mm free border, even without adjuvant hormonal treatment, could ensure adequate and effective treatment.

Impact of adoption of patient-reported outcomes in clinical practice on the accuracy of symptom reporting in medical records of cancer patients.

PURPOSE: Medical records are a relevant source for real-world evidence. We introduced patient-reported outcomes (PROs) in clinical practice, demonstrating a significant quality-of-life improvement, compared to usual visit. In this secondary analysis, we describe the agreement between patients' and physicians' reports of 5 symptoms. Our hypothesis was that adoption of PROs questionnaire could significantly improve the agreement. METHODS: Eligible patients were receiving active anti-cancer treatment. Patients in the control group underwent usual visits (group A), while patients of group B, before each visit, filled a PROs paper questionnaire, to provide information about symptoms and toxicities. No specific instructions were provided to physicians to integrate such information in medical records. Agreement between patient and physician evaluations was assessed by Cohen's κ, calculating under-reporting as proportion of toxicities reported by patients but not recorded by physicians. RESULTS: 211 patients (412 visits) have been analyzed. For all symptoms, Cohen's κ was better for group B: emesis (0.25 group A vs. 0.36 group B), diarrhea (0.16 vs. 0.57), constipation (0.07 vs. 0.28), pain (0.22 vs. 0.42), fatigue (0.03 vs. 0.08). For all symptoms, although under-reporting was relevant in both groups, it was lower for group B: emesis (75.49% vs. 60.0%, p=0.031), diarrhea (82.89% vs. 50.0%, p<0.001), constipation (92.11% vs. 69.57%, p<0.001), pain (59.57% vs. 42.31%, p=0.01), fatigue (82.11% vs. 64.10%, p<0.001). CONCLUSION: Adoption of paper PROs allowed a significant reduction in under-reporting of symptoms, but agreement remained suboptimal. Direct integration of electronic PROs could minimize the issue of under-reporting of medical records, increasing their accuracy.

Robotic Transnasal Endoscopic Skull Base Surgery: Systematic Review of the Literature and Report of a Novel Prototype for a Hybrid System (Brescia Endoscope Assistant Robotic Holder).

BACKGROUND: Although robotics has already been applied to several surgical fields, available systems are not designed for endoscopic skull base surgery (ESBS). New conception prototypes have been recently described for ESBS. The aim of this study was to provide a systematic literature review of robotics for ESBS and describe a novel prototype developed at the University of Brescia. METHODS: PubMed and Scopus databases were searched using a combination of terms, including Robotics OR Robot and Surgery OR Otolaryngology OR Skull Base OR Holder. The retrieved papers were analyzed, recording the following features: interface, tools under robotic control, force feedback, safety systems, setup time, and operative time. A novel hybrid robotic system has been developed and tested in a preclinical setting at the University of Brescia, using an industrial manipulator and readily available off-the-shelf components. RESULTS: A total of 11 robotic prototypes for ESBS were identified. Almost all prototypes present a difficult emergency management as one of the main limits. The Brescia Endoscope Assistant Robotic holder has proven the feasibility of an intuitive robotic movement, using the surgeon's head position: a 6 degree of freedom sensor was used and 2 light sources were added to glasses that were therefore recognized by a commercially available sensor. CONCLUSIONS: Robotic system prototypes designed for ESBS and reported in the literature still present significant technical limitations. Hybrid robot assistance has a huge potential and might soon be feasible in ESBS.

[Laparoscopic surgery for acute cholecystitis in the elderly. Our experience]. / Approccio laparoscopic nella colecistite acuta dell'anziano. La nostra esperienza.

Acute cholecystitis in the elderly is a severe illness with high operative risks and mortality, which, even if less than in the past, is still too high. The surgical approach has significantly changed over the past 10 years: conservative therapy in the early 1990's was considered the only sure approach, while the laparoscopic surgical approach is recommended today for the emergency treatment of acute cholecystitis, also in the elderly. The aim of this retrospective study was to define the safety and effectiveness of early surgery for acute cholecystitis with the laparoscopic approach in the elderly. From September 2002 to September 2006, 287 patients were admitted to our unit for cholelithiasis, including 135 for acute cholecystitis. The patients with acute illness and age > 70 yrs numbered 73. After immediate monitoring of vital parameters and a brief diagnostic and therapeutic interval to restore the patient's general condition in intensive care (fasting, SNG, antibiotics, parenteral fluid therapy and analgesic drugs) all patients underwent emergency surgery within 24-96 hours. Fifty-nine (80.8%) underwent laparoscopic cholecystectomy, whereas the remaining 14 (19.2%) underwent open cholecystectomy due to their high-risk for cardiovascular, respiratory and metabolic status (ASA III-IV). In group 1 treated laparoscopically, morbidity was 11.9% versus 35.7% in group 2 treated with open cholecystectomy (p < 0.001). Mortality was 0 in group 1; and 7% (1 patient) in group 2 (p < 0.05). The median hospital stay was 3.87 (2-9) days in group 1 vs 10.5 (8-29) days in group 2 (p < 0.001). The results of our study confirm the safety and effectiveness of laparoscopic cholecystectomy in expert hands in the management of acute cholecystitis in elderly patients. This choice allowed a statistically significant reduction in morbidity and overall hospital stay. Nevertheless, open cholecystectomy remains a valuable procedure for high-risk elderly patients undergoing emergency surgery. Poor outcome is related to the almost constant presence of comorbidity in the elderly = ASA score (ASA II vs. IV: p < 0.001) and independent of the type of surgical intervention (laparoscopic cholecystectomy vs open cholecystecotmy: p = n.s.). Early cholecystectomy in case of symptomatic cholelithiasis, before infectious complications set in, could partly reduce the poor prognosis in the elderly.

Is left stroke a risk-factor for selective serotonin reuptake inhibitor antidepressant treatment resistance?

The objective of the study was to detect changes of depression and cognitive level associated with right and left brain damage during SSRI treatment in subjects with post-stroke Major Depressive Disorder (MDD). After the baseline evaluation, the 45 patients included received a single oral dose of 20-40 mg of fluoxetine or 50-100 mg of sertraline. At day 0, 7, 14, 28, 42, and 56 a psychometric test battery comprising the Hamilton Depression Rating Scale (HDRS) and the Mini Mental State Examination (MMSE) was administered. In the whole group repeated measures ANOVAs revealed a highly significant (p < 0.0001) time effect for HDRS and MMSE scores. However, depression improved much more in right stroke subjects in comparison with left stroke subjects (p < 0.001 for the HDRS by laterality interaction). Moreover, there is a suggestion of a possible selective serotonin reuptake inhibitor (SSRI) efficacy in cognitive impairment associated to post-stroke MDD but in treatment-responders only. At the endpoint, chi-square analysis showed that there was a different prevalence rate of MDD between left (n = 10; 50 %) and right (n = 4; 16 %) stroke patients, whereas the prevalence rate of Minor Depression was identical (25 %). The SSRIs fluoxetine and sertraline could be efficacious treatments for post-stroke MDD but these findings suggest that left stroke could be a predictor of treatment resistance.

Predictors of cognitive level and depression severity are different in patients with left and right hemispheric stroke within the first year of illness.

Causes of cognitive impairment after stroke are not yet clear because a large number of sociodemographic and clinical variables complicate the understanding of the phenomenon. We aim to evaluate sociodemographic and clinical predictors of cognitive level and depression in subjects with different lesion laterality. We assessed 153 right (n = 87) and left (n = 66) unilateral first-ever stroke patients within the first year of illness with the Structured Clinical Interview for DSM-IV-Patient Edition, the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the State Trait Anger Expression Inventory, the Barthel Index, and the Mini Mental State Examination (MMSE). Sociodemographic variables were also measured. Sixty-two (41 %) patients suffered from Major Depression (MDD), and 26 (17 %) suffered from Minor Depression (MIND). An univariate analysis of variance showed that MMSE scores were different throughout the groups of left and right stroke patients with MDD, MIND and without depression. Left stroke patients with MDD were more cognitively impaired than all the other groups. This result was valid after controlling for the effect of lesion location on cognitive level difference between the groups. A series of stepwise multiple regression analyses indicated that depression severity was a predictor of cognitive level and vice-versa in left hemispheric stroke patients only. Moreover, educational level in right hemispheric stroke patients and state-anger and number of regions affected in left hemispheric stroke patients were other predictors of cognitive level. The study confirms the hypothesis that predictors of cognitive level and depression severity are different in subjects with different laterality of lesion and that MDD is associated with cognitive impairment in left stroke patients.