Laparoscopic Incisional and Ventral Hernia Repair with Absorbable Tacks in a Long Term Follow-up: A Retrospective Control Study.

BACKGROUND: Laparoscopic Incisional and Ventral Hernia Repair (LIVHR) is a safe and worldwide accepted procedure performed using absorbable tacks. The aim of the study was to evaluate recurrence rate in a long term follow-up and whether the results of laparoscopic IVH repair in the elderly (≥65 years old) are different with respect to results obtained in younger patients. METHODS: One hundred and twenty-nine consecutive patients (74 women and 55 men, median age 67 years, range = 30-87 years) with ventral (N = 42, 32.5%) or post incisional (N = 87, 67.5%) hernia were enrolled in the study. Patients were divided into two groups according to their age: group A (N = 55, 42.6%) aged <65 years and group B (N = 74, 57.4%) aged ≥65 years. RESULTS: The mean operative time was not significantly different between groups (66.7 ± 37 vs. 74 ± 48.4 min, p = 0.4). To the end of 2016, seven recurrences had occurred (group A = 3, group B = 4, p = 1). Complications occurred in 8 (16%) patients in group A and 21 (28.3%) patients in group B. CONCLUSION: In conclusion, our results confirm that the use of absorbable tacks does not increase recurrence frequency and laparoscopic incisional and ventral repair is a safety procedure also in elderly patients.

Arnica compositum, Hekla lava and Acidum Nitricum Together are Superior to Arnica compositum Alone in the Local Treatment of Symptomatic Calcific Periarthritis of the Shoulder: A Pilot Study.

BACKGROUND: To evaluate the usefulness of Arnica compositum (AC) + Acidum nitricum (AN) + Hekla lava (HL) ointment in Emergency Medicine Department (EMD) as alternative nonpharmacological local treatment of patients with symptomatic calcific periarthritis of the shoulder (CPS) and to compare the effectiveness of this mixture against AC ointment alone. METHODS: A series of 41 consecutive patients (20 women, 19 men, median age 49 years, range 25-80 years) with non-traumatic painful unilateral CPS were randomly assigned to receive local treatment with AC+AN+HL ointment mixture (Group A, cases, N=21) or AC ointment alone (Group B, controls, N=20). The radiological Gartner classification of the CPS, and the quantification of pre- and post-treatment pain intensity using a Visual Analogue Scale (VAS) were obtained. The orthopedic evaluation of Shoulder Motion (SM) was also performed. The use of painkillers was reported as a number of doses needed. RESULTS: Age, gender distribution, Gartner type, main calcification size, baseline VAS (VAS-0) and degree of SM did not differ (p=NS) between Groups. After 3-day therapy, the reduction of pain in Group A (4.5±2.5) was superior to that observed in Group B (2.7±2.6) (p =0.03). The same result was observed in the improvement of SM in Group A (69.4±24.9) than in Group B (51.1±21.1) (p =0.015). No local or general adverse effects were noted. The number of doses of paracetamol was similar, but Group A patients used less ibuprofen (p =0.007). CONCLUSION: Local administration of the AC+AN+HL ointment mixture, which in our pilot study was superior to AC alone, could be safely suggested as an alternative uneventful treatment of patients with CPS.

How formative courses about damage control surgery and non-operative management improved outcome and survival in unstable politrauma patients in a Mountain Trauma Center.

AIM: Aim of this study is to analyze how the starting of Course of Trauma in our hospital improved survival and organization in management of polytraumatized patients. MATERIAL OF STUDY: We analysed all major trauma patients (Injury Severity Score (Injury Severity Score (ISS)> 15) treated at Emergency Department of the Santa Chiara Hospital between January 2011 and December 2014. The training courses (TC) were named "management of polytrauma" (MP) and "clinical cases discussion" (CCD), and started in November 2013. We divided the patients between two groups: before November 2013 (pre-TC group) and after November 2013 (post-TC group). RESULTS: MTG's courses (EMC accredited), CCD and MP courses started in November 2013. The target of these courses was the multidisciplinary management of polytrauma patient; the courses were addressed to general surgeons, anaesthesiologists, radiologists, orthopaedics and emergency physicians. Respectively 110 and 78 doctors were formed in CCD's and MP's courses. Patients directly transported to our trauma centre rose from 67.5% to 83% (p<0,005), and E-FAST grew from 15.6% in the pre-TC group to 51.3% in the post-TC group. Time of access in operatory theatre decreased from 62 to 44 minutes. Early Mortality (within 48 hours from the hospital arrival) was 9% in the pre-TC group and 4.5% in the post-tc group (p<0.005). DISCUSSION: Be needed to complete our goal. Further analysis and possible comparison with other trauma centers be needed to complete our goal CONCLUSIONS: Our results show that in our experience the multidisciplinary approach to polytrauma patients increased early survival and improved outcome with an evidence of worker's satisfaction. However, the best practice would ask to start with the approval of procedures and guidelines by the hospital governance, followed by clinical practice changes, in order to create a dedicated emergency and trauma surgery group. KEY WORD: Damage Control Surgery, Non Operative Management, Trauma Course, Trauma Team, Trauma Center.

Abnormality of Auditory Mismatch Negativity in Depression and Its Dependence on Stimulus Intensity.

Mismatch negativity (MMN) is thought to reveal several abnormalities of cognitive functioning. Although depression often affects cognitive functioning, previous studies concerning MMN in depressed patients provided conflicting results. In recent reports, it has been suggested that depressed patients may show abnormal auditory response to regular auditory stimuli presented with at a relatively high intensity. We thus recorded acoustic MMN in 16 drug-free patients suffering from moderate depression and in 10 healthy subjects at 2 different stimulus intensities. Differences in MMN latency and amplitude between depressed patients and healthy subjects reached the significance level only for high intensity stimulation, and they were consistent with a dysfunction of frontal MMN subcomponents in depressed patients. This finding suggests that consistent MMN abnormalities can be observed in depressed patients by using high-intensity stimulation; moreover, it supports the hypothesis of disturbances of frontal networks in depression even in early stages of disease.

A simplified way for the urgent treatment of somatic pain in patients admitted to the emergency room: the SUPER algorithm.

Somatic pain is one of the most frequent symptoms reported by patients presenting to the emergency department (ED), but, in spite of this, it is very often underestimated and under-treated. Moreover, pain-killers prescriptions are usually related to the medical examination, leading to a delay in its administration, thus worsening the patient's quality of life. With our study, we want to define and validate a systematic and homogeneous approach to analgesic drugs administration, testing a new therapeutic algorithm in terms of earliness, safety, and efficacy. 442 consecutive patients who accessed our ED for any kind of somatic pain were enrolled, and then randomly divided into two groups: group A follow the normal process of access to pain-control drugs, and group B follow our SUPER algorithm for early administration of drugs to relieve pain directly from triage. We excluded from the study, patients with abdominal pain referred to the surgeon, patients with headache, recent history of trauma, history of drug allergies, and life-threatening conditions or lack of cooperation. Drugs used in the study were those available in our ED, such as paracetamol, paracetamol/codeine, ketorolac-tromethamine, and tramadol-hydrochloride. Pain level, risk factors, indication, and contraindication of each drug were taken into account in our SUPER algorithm for a rapid and safe administration of it. The Verbal Numeric Scale (VNS) and the Visual Analog Scale (VAS) were used to verify the patient's health and perception of it. Only 59 patient from group A (27.1 %) received analgesic therapy (at the time of the medical examination) compared to 181 patients (100 %) of group B (p < 0.001). Group B patients, received analgesic therapy 76 min before group A subjects (p < 0.01), resulting in a significant lower VNS (7.31 ± 1.68 vs 4.75 ± 2.3; p < 0.001), and a superior VAS after discharge (54.43 ± 22.16 vs 61.30 ± 19.13; p < 0.001) compared to group A subjects. No significant differences concerning side effects were observed between group A and group B patients. Early administration of a pain-control therapy directly from triage is safe and effective, and significantly improves patients perceptions of their own health.

Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair in the Elderly: A Prospective Control Study.

Inguinal hernia (IH) repair can be obtained with both open and laparoscopic techniques, which are usually performed using a transabdominal preperitoneal (TAPP) or a totally extraperitoneal (TEP) approach. The aim of the study was to evaluate whether the results of laparoscopic TEP IH repair in the elderly (≥65 years old) are different with respect to results obtained in younger patients. One hundred and four consecutive patients (four women and 100 men, median age of 57 years, range=21-85 years) with unilateral (N=21, 20.2%) or bilateral (N=83, 79.8%) IH were prospectively enrolled in the study. Patients were divided into two groups according to their age: group A (N=68, 65.4%) aged <65 years and group B (N=36, 34.6%) aged ≥65 years. The mean operative time was not significantly different between groups (48±20 vs. 52±20 min, p=0.33). One case of increased PaCO2 was observed in each group (p=0.72) and two and one case of pneumoperitoneum (p=0.57) in groups A and B, respectively. Two (1.9%) patients (one in each group; p=0.55) required TEP conversion. Mild postoperative complications developed in four patients of each group (p=0.44). After one-year follow-up, three (2.9%) recurrences occurred (group 1=1, group 2=2, p=0.55), both in patients who had undergone direct IH repair. The overall postoperative relative risk of complications related to age was 1.08 (95% confidence interval=0.91-1.27, p=0.53). In conclusion, our results suggest that in patients with IH scheduled for TEP repair, age does not represent a contraindication to surgery in terms of complication rate and postoperative results.

Prevalence of virulent Helicobacter pylori strains in patients affected by idiopathic dysrhythmias.

Helicobacter pylori virulent strains have been shown to affect cardiovascular diseases through molecular mimicry mechanisms. Silent autoimmune myocarditis has been hypothesized to be the cause of idiopathic dysrhythmias (IA). The aim of this study is to assess the prevalence of virulent H. pylori strains in patients affected by IA. In this study,54 patients (40 men, mean age 44 ± 17 years) affected by IA and 50 healthy subjects (34 men, mean age 45 ± 9) were evaluated. IA, defined as dysrhythmias with no evidence of other cardiac pathology, were either supraventricular (SVA, 23 patients; mean age 45 ± 15 years) or ventricular (VA, 31 patients; mean age 42 ± 18 years). H. pylori infection and gastrointestinal (GI) symptoms were evaluated. H. pylori strains expressing the cytotoxin-associated gene A (cagA) and the vacuolating-cytotoxin A (vacA) were also assessed through western blot. The prevalence of H. pylori is similar in IA patients and in controls (42 vs. 44%; p > 0.05); H. pylori infection is observed in 48 and 39% of the patients are affected by SVA and VA, respectively. The prevalence of CagA-positive strains is increased in IA patients compared to controls (65 vs. 42%; p < 0.01); similarly, the prevalence of VacA-positive strains is also increased in IA patients (74 vs. 46%; p < 0.006). Excluding belching, infected patients did not show any difference in GI symptoms, when compared to non-infected subjects. From this study it is concluded that there is an epidemiological link between CagA and VacA-positive H. pylori strains in IA patients.

Comparison of diagnostic accuracy between three different rules of interpreting high sensitivity troponin T results.

With the introduction of high sensitivity troponin-T (hs-TnT) assay, clinicians face more patients with 'positive' results but without myocardial infarction. Repeated hs-TnT determinations are warranted to improve specificity. The aim of this study was to compare diagnostic accuracy of three different interpretation rules for two hs-TnT results taken 6 h apart. After adjusting for clinical differences, hs-TnT results were recoded according to the three rules. Rule1: hs-TnT >13 ng/L in at least one determination. Rule2: change of >20 % between the two measures. Rule3: change >50 % if baseline hs-TnT 14-53 ng/L and >20 % if baseline >54 ng/L. The sensitivity, specificity and ROC curves were compared. The sensitivity analysis was used to generate post-test probability for any test result. Primary outcome was the evidence of coronary critical stenosis (CCS) on coronary angiography in patients with high-risk chest pain. 183 patients were analyzed (38.3 %) among all patients presenting with chest pain during the study period. CCS was found in 80 (43.7 %) cases. The specificity was 0.62 (0.52-0.71), 0.76 (0.66-0.84) and 0.83 (0.74-0.89) for rules 1, 2 and 3, respectively (P < 0.01). Sensitivity decreased with increasing specificity (P < 0.01). Overall diagnostic accuracy did not differ among the three rules (AUC curves difference P = 0.12). Sensitivity analysis showed a 25 % relative gain in predicting CCS using rule 3 compared to rule 1. Changes between two determinations of hs-TnT 6 h apart effectively improved specificity for CCS presence in high-risk chest pain patients. There was a parallel loss in sensitivity that discouraged any use of such changes as a unique way to interpret the new hs-TnT results.

Plasma magnesium levels and treatment outcome in depressed patients.

OBJECTIVES: High, normal, or low plasma magnesium (Mg) levels have been observed in depressed patients. The aim of our study was to investigate the relationship of Mg levels with depression severity, specific psychopathological dimensions, and treatment outcome. METHODS: A total of 123 outpatients during a major depressive episode were recruited. All patients showed at least two major depressive episodes and did not achieve remission in the former treatment trial. A blood sample was collected to determine total plasma Mg levels. The psychopathological status was assessed using Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Depression Retardation Rating Scale for psychomotor retardation, and Snaith-Hamilton Pleasure Scale for anhedonia. Hamilton Depression Rating Scale was repeated at 3 months after treatment. RESULTS: All patients showed Mg levels mostly within the normal range. No association between Mg levels and psychopathological severity was reported. Patients who responded to antidepressant treatment showed higher Mg levels and higher retardation scores at basal evaluation in comparison with non-responders. DISCUSSION: Although further studies investigating the relationship between hypomagnesaemia, depression, and treatment outcome are certainly necessary, we have hypothesized that hypomagnesaemia could be an epiphenomenic biochemical trait in less drug-responsive depressed patients. It is also plausible that lower Mg levels and hyperactive traits identify a biological subtype of patients with increased catecholaminergic functioning and a poorer response to aminergic drugs. Moreover, Mg depletion could partly account for the correlation between low Mg levels and poor outcome and this raises the question of Mg's possible therapeutic role in depression.

Efficacy and safety of vernakalant in recent-onset atrial fibrillation after the European medicines agency approval: systematic review and meta-analysis.

Vernakalant is an emergent antiarrhythmic drug that, in preclinical studies, has demonstrated high efficacy in restoring sinus rhythm and safety in patients with rapid recent-onset atrial fibrillation. The aim of this work was to evaluate the efficacy and safety of vernakalant for cardioversion of recent-onset atrial fibrillation. PubMed, EMBASE, Clinical Trials Registry, and European Medicines Agency public reports were searched for randomized clinical trials, until May 2011, of vernakalant compared with controls (placebo/other antiarrhythmic drug) in enrolled patients with high ventricular rate atrial fibrillation. Five randomized trials that met inclusion criteria enrolled a total of 1099 patients. Among these, 810 had recent-onset atrial fibrillation. When compared with controls (placebo/other oral antiarrhythmic drugs), vernakalant was associated with a significant increase in cardioversion within 90 minutes from drug infusion (relative risk, 8.4; 95% confidence interval, 4.4-16.3; P < .00001). Compared with controls, vernakalant was not associated with a significant difference in serious adverse events (relative risk, 0.9; 95% confidence interval, 0.6-1.4; P = .64). The authors conclude that compared with controls, vernakalant is effective and safe for rapidly converting recent-onset atrial fibrillation. Questions remain surrounding safety because 1 unpublished trial was discontinued for this reason. Further cost-effective analysis and comparison with other antiarrhythmic agents, such as class I antiarrhythmic agents, should be investigated, especially in the emergency department.

Disparities in management of new-onset atrial fibrillation in the emergency department despite adherence to the current guidelines: data from a large metropolitan area.

Atrial Fibrillation management is still a matter for debate. Past research has largely been based on the outpatient setting in which patients are followed during ambulatory visits. Very little data exist on the optimal management of AF in the Emergency Department (ED). This study investigated which factors drive different AF treatments in the ED, describing their use in different hospitals. Finally, the efficacy of different strategies in terms of cardioversion in the ED was analyzed. Charts of patients treated for atrial fibrillation (AF) were collected in 6 EDs in a large metropolitan area over a 24-consecutive month period and were reviewed and analysed. Demographics, comorbidities, treatment strategy and ED outcome were collected. Inclusion criteria were symptom onset <3 weeks and stable hemodynamic conditions at presentation. A propensity score was used to adjust for baseline clinical characteristics and to compare the efficacy of different treatments. 3,085 patients were included in the analysis. Variables associated with a rhythm control strategy were onset of symptoms <48 h, age, dyspnea, palpitations, renal failure and the presence of a mechanical valve. Different EDs applied different strategies in terms of drugs used and the electrocardioversion rate, showing heterogeneity in AF management. Adjusting for the propensity score, electrocardioversion and antidysrhythmic drugs of class Ic were more effective than a wait-and-watch strategy in the ED. Despite international guidelines being respected, AF management is heterogeneous in different ED settings. A rhythm control strategy with electrocardioversion and Class Ic drugs is more effective than a wait-and watch approach during the ED visit. Further research, toward an evidence-based approach to the emergent management of AF in the ED, is still needed.

Utility of routine thyroid-stimulating hormone determination in new-onset atrial fibrillation in the ED.

INTRODUCTION: Hyperthyroidism is a relative uncommon but important cause of atrial fibrillation. The aim of this study was to investigate the utility of routine thyroid-stimulating hormone (TSH) determination in the emergency department (ED) in patients presenting to the ED with stable, new-onset atrial fibrillation. We derive a set of clinical criteria in which TSH is likely to be normal and therefore thyroid function evaluation deferrable to a different time from ED visit. METHODS: Cross-sectional observational study in a university hospital. Thyroid-stimulating hormone was measured in all patients admitted to the ED observational unit for new-onset atrial fibrillation in a 30 consecutive months' period. Patients' clinical characteristics and treatment received in the ED were recorded. Recursive partitioning analysis technique was used to determine which predictors were associated with a TSH level less than 0.35 µIU/mL. RESULTS: Of 433 patients enrolled, 47 (10.8%) had a low TSH. Thyroid-stimulating hormone highly correlated with FT3 and FT4 levels (P < .001) confirming its good predictive value as screening tool. Recursive partitioning analysis showed that previous thyroid disease (P < .01), stroke/transient ischemic attack (P < .01), and hypertension (P = .10) were associated with low TSH. The final model had sensitivity of 93% and specificity of 31%, corresponding to a negative likelihood ratio of 0.02 (0.01-0.07). CONCLUSION: Hyperthyroidism is present in nearly 10% of new-onset atrial fibrillation. Although thyroid function screening is recommended in all patients, a simple model that included previous thyroid disease, stroke, and hypertension might help to identify those patients at high risk (low TSH) in the ED.

Predictive value of NT-proBNP for cardioversion in a new onset atrial fibrillation.

OBJECTIVE: To detect the clinical use of N-terminal pro B-type natriuretic peptide (NT-proBNP) values for predicting cardioversion in a new onset atrial fibrillation (AF) in the emergency department. METHODS: NT-proBNP was measured in 200 patients admitted to the emergency department, in the observational unit with primary diagnosis of a new onset AF (<2 weeks). Cohort was divided into rate-control and rhythm-control groups according to the strategy used by the admitting physician. Patients treated with electric cardioversion were excluded. Primary endpoint was conversion to sinus rhythm during hospital admission. RESULTS: In rhythm and rate controls, NT-proBNP was lower in patients who restored sinus rhythm (P<0.001). Same result was observed even when logistic regression was used to adjust for differences at baseline clinical characteristics. NT-proBNP of less than 450 pg/ml was associated with cardioversion in both the groups (likelihood ratio of 0.19 for rate control, and 0.27 for rhythm control) whereas a value of more than 1800 pg/ml was associated with persistent AF at discharge (likelihood ratio of 2.02 and 2.01, respectively). CONCLUSION: In the acute setting of a new onset AF, NT-proBNP seems to predict cardioversion in rate-control and rhythm-control strategies when it is less than 450 pg/ml or more than 1800 pg/ml. In this ranges of values it might help to allocate resources and plan for patient admission and further management. There is a grey area (450-1800 pg/ml) in which NT-proBNP did not seem to be clinically useful.

Acute decompensated heart failure: formulating an evidence-based approach to diagnosis and treatment (part II).

Acute decompensated heart failure (ADHF) is a disease of enormous scope and impact. Despite significant advances in our understanding of the pathophysiology of the disease, the initial treatment of ADHF has changed little in the past 40 years. This article, the second in a two-part series, will examine the emergency department approach to ADHF, including the issues of risk stratification and goal-directed therapy. It will also review therapeutic interventions, including available medications and the role of non-invasive ventilation devices for the stabilization and treatment of ADHF.

[Hibernating and stunned myocardium. Pathogenetic mechanisms during and after myocardial ischemia]. / Miocardio ibernato e stordito. Meccanismi patogenetici durante e dopo ischemia miocardica.

In this paper the Authors consider the concept of stunning/hibernating myocardium, analizing the most recent articles and reviews in literature, until April 2002 (database PubMed). Dysfunctional segments with normal perfusion and normal glucose utilization are considered to be "stunned", and dysfunctional segments with reduced perfusion and preserved glucose utilization are considered to be "hibernated". Together with the two major hypothesis (generation of oxygen-derived free radicals and transient calcium overload) in developing of dysfunctional myocardium after ischaemia, recent studies have demonstrated an important role in down-regulation of beta-adrenergic receptors both in the stunned and in the hibernated segments. Moreover, the increase of negatively inotropic cytokines TNF-alpha and NOS2 has been observed in dysfunctional segments. The number of copies of mRNA has been quantified by reverse transcription-polymerase chain reaction (reverse-PCR).