Acute Appendicitis During Coronavirus Disease 2019 (COVID-19): Increasing Incidence of Complicate Appendicitis, Severity and Length of Hospitalization.

BACKGROUND/AIM: COVID-19 is rapidly spreading, and due to the high morbidity and mortality caused by the pandemic many Governments have introduced social restrictions. Those measures combined with infection-related patient anxiety, led to hiding other diseases. The aim of this study was to evaluate the impact of COVID-19 on numbers and severity of acute appendicitis cases referred during the pandemic. PATIENTS AND METHODS: Between March 2019 and March 2021, all patients who underwent appendectomy in Tor Vergata Hospital, Rome were included. Patients were divided in two groups (COVID-19/pre-COVID-19). Clinical features, intraoperative findings, hospital stay, and histologic examination data were included in the retrospective analysis. RESULTS: Out of 334 admitted patients, 36 (10.7%) had a diagnosis of acute appendicitis (COVID-19 group) vs. 59(11.2%) in the pre-COVID-19 group. The COVID-19 group presented significantly longer hospitalization, incidence of appendicular abscess, perforation, and severity of inflammation at univariate analysis p=0.002, p=0.021, p=0.001, p=0.006, p=0.001, respectively. At multivariate analysis, appendicular abscess (p=0.015) and higher serum levels of C reactive protein (p<0.008) were associated with prolonged hospital stay. CONCLUSION: This study highlights the correlation between COVID-19 pandemic and the severity of acute appendicitis presentations.

A case report of atraumatic splenic rupture after coronary stenting and dual antiplatelet therapy: Causality or relationship?

INTRODUCTION AND IMPORTANCE: Atraumatic splenic rupture(ASR) is a rare event with challenging management, due to absence of clinical history of trauma and delayed diagnosis. Current clinical report could provide detailed information regarding clinical presentation and management to physicians. CASE PRESENTATION: A 61 years-old woman underwent percutaneous coronary intervention(PTCA) after ST elevation myocardial infarction(STEMI). In the first day after PTCA epigastric abdominal disconfort was reported, and new PTCA excluded early complication. During hospitalization, due to anemization and hypotension CT scan was performed which revealed ASR with large hemoperitoneum. Emergency surgical splenectomy was performed. Postoperative course was uneventful and patient started 90 mg Ticageclor twice daily in the first post-operative day(POD) plus low molecular weight Heparin and restarted dual antiplatelet therapy(DAPT) the seventh POD. During follow up, patient underwent to assessment of platelet function showing normal level of DAPT inhibition. Due to the lack of pathological aggregation activity, DAPT was maintained. CLINICAL DISCUSSION: ASR is mainly linked to oncological, malformative, inflammatory and thromboembolic conditions. Despite anticoagulant and anti-aggregating drug-related ASR has been already described, we report the first case of drug-related ASR as immediate complication of PTCA due to DAPT. After surgery, careful anti-aggregating management was required to balance in stent restenosis and hemorragic risk. Assessment of platelet activity was performed to design a tailored anti-aggregating therapy. CONCLUSION: Drug-related ASR is dangerous complication due to the high mortality rate and misleading symptoms. After major bleeding events, such as drug-related ASR, evaluation of platelet function could provide a tailored DAPT.

Extremely Advanced Breast Cancer Presentation: Possible Effect of Coronavirus Pandemic Anxiety.

BACKGROUND/AIM: Corona virus infection dramatically spread worldwide during 2020 and extraordinary restrictions have been implemented in order to reduce viral transmission. These measures compelled a complete restructuring of the health system, including temporary cancer screening suspension and a significant slow-down in cancer diagnoses and treatments. CASE REPORT: We report five cases of extremely advanced breast cancer referred to our Department amid the COVID-19 pandemic. These patients exhibited a poor prognosis or worse quality of life due to their oncological disease. CONCLUSION: In our opinion, both the slow-down of diagnosis and treatment of oncological disease and anxiety over COVID-19 influenced this presentation. Moreover, other patients were unable to receive palliative care. Hopefully, these cases will not develop into extremely advanced-stage disease, and we will be able to provide at least the necessary palliative care.

Case Report: Early Breast Cancer Recurrence Mimicking BIA-ALCL in a Patient With Multiple Breast Procedures.

Breast reconstruction plays a fundamental role in the therapeutic process of breast cancer treatment and breast implants represents the leading breast reconstruction strategy. Breast Implant Associated-Anaplastic Large Cell Lymphoma (BIA-ALCL), locoregional recurrence in the skin flap, and skin flap necrosis are well-known complications following mastectomy and immediate breast reconstruction (IBR). We report a case of locoregional cancer recurrence in the mastectomy flap mimicking BIA-ALCL, in a patient who underwent 6 breast procedures in four facilities across 15 years including immediate breast reconstruction with macrotextured breast implants. Despite the rate and onset of the disease, clinicians should be aware of BIA-ALCL. Due to the risk of false negative results of fine needle aspiration, clinical suspicion of BIA-ALCL should drive clinicians' choices, aside from cytological results. In the present case, surgical capsulectomy of the abnormal periprosthesic tissue revealed locoregional recurrence.

Breast Trauma and Triple-Negative Hemorrhagic Cystic Carcinoma: Management and Treatment.

BACKGROUND Breast trauma can always have diagnostic pitfalls. In the presence of a recurrent hemorrhagic cysts, cancer should always be suspected. CASE REPORT A 59-year-old woman noted a palpable mass after breast trauma from falling at home. Radiological exams showed a breast cyst with well-defined margins, with corpuscular and dense fluid components. First, a conservative approach was implemented. One week later, a fine-needle aspiration cytology (FNAC) of the mass showed bloody fluid without atypical cells. Three weeks later, the patient was emergently evaluated due to increased size of the lesion and anemia. To avoid further blood loss and due to suspected malignancy, an urgent surgical excision biopsy was planned. Histopathology revealed a poorly-differentiated carcinoma and the patient was treated with left modified radical mastectomy with axillary dissection. Adjuvant chemotherapy was administered. At 6-month follow-up, the patient was free from recurrences. CONCLUSIONS Recurrent hemorrhagic cysts should always be investigated and considered as a possible cancer lesion. Sonography and cytological exam are the first steps in case of suspicious cysts, but false-negative results are common. In such cases, resection of the cyst should be considered. Immediate resection is valid in cases of diagnostic uncertainty or inability to assess the cyst with imaging or biopsy.

Delay in Breast Cancer Treatments During the First COVID-19 Lockdown. A Multicentric Analysis of 432 Patients.

BACKGROUND/AIM: Extraordinary restrictions aimed to limit Sars-CoV-2 spreading; they imposed a total reorganization of the health-system. Oncological treatments experienced a significant slowdown. The aim of our multicentric retrospective study was to evaluate screening suspension and surgical treatment delay during COVID-19 and the impact on breast cancer presentation. PATIENTS AND METHODS: All patients who underwent breast surgery from March 11, 2020 to May 30, 2020 were evaluated and considered as the Lockdown group. These patients were compared with similar patients of the previous year, the Pre-Lockdown group. RESULTS: A total of 432 patients were evaluated; n=223 and n=209 in the Lockdown and Pre-lockdown-groups, respectively. At univariate analysis, waiting times, lymph-nodes involvement and cancer grading, showed a statistically significant difference (p<0.05). Multivariate analysis identified waiting-time on list (OR=1.07) as a statistically significant predictive factor of lymph node involvement. CONCLUSION: Although we did not observe a clinically evident difference in breast cancer presentation, we reported an increase in lymph node involvement.

Breast cancer patients with hormone neoadjuvant bridging therapy due to asymptomatic Corona virus infection. Case report, clinical and histopathologic findings.

INTRODUCTION: Breast cancer management during COVID-19 pandemic has changed and in case of COVID-19 patients with simultaneous neoplasia, it has been strongly recommended to treat Sars-CoV-2 infection firstly. PRESENTATION OF CASE: We reported a case of a 53-years-old women with early breast cancer and simultaneous asymptomatic SARS-CoV-2 infection. According to COVID-19 breast cancer recommendations she underwent hormone neoadjuvant treatment as a bridging therapy for surgery. Six months from the diagnosis, after virus eradication, patient underwent breast surgery. No SARS-CoV-2 RNA was found both in the surgical specimen and sentinel lymph node but micrometastasis were reported. During the last follow-up, the patient was in good clinical condition and started the adjuvant chemotherapy. DISCUSSION: COVID-19 outbreak determined the publication of temporary recommendation leading to an extensive use of neoadjuvant chemotherapy in breast cancer patients. Although endocrine therapy is a mainstay in the adjuvant treatment, its role in the neoadjuvant schedule is unclear. CONCLUSION: Upfront awake surgery should be preferred especially in asymptomatic COVID-19 patient with early breast cancer when monitoring of tumor response is not feasible.

Effect of Lockdown in Surgical Emergency Accesses: Experience of a COVID-19 Hospital.

BACKGROUND/AIM: SARS-CoV-2 pandemic imposed extraordinary restriction measures and a complete reorganization of the Health System. The aim of the study was to evaluate the impact of COVID-19 on emergency surgical department accesses. PATIENTS AND METHODS: Patients admitted to surgical emergency departments was retrospectively recorded during the Lockdown (March 11, 2020-May 3, 2020) and compared with the same number of days in 2019 and immediately before Lockdown (January 16, 2020-March 10, 2020). Diagnoses, priority levels, modes of patient's transportation, waiting times and outcomes were analysed. RESULTS: During the lockdown phase, we ob-served a reduction in the access to emergency surgical departments of 84.45% and 79.78%, com-pared with the Pre-Lockdown2019 and Pre-Lockdown2020 groups, respectively. Patient's transportation, hospitalization and patients discharge with indications to an outpatient visit, waiting and total times exhibited a significant difference during the lockdown (p<0.005). CONCLUSION: We observed a reduction of surgical emergency accesses during the lockdown. Implementing the use of the regional systems and preventing overcrowding of emergency departments could be beneficial for reducing waiting times and improving the quality of treatments for patients.

Ulcerated breast cancer with single brain metastasis: A combined surgical approach. Clinical presentation at one year follow up - A case report.

INTRODUCTION: Breast cancer is the most common malignancy in woman. Approximately 5-10% of breast cancer occurs as de novo stage IV and some studies have shown that from 10% to 30% of those patients presents Brain Metastasis. PRESENTATION OF CASE: In this study, we report a case of solitary brain metastasis of breast cancer in a 63-year-old Italian Caucasian woman with neurological symptoms as first clinical presentation. After the correct diagnosis and multidisciplinary meeting it was decided to simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction. In our clinical practice we report a successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up. DISCUSSION: Metastasectomy plus mastectomy provided neurological control of acute complication of metastatic disease and complete breast cancer local control. One-time operation could be the best option when diagnosis of breast cancer is made thanks to the onset of oncological emergency like intracranial hypertension due to single brain metastasis. CONCLUSION: Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Breast Cancer and COVID-19: The Effect of Fear on Patients' Decision-making Process.

BACKGROUND/AIM: Coronavirus-19 (COVID-19) pandemic outbreak is currently having a huge impact on medical resource allocation. Breast Cancer (BC) patients are concerned both with BC treatment and COVID-19. This study aimed to estimate the impact of anxiety among patients, caused by the spreading of COVID-19. PATIENTS AND METHODS: Between the 16th of January and the 20th of March 2020, we retrospectively enrolled 160 patients. Eighty-two patients with a suspected breast lesion (SBL) were divided into two groups: PRE-COVID-19-SBL and POST-COVID-19-SBL. Seventy-eight BC patients were divided into PRE-COVID-19-BC and POST-COVID-19-BC. Patient characteristics including age, marital status, SBL/BC diameter, personal and family history of BC, clinical stage and molecular subtype were recorded. Procedure Refusal (PR) and Surgical Refusal (SR) were also recorded with their reason. RESULTS: BC and SBL analysis showed no difference in pre-treatment characteristics (p>0.05). Both POST-COVID-19-SBL and POST-COVID-19-BC groups showed higher rates of PR and SR (p=0.0208, p=0.0065 respectively). Infection risk represented primary reason for refusal among POST-COVID-19 patients. CONCLUSION: COVID-19-related anxiety could affect patients' decision-making process.

The Effect of Coronavirus (COVID-19) on Breast Cancer Teamwork: A Multicentric Survey.

BACKGROUND/AIM: Despite the large amount of clinical data available of Coronavirus-19 (COVID-19), not many studies have been conducted about the psychological toll on Health Care Workers (HCWs). PATIENTS AND METHODS: In this multicentric descriptive study, surveys were distributed among 4 different Breast Cancer Centers (BCC). BCCs were distinguished according to COVID-19 tertiary care hospital (COVID/No-COVID) and district prevalence (DP) (High vs. Low). DASS-21 score, PSS score and demographic data (age, sex, work) were evaluated. RESULTS: A total of 51 HCWs were analyzed in the study. Age, work and sex did not demonstrate statistically significant values. Statistically significant distribution was found between DASS-21-stress score and COVID/No-COVID (p=0.043). No difference was found in the remaining DASS-21 and PSS scores, dividing the HCWs according to COVID-19-hospital and DP. CONCLUSION: Working in a COVID-19-hospital represents a factor that negatively affects psychosocial well-being. However, DP seems not to affect the psychosocial well-being of BCC HCWs. During the outbreak, psychological support for low risk HCWs should be provided regardless DP.

Influence of amino acids on low-density Escherichia coli responses to nutrient downshifts.

A vast bibliography on nutrient effects on high-density cultures exists, while it has been overlooked that low densities of starving cells are often the rule in natural environments. By means of a novel sensitive beta-galactosidase assay, we examined Escherichia coli transitions to minimal media when the cell concentration was 100 to 10,000 cells per ml. As in high-density cultures, the enzyme activity depended on amino acid availability and was subject to catabolite repression and stringent control. In all conditions tested, despite the presence of other nutrient sources, the relationship between beta-galactosidase activity and the l-amino acid pool was hyperbolic. The affinity constant when the amino acid pool was the only nutrient source averaged 14 muM after 90 min and increased up to 222 muM after 4.5 h. While investigating the transition from lag phase to exponential phase, we observed that the cells did not enter into starvation mode in the presence of amino acids, even when the nutrient amount was insufficient to support full survival. Based on these premises, the switch from starvation to hunger was investigated in relation to the amino acid pools. A critical range of concentrations at which E. coli linearly synthesized beta-galactosidase despite, at the same time, suffering a large decrease in cell viability was then recognized. Since both beta-galactosidase production and the dilution rate were reduced by more than half in the absence of leucine, we examined the contribution of leucine to cell recovery capabilities.