Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta-analysis.

OBJECTIVE: This study aimed to evaluate the incidence of chronic groin pain (primary outcome) and alterations of sensitivity (secondary outcome) after Lichtenstein inguinal hernia repair, comparing neurectomy with ilioinguinal nerve preservation surgery. The exact cause of chronic groin postoperative pain after mesh inguinal hernia repair is usually unclear. Section of the ilioinguinal nerve (neurectomy) may reduce postoperative chronic pain. METHODS: We followed PRISMA guidelines to identify randomized studies reporting comparative outcomes of neurectomy versus ilioinguinal nerve preservation surgery during Lichtenstein hernia repairs. Studies were identified by searching in PubMed, Scopus, and Web of Science from April 2020. The protocol for this systematic review and meta-analysis was submitted and accepted from PROSPERO: CRD420201610. RESULTS: In this systematic review and meta-analysis, 16 RCTs were included and 1550 patients were evaluated: 756 patients underwent neurectomy (neurectomy group) vs 794 patients underwent ilioinguinal nerve preservation surgery (nerve preservation group). All included studies analyzed Lichtenstein hernia repair. The majority of the new studies and data comes from a relatively narrow geographic region; other bias of this meta-analysis is the suitability of pooling data for many of these studies. A statistically significant percentage of patients with prosthetic inguinal hernia repair had reduced groin pain at 6 months after surgery at 8.94% (38/425) in the neurectomy group versus 25.11% (113/450) in the nerve preservation group [relative risk (RR) 0.39, 95% confidence interval (CI) 0.28-0.54; Z = 5.60 (P < 0.00001)]. Neurectomy did not significantly increase the groin paresthesia 6 months after surgery at 8.5% (30/353) in the neurectomy group versus 4.5% (17/373) in the nerve preservation group [RR 1.62, 95% CI 0.94-2.80; Z = 1.74 (P = 0.08)]. At 12 months after surgery, there is no advantage of neurectomy over chronic groin pain; no significant differences were found in the 12-month postoperative groin pain rate at 9% (9/100) in the neurectomy group versus 17.85% (20/112) in the inguinal nerve preservation group [RR 0.50, 95% CI 0.24-1.05; Z = 1.83 (P = 0.07)]. One study (115 patients) reported data about paresthesia at 12 months after surgery (7.27%, 4/55 in neurectomy group vs. 5%, 3/60 in nerve preservation group) and results were not significantly different between the two groups [RR 1.45, 95% CI 0.34, 6.21;Z = 0.51 (P = 0.61)]. The subgroup analysis of the studies that identified the IIN showed a significant reduction of the 6th month evaluation of pain in both groups and confirmed the same trend in favor of neurectomy reported in the previous overall analysis: statistically significant reduction of pain 6 months after surgery at 3.79% (6/158) in the neurectomy group versus 14.6% (26/178) in the nerve preservation group [RR 0.28, 95% CI 0.13-0.63; Z = 3.10 (P = 0.002)]. CONCLUSION: Ilioinguinal nerve identification in Lichtenstein inguinal hernia repair is the fundamental step to reduce or avoid postoperative pain. Prophylactic ilioinguinal nerve neurectomy seems to offer some advantages concerning pain in the first 6th month postoperative period, although it might be possible that the small number of cases contributed to the insignificancy regarding paresthesia and hypoesthesia. Nowadays, prudent surgeons should discuss with patients and their families the uncertain benefits and the potential risks of neurectomy before performing the hernioplasty.

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair.

BACKGROUND: Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months. MATERIAL: A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation. RESULTS: Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542). CONCLUSION: The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

Antimicrobial Stewardship Program, COVID-19, and Infection Control: Spread of Carbapenem-Resistant Klebsiella Pneumoniae Colonization in ICU COVID-19 Patients. What Did Not Work?

The Italian burden of disease associated with infections due to antibiotic-resistant bacteria has been very high, largely attributed to Carbapenem-Resistant Klebsiella pneumoniae (CR-Kp). The implementation of infection control measures and antimicrobial stewardship programs (ASP) has been shown to reduce healthcare-related infections caused by multidrug resistance (MDR) germs. Since 2016, in our teaching hospital of Terni, an ASP has been implemented in an intensive care unit (ICU) setting, with the "daily-ICU round strategy" and particular attention to infection control measures. We performed active surveillance for search patients colonized by Carbapenem-Resistant Enterobacteriaceae (CRE). In March 2020, coronavirus disease 2019 (COVID-19) arrived and the same ICU was reserved only for COVID-19 patients. In our retrospective observational study, we analyzed the bimonthly incidence of CRE colonization patients and the incidence of CRE acquisition in our ICU during the period of January 2019 to June 2020. In consideration of the great attention and training of all staff on infection control measures in the COVID-19 era, we would have expected a clear reduction in CRE acquisition, but this did not happen. In fact, the incidence of CRE acquisition went from 6.7% in 2019 to 50% in March-April 2020. We noted that 67% of patients that had been changed in posture with prone position were colonized by CRE, while only 37% of patients that had not been changed in posture were colonized by CRE. In our opinion, the high intensity of care, the prone position requiring 4-5 healthcare workers (HCWs), equipped with personal protective equipment (PPE) in a high risk area, with extended and prolonged contact with the patient, and the presence of 32 new HCWs from other departments and without work experience in the ICU setting, contributed to the spread of CR-Kp in our ICU, determining an increase in CRE acquisition colonization.

Media-Based Research on Selfie-Related Deaths in Italy.

BACKGROUND: The incidence of taking selfies and sharing them on social media as well as selfie-related dangerous behaviors is increasing, particularly among young people, also leading to selfie-related trauma and death. This study was performed to obtain epidemiological characteristics of selfie-related mortality in Italy. METHODS: Scientific literature and Italian media were reviewed. RESULTS: Twelve victims from 11 events, from 2014 to 2018, were analyzed (sex, age, accident types, the nationality, the Italian region where the incident took place, if the person involved was indigenous or a tourist, the dynamics and the causa mortis, if other people have been involved in the selfie, and if other people were deceased). The majority of selfie victims were male teenagers, the average age was 23.6 years, the most preferred site of taking selfies was the natural environment followed by the railway one, the most frequently reported event or accident type was falling from a height, and the most frequent causes of selfie-related deaths were multitrauma and drowning. CONCLUSIONS: Selfie-related deaths in Italy appear to be an issue and appear to be increasing. Particularly, male teenagers and young adults are at high risk for selfie-related deaths. Measures should be taken to reduce their incidence.

Fatal Acute Intracranial Subdural Hematoma After Spinal Anesthesia for Cesarean Delivery: Case Report and Review of the Literature.

The authors report on the autopsy case of a 40-year-old primigravida without either coagulation disorders or anticoagulant/antiplatelet therapy, who developed a fatal intracranial subdural hematoma after spinal anesthesia (SA) for elective cesarean delivery for tocophobia.Intracranial subdural hematoma is the most dreaded complication of SA and is often misdiagnosed with postdural puncture headache.In this article, the authors discuss pathophysiological mechanisms and risk factors for the development of an intracranial subdural hematoma after SA and review the pertinent literature.

A Case of Bilateral Extracranial Internal Carotid Artery Dissection Due to the Helmet Strap After Motorcycle Crash.

The authors report a case of a man who developed stroke symptoms a few days after a road accident on his motorcycle. Radiographic examinations revealed the presence of bilateral dissection of the extracranial internal carotid arteries with signs of involvement of the brain parenchyma.The location, timing, and presentation lead to the conclusion that the carotid lesions were secondary to the motorcycle collision; in particular, we suppose that it is due to the pressure exerted by the helmet strap worn. Although helmets have undoubtedly prevented serious injuries, this report highlights that the helmets themselves may cause injuries, especially to cervical soft tissues and vessels.

La morte in carcere conseguente all'inalazione di gas: la responsabilità dello psichiatra.

In ambito penitenziario il suicidio e l'autolesionismo rappresentano quasi una caratteristica strutturale, rendendo la prevenzione un obiettivo primario. L'Amministrazione penitenziaria ha emanato in materia di prevenzione del suicidio un ampio spettro di provvedimenti. Il presente studio prende in esame la misura attualmente vigente in alcuni istituti di valutare i detenuti autorizzati all'utilizzo dello strumentario a gas, con monitoraggio delle condotte, da parte dello psichiatra.

Two Fatal Intoxications Due to Tramadol Alone: Autopsy Case Reports and Review of the Literature.

Since tramadol was marketed, it has been widely prescribed as a pain killer because of its relatively safe profile among opioids.Nevertheless, intoxication can occur: overdose can lead to fatal outcomes mostly in association with other drugs, via the potential interaction with serotonergic antidepressant medications, as well as the potential for increased central nervous system (CNS) depression.Fatal outcomes only attributable to tramadol are a rare entity. In this case report, 2 fatal cases are described due to tramadol stand-alone intoxication with peculiar characteristics.In case 1, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (32 µg/mL in the heart blood, 23.9 µg/mL in the femoral blood, 3.3 µg/mL in the bile, and 1.4 µg/mL in the urine). No other CNS depressants were detected by toxicological analysis.In case 2, gas chromatography - mass spectrometry analysis detected tramadol in all specimens (7.5 µg/mL in the heart blood, 5.8 µg/mL in the femoral blood, and 18 µg/mL in the urine). No other CNS depressants were detected by toxicological analysis.Review of the literature was performed to clarify the actual knowledge on this topic.

Fatal Clostridium perfringens Septicemia After Colonoscopic Polypectomy, Without Bowel Perforation.

Since its introduction, colonoscopy has played an important role as a diagnostic, therapeutic, and screening tool. In general, colonoscopy is regarded as a safe procedure, but complications may occur. The most dreaded of these complications is colonic perforation. Bacteremia postprocedure may occur, and although it is not uncommon, it rarely results in clinically significant complications. Patients with IBD (inflammatory bowel disease) are a high-risk population for bacteremia, which may leads to bowel wall overstepping by the bacteria. With regard to that, we report a fatal case of gas gangrene complicating colonoscopy polypectomy without bowel perforation in a healthy adult. To the best of our knowledge, only two other cases of retroperitoneal gas gangrene associated with colonoscopy polypectomy without bowel perforation have been described in international literature, but none of which was completed by a molecular biology analysis.

A Fatal Case of Acute Butane-Propane Poisoning in a Prisoner Under Psychiatric Treatment: Do These 2 Factors Have an Arrhythmogenic Interaction, Thus Increasing the Cardiovascular Risk Profile?

Sudden death due to inhalation of aliphatic hydrocarbons such as butane and propane is well described in the literature. The main mechanism involved is the induction of a fatal cardiac arrhythmia. This phenomenon is frequently associated with prisoners who accidentally die while sniffing these volatile substances with an abuse purpose. Furthermore, such prisoners are often under psychiatric treatment; specific drugs belonging to this pharmacological class lead to a drug-related QT interval prolongation, setting the stage for torsade de pointes. In this article, we present the case of a prisoner died after sniffing a butane-propane gas mixture from a prefilled camping stove gas canister. The man was under psychiatric drugs due to mental disorders. He was constantly subjected to electrocardiogram to monitor the QTc (corrected QT interval), which was 460 milliseconds long. Toxicological analysis on cadaveric samples was performed by means of gas chromatography (head space) and revealed the presence of butane and propane at low levels. The aim of this article was to discuss a possible arrhythmogenic interaction of QT interval prolongation induced by psychiatric drugs and butane-propane inhalations, increasing the cardiovascular risk profile. In other words, evidence may suggest that prisoners, under these circumstances, are more likely to experience cardiovascular adverse effects. We believe that this study underlines the need to take this hypothesis into account to reduce death risk in prison and any medical-related responsibilities. Further studies are needed to validate the hypothesis.

An Enigmatic Death in Farm Chopping Machine: Is This the Perfect Murder?

Forensic autopsy, like the other sectors in medicine, has benefited from the technological progress and the creation of multidisciplinary teams to unveil more and more finely planned criminal intents.Forensic pathologists, however, can sometimes deal with very enigmatic cases, meeting so with the limits of their own knowledge. Therefore, in these cases, they must not allow themselves to be pressured by inquiring agencies, remaining instead always faithful to empiric observations.With regard to that, we present a peculiar case of death by shredding inside a grinding machinery. The magistrature consequently opened a dossier for willful murder. Lots of figures were appointed to solve the case and among them is the forensic pathologist. However, a great number of obstacles were put in the investigators' inquiries.Was it a perfect murder?

An unusual case of unintentional firearm death of a 3-year-old child.

The authors report the case of an accidental death of a 3-year-old child who unintentionally shot himself while he was handling his father's handgun.The peculiarity of the observed injury makes the case particularly interesting, along with the fact that, in Italy, unintentional firearm-related deaths are rather uncommon among children and adolescents.Because of the presence of only 1 bullet hole on the parietal-occipital region, radiological cranial examinations were performed before proceeding with the autopsy.Computed tomographic scans were useful to confirm the entrance site of the bullet and, especially, to establish the trajectory with the whole spectrum of fractures.The case shows that the unusual entrance site of the bullet through the nose led to a fatal cranial injury, as a result of curiosity of a 3-year-old child in the presence of an unsupervised handgun.

Instantaneous death due to transorbital reverse penetration of a screw in an accidental fall: unusual autopsy case report and review of the literature.

We present a peculiar autopsy case of a transorbital penetrating head injury, in a male worker, after an accidental fall onto a screw not completely stuck into a wooden board. A 13-cm screw entered the cranium 9.5 cm deep, penetrating with the flat end, a condition defined in literature as "reverse penetration." The death was instantaneous and caused by a neurogenic shock due to injuries to the brain stem and the right cerebellar hemisphere. These injuries, enabled by the length of the screw, are generally described in literature as due to nontransorbital penetrations, frequently associated with posterior entry and a large intracranial injury. The ocular globe has been, furthermore, perfectly preserved thanks to its mobility in the orbit. Even the dynamic of the incident is peculiar because of the stationary nature of the penetrating object, which the victim actively fell on by accident. To the best of our knowledge, the matter is therefore a very peculiar mortal case of transorbital intracranial penetration, whose verified injuries and dynamics are absolutely atypical. The case is now under discussion, and a review of pertinent literature is performed.

An unusual autopsy case of incomplete decapitation of a motorcyclist with herniation of thoracic organs through a helmet-related neck wound.

The authors report an unusual autopsy case of a motorcyclist who wore a full-face type helmet and had incomplete decapitation and herniation of the heart and a portion of the right lung through an extensive lacerate wound on the front of the neck after his motorcycle crashed. The authors identified 2 main offensive dynamics that occurred simultaneously: First, partial decapitation with a extensive gaping wound on the neck caused by the chin strap after a violent angular movement of the head; second, the translocation of the abdominal organs into the thorax and the herniation of the thoracic organs through the neck wound generated by a compressive trauma of the thorax and abdomen. This singular case, like few others in forensic literature, shows the possibility of helmet chin strap-related traumas and highlights the limitations of modern protective helmets. If the postulated mechanism is confirmed despite the massive benefits derived from the compulsory use of protective helmets, the properties of the helmet chin strap would need to be reassessed to improve the protection of the soft tissue and bones in the neck.

Two cases of acute propane/butane poisoning in prison.

Hydrocarbon inhalation is seldom chosen as a means to commit suicide. This practice is exclusively a prerogative of the prison population; it is, however, only exceptionally found in this environment. The two cases of lethal inhalation of propane/butane gas observed by us over a very short time occurred in this context. Toxicologic analyses were performed by means of gas chromatography (head space) and revealed a propane/butane mixture in all specimens (heart blood, bile, and urine) except vitreous humor. Although fatal arrhythmia posthydrocarbon gas abuse is well known, the concentrations of the two hydrocarbons were sufficient to induce death by asphyxiation and were distributed (fairly) homogeneously in all biological fluids and organs examined, a parameter permitting one to assume that death occurred within a relatively short period of time. The absence of finding in vitreous humor and the trace amount in urine suggests that both men died very quickly.

An unusual case of suicidal carbon monoxide poisoning.

The authors present a case of suicide by carbon monoxide poisoning in a confined space with interesting elements related to the method and the circumstances in which it took place. Carbon monoxide poisoning is a very common cause of death in accidental and suicidal cases, but the method used in this case, consisting of burning charcoal in a small office bathroom, presents some particularly interesting aspects. The circumstances, moreover, appear very interesting because the person who committed suicide was an employee of the Public Administration and he had received notification regarding his involvement in a legal prosecution.