Late is too late? Surgical timing and postoperative complications after primary ileocolic resection for Crohn's disease.

BACKGROUND: Despite the recent advances in medical therapy, the majority of patients with Crohn's disease (CD) still require surgery during the course of their life. While a correlation between early primary surgery and lower recurrence rates has been shown, the impact of surgical timing on postoperative complications is unclear. The aim of this study is to assess the impact of surgical timing on 30-day postoperative morbidity. METHODS: This is a retrospective analysis of a prospectively collected database of 307 consecutive patients submitted to elective primary ileocolic resection for CD at our institution between July 1994 and July 2018. The following variables were considered: age, gender, year of treatment, smoking habits, preoperative steroid therapy, presence of fistula or abscess, type of anastomosis, and time interval between diagnosis of CD and surgery. Univariate and multivariate logistic regressions were performed to examine the association between risk factors and complications. RESULTS: Major complications occurred in 29 patients, while anastomotic leak was observed in 16 patients. Multivariate logistic regression analysis showed that surgical timing in years (OR 1.10 p = 0.002 for a unit change), along with preoperative use of steroids (OR 5.45 p < 0.001) were independent risk factors for major complications. Moreover, preoperative treatment with steroids (6.59 p = 0.003) and surgical timing (OR 1.10 p = 0.023 for a unit change) were independently associated with anastomotic leak, while handsewn anastomosis (OR 2.84 p = 0.100) showed a trend. CONCLUSIONS: Our results suggest that the longer is the time interval between diagnosis of CD and surgery, the greater is the risk of major surgical complications and of anastomotic leak.

Sudden death caused by aortic dissection in a patient with polycystic kidney disease.

A 43-year-old man presented at the emergency medical unit with chest pain. The results of a clinical examination were normal, apart from sternum pain (without radiation) on palpation. The patient had no respiratory problems and the pain was relieved by paracetamol. The electrocardiogram, laboratory tests and chest X-ray were normal. However, the man was found dead the next morning. In the autopsy, we noted the presence of haemopericardium, aortic dissection (starting from the vessel's origin and extended to the aortic arch and on through the diaphragm), polycystic kidney disease and liver cysts. In adult autosomal dominant polycystic kidney disease (ADPKD) patients, the main causes of death are ruptured intracerebral aneurysms, coronary artery disease, congestive heart failure, valvular heart disease and ruptured abdominal aortic aneurysms. Aortic dissection is considered to be rare cause of sudden death in ADPKD sufferers. ADPKD can have serious consequences for the vascular system. The families of confirmed ADPKD sufferers must be informed and screened as early as possible, in order to prevent renal and cardiovascular complications.

Mid-transverse colon cancer and extended versus transverse colectomy: Results of the Italian society of surgical oncology colorectal cancer network (SICO CCN) multicenter collaborative study.

INTRODUCTION: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. MATERIALS AND METHODS: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. RESULTS: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). CONCLUSIONS: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Alcohol, cigarette, and illegal substance consumption among medical students: a cross-sectional survey.

This study investigated addictive substance use by French medical students. A cross-sectional survey was distributed to 255 participants randomly selected from 1,021 second- to sixth-year medical students. Questionnaires were self-administered and included questions on sociodemographic characteristics, mental health, and alcohol (The Alcohol Use Disorders Identification Test [AUDIT test]), tobacco (Fagerstrom test), and illegal substance consumption (Cannabis Abuse Screening Test [CAST test]). The AUDIT scores indicated that 11% of the study participants were at risk for addiction and 21% were high-risk users. Tobacco dependence was strong or very strong for 12% of the participants. The CAST score showed that 5% of cannabis users needed health care services. Cannabis users were also more likely than non-users to fail their medical school examinations (89% vs. 39%, p<.01). One quarter of medical student participants (n=41) had used other illegal drugs, and 10% of study participants had considered committing suicide during the previous 12 months. Psychoactive substance consumption by French medical students requires preventive measures, screening, and health care services.

The major inherited disorders of cornification. New advances in pathogenesis.

This article provides a synopsis of the major (most common) inherited disorders of cornification. It also reviews the recent advances that have been made for each disorder and their practical applications.

[Prehospital management of patients with severe head injuries]. / Prise en charge préhospitalière du traumatisé crânien grave.

Advanced prehospital emergency medical care of patients with a severe head injury must essentially focus on the impact of secondary cerebral insults of systemic origin on the outcome. The first objective of prehospital care is to prevent hypoxaemia and hypercapnia. Therefore, all patients with a Glasgow Coma Scale score equal to or lower than 8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring of SpO2 and PETCO2. Treatment is similar in head-injured patients with significant deterioration of consciousness level, seizures, respiratory distress, or severe facial and thoracoabdominal injuries. The endotracheal tube is inserted by the orotracheal route under direct laryngoscopy, after a rapid induction sequence of anaesthesia and immobilization of the cervical spine in neutral position. For the induction of anaesthesia in these high-risk patients (full stomach, unknown medical history, deteriorated haemodynamic status), etomidate and suxamethonium are the preferred agents. Sedation is maintained with an hypnoticopioid association (fentanyl). Simultaneously, the main goal is the maintenance of an optimal cerebral perfusion pressure, as arterial hypotension severely worsens cerebral ischaemia. Volume loading is accomplished with 0.9% saline and hydroxyethyl starch.

[Oncocytoma of the parotid gland (observations on a case)]. / L'oncocitoma della parotide (osservazione di un caso).

The authors report on an isolated case of parotid gland oncocytoma observed in an elderly patient who developed an oxyphilic cell adenoma of the parotid gland. As this conditions is very rare, they describe the clinical features of the case and review the available literature on the disease.

Use of an automated external defibrillator: a prospective observational study of first-year medical students.

UNLABELLED: This study evaluated the ability of young adults to respond to a simulated cardiac arrest using an automated external defibrillator (AED). METHOD: The study population was first-year medical students. None had received their mandatory training in emergency medicine. They role-played in pairs and entered a room in which a third person was lying on the floor and simulating unconsciousness and respiratory arrest. An AED and the corresponding poster-format instructions were clearly visible in the room, next to a telephone. The actions of pairs of responders were recorded. RESULTS: Interpretable results were obtained for 90 pairs of subjects. Most (96%) assessed vital signs and 20% performed this assessment correctly. Chest compressions were performed by 57%, 71% called emergency services, 4.5% removed the AED from the wall (but only one pair used it) and 8.9% did nothing. For 41% of the pairs, at least one member already had a cardiopulmonary resuscitation (CPR) certificate. The only statistically significant difference between students with and without a CPR certificate concerned use of the telephone to call emergency services. DISCUSSION: Despite the presence of an AED next to the telephone, the defibrillator was almost never used by the participants. Four out of ten pairs did not start chest compressions. The absence of any significant differences in performance between students with and without a CPR certificate casts doubt on the efficacy of the CPR training they had received. CONCLUSION: Results indicate the need for greater awareness of how to deal with cardiac arrest and the use of an AED when one is available.

Practical aspects of laser safety.

Lasers have several unique properties that allow for the production of intensely powerful beams of light. These same properties also carry significant hazards for those not familiar with their safe use. If misdirected, laser beams can produce blindness or full-thickness cutaneous burns. Dry surgical gauze and drapes can ignite with sufficient exposure to laser energy, and treatment of infected tissue can generate a plume that poses a biohazard risk to the physician and staff as well. In order to use these powerful devices most effectively and safely, the physician should understand the basics of laser safety and be able to implement practical methods of operation.

Multiple eruptive dermatofibromas in three men with HIV infection.

BACKGROUND: Multiple eruptive dermatofibromas (MEDF) are rare and their etiology is unknown. An association with immunosuppression has led to the speculation that they are the result of an abortive immunoreactive process. In the literature, there have been 5 isolated case reports of multiple dermatofibromas and human immunodeficiency virus (HIV) infection. Three of these cases had other immune modulators present (i.e. prednisone, systemic lupus erythematosus, alpha-interferon, UVB phototherapy). The other 2 cases had disseminated mycobacteriosis. OBSERVATIONS: A series of 3 men with HIV infection and MEDF is described. In contrast to previous case reports, our patients did not have other immune modulators besides HIV infection nor did they have disseminated mycobacteriosis. CONCLUSIONS: This series lends support to the speculation that MEDF may be associated with immunosuppression. Further study is needed to delineate the exact mechanism for this relationship. These patients presented within a 4-month period and illustrate the frequency at which MEDF may be seen in the HIV-positive population. As clinicians who care for patients with HIV infection, it is important to be aware that MEDF may be seen in this immunosuppressed population.

Laser treatment of facial vascular lesions.

For years, the traditional 577 to 585-nm pulsed dye laser has provided safe and effective treatment for many facial vascular lesions. Currently, interest is focused on how selective epidermal cooling, longer wavelengths, and varied pulse durations may expand the pulsed dye laser's therapeutic range to include treatment-resistant port wine stains, nonablative wrinkle reduction, scar revision, and nonsurgical flap delay. Despite these manipulations, the generation of objectionable purpura remains a concern to patients with limited lesions. To this effect, a long pulsed 532-nm laser has recently become available. This laser is effective for the treatment of facial telangiectasias and does not cause any purpura. It has had minimal complications in two series.

Immediate postoperative laser resurfacing improves second intention healing on the nose: 5-year experience.

BACKGROUND: Mohs surgery defects on convex nasal surfaces do not reliably heal well by second intention. Prior to the availability of laser resurfacing we found that immediate postoperative dermabrasion improved the predicted outcome from second intention healing for these defects. OBJECTIVE: To determine the ability of immediate postoperative CO2 and Er:YAG laser resurfacing to improve predicted healing by second intention. METHODS: Seventy-four patients with Mohs surgical defects on the nose underwent immediate postoperative resurfacing with either a scanned CO2 or long-pulsed Er:YAG laser. Thirty patients had photographs of appropriate quality and follow-up for evaluation by a panel of nine objective physicians. RESULTS: All 74 patients were satisfied with their result and none have requested scar revision. Of the 30 patients evaluated by the panel, all were scored acceptable to excellent. CONCLUSION: Immediate laser resurfacing can improve the predicted outcome from second intention healing on the nose and should be considered for select patients.