Laparoscopic right hemicolectomy: a SICE (Società Italiana di Chirurgia Endoscopica e Nuove tecnologie) network prospective study on the approach to right colon lymphadenectomy in Italy: is there a standard?-CoDIG 2 (ColonDx Italian Group).

BACKGROUND: Colon cancer is a disease with a worldwide spread. Surgery is the best option for the treatment of advanced colon cancer, but some aspects are still debated, such as the extent of lymphadenectomy. In Japanese guidelines, the gold standard was D3 dissection to remove the central lymph nodes (203, 213, and 223), but in 2009, Hoenberger et al. introduced the concept of complete mesocolic excision, in which surgical dissection follows the embryological planes to remove the mesentery entirely to prevent leakage of cancer cells and collect more lymph nodes. Our study describes how lymphadenectomy is currently performed in major Italian centers with an unclear indication on the type of lymphadenectomy that should be performed during right hemicolectomy (RH). METHODS: CoDIG 2 is an observational multicenter national study that involves 76 Italian general surgery wards highly specialized in colorectal surgery. Each center was asked not to modify their usual surgical and clinical practices. The aim of the study was to assess the preference of Italian surgeons on the type of lymphadenectomy to perform during RH and the rise of any new trends or modifications in habits compared to the findings of the CoDIG 1 study conducted 4 years ago. RESULTS: A total of 788 patients were enrolled. The most commonly used surgical technique was laparoscopic (82.1%) with intracorporeal (73.4%), side-to-side (98.7%), or isoperistaltic (96.0%) anastomosis. The lymph nodes at the origin of the vessels were harvested in an inferior number of cases (203, 213, and 223: 42.4%, 31.1%, and 20.3%, respectively). A comparison between CoDIG 1 and CoDIG 2 showed a stable trend in surgical techniques and complications, with an increase in the robotic approach (7.7% vs. 12.3%). CONCLUSIONS: This analysis shows how lymphadenectomy is performed in Italy to achieve oncological outcomes in RH, although the technique to achieve a higher lymph node count has not yet been standardized. Trial registration (ClinicalTrials.gov) ID: NCT05943951.

A SICE (Società Italiana di Chirurgia Endoscopica e Nuove Tecnologie) observational prospective multicenter study on anatomical variants of the superior mesenteric artery: intraoperative analysis during laparoscopic right hemicolectomy-CoDIG 2 database (ColonDx Italian Group).

Colorectal cancer, the third most common cancer worldwide, affects 40-45% of patients on the right side. Surgery, especially minimally invasive methods such as laparoscopic and robotic procedures, is the preferred treatment. However, these techniques present technical complications. The anatomical complexity and variations in vessel branching patterns pose challenges, particularly for less experienced surgeons. The CoDIG 2 is a nationwide observational study involving 76 specialized Italian general surgery departments focused on colorectal surgery. The centres were directed to maintain their standard surgical and clinical practices. The aim of this study was to analyse the intraoperative vascular anatomy of Italian patients who underwent laparoscopic right colectomy and explore the ligature techniques used by Italian surgeons. Surgeons reported information about vascularization of the right colon for 616 patients and about surgical anatomy of RCA for 368 patients. Fifty-three patients (10.8%) showed no RCA intraoperatively. The right colic artery (RCA) was categorized according to the Yada classification (types 1-4) during evaluation, and intraoperative assessments revealed that Yada type 1 was the most common type (55.2%), while radiologic evaluations revealed a higher prevalence of type 2. Furthermore, compared with the superior mesenteric vein (SMV), the RCA is more often located anteriorly according to intraoperative and contrast-enhanced CT examination; 59.9% were found in the anterior position during intraoperative examination, while 40.1% were found in the same position on preoperative contrast-enhanced CT. Vascularization of the right colon, including missing branches, additional branches, shared trunks, and retro-superior courses of the mesenteric vein, exhibited notable variations. To understand vascular variations, a preoperative radiological study is necessary; although there was no concordance between the intraoperative and radiological evaluations, this is a limitation of preinterventional radiological evaluation (PII) because it is always needed for oncological staging. This approach is especially critical for inexperienced surgeons to avoid potential complications, such as problematic bleeding.

Predictive value of changes in R-wave amplitude after exercise in coronary heart disease.

To assess the predictive value of coronary events reflected by changes in R-wave amplitude after exercise, 146 patients with angiographically documented coronary heart disease were studied. All patients were followed up for 6 years, during which time myocardial infarction and death of cardiovascular origin were considered endpoints. The incidence of events in patients in whom R-wave amplitude decreased (normal response) and in those in whom R-wave amplitude did not change or increase (abnormal response) were compared. The incidence of coronary events in patients with a normal response was 23% and in those with an abnormal response, 45.8% (p less than 0.01). Correlating the results with several noninvasive and angiographic variables, an abnormal R-wave response showed a significantly higher rate of events in the subsets of patients with prior myocardial infarction, absence of cardiomegaly, maximal functional capacity lower than 4 METs, maximal heart rate higher than 140 beats/min and abnormal left ventricular function. Thus, the changes in R-wave amplitude after exercise is a variable that should be taken into account when assessing the risk of future events in patients with coronary heart disease.

Effects of nitrates on R-wave variations after exercise in coronary heart disease: differences in patients with and without angina pectoris.

With the purpose of investigating the pathophysiology of changes in the R wave after exercise and its relationship with left ventricular function, we studied 44 patients with coronary heart disease. They were classified into the following three groups: group A, 11 patients with angina pectoris and no prior myocardial infarction; group B, 18 patients with angina pectoris and prior myocardial infarction; and group C, 15 patients with prior myocardial infarction but no angina. All patients performed two exercise tests; one was a control test, and the other was performed after the sublingual administration of 5 mg of isosorbide dinitrate. In group A, variations in the R-wave voltage in control test and in the test after isosorbide dinitrate were 1.5 +/- 0.8 mm and -1.2 +/- 0.9 mm (P less than 0.05), respectively. In group B, results were 1.2 +/- 0.7 mm on the control test and -0.7 +/- 0.6 mm after isosorbide dinitrate (P less than 0.002), and in group C were -1.6 +/- 1.2 mm on the control test and -0.7 +/- 0.7 mm after isosorbide dinitrate (not significant). Thus, the two groups of patients with angina showed an increase of the R-wave after exercise in the control test but a decrease after the administration of nitrates, whereas the patients without angina showed a reduced R-wave after exercise both before and after the administration of nitrates (like normal subjects). This study suggests that ischemic ventricular dysfunction with exercise results in an increase in the R-wave, while exercise after nitrates results in a decrease in the R-wave consistent with less or no ventricular dysfunction due to nitrate therapy.

Effect of infused hypothalamic phospholipids on the maturation of foetal rabbit lungs.

The effect of hypothalamic phospholipids on the maturation of foetal lung was investigated in a series of experiments in rabbits. Sixteen pregnant does were injected with hypothalamic phospholipids (2 mg day-1 kg-1) from day 21 of gestation. A second group of 16 does was injected with saline, and served as controls. The foetuses were delivered at gestational ages between 27 and 28 days by means of caesarean section under intravenous pentothal anaesthesia. Foetuses born from treated mothers were more active, breathed better, and their lungs expanded to a greater extent compared with the foetuses born to control mothers. In the animals of treated mothers there was, on electron microscopy, evidence of accelerated maturation of alveolar epithelial cells.

Dysfunctional voiding.

Wetting may be considered the Cinderella of paediatric medicine. Before discussing dysfunctional voiding, the milestones of the normal development of continence in the child and the definitions used to describe this topic are presented. Bladder storage requires (1): accommodation of increasing volumes of urine at low intravesical pressure and with appropriate sensation; (2): a bladder outlet that is closed and not modified during increase in intra-abdominal pressure; (3): absence of involuntary bladder contractions. Development of continence in the child involves three independent factors maturing concomitantly: (1) development of normal bladder capacity; (2) maturation of urethral sphincter function; (3) development of neural control over bladder-sphincter function. All these processes are discussed. Abnormalities of any of these maturational sequences, which run parallel and overlapping, may result in clinically evident abnormalities of bladder sphincter control. Although dysfunctional voiding (DV) in children is very common its prevalence has not been well studied and, to date, and its origin is not well known. In a correct evaluation of functional voiding we must take into account different elements: the bladder capacity (that increases during the first 8 years of life roughly 30 ml per year), the micturition frequency, post-void residual volumes, bladder dynamics, urinary flow rates. Thus the correct assessment of children with lower urinary tract dysfunction should include a detailed history. Signs of DV range from urge syndrome to complex incontinence patterns during the day and the night. In addition to incontinence problems, children may have frequency, urgency, straining to void, weak or interrupted urinary stream, urinary tract infections (UTIs) and chronic constipation with or without encopresis. DV are also referred in enuretic children who wet the bed more than one time per night and have a functional bladder capacity lower than attended for age. Recently standardisation and definitions of children's lower urinary tract dysfunction have been approved by International Children's continence Society (ICCS). The ICSS distinguishes between urinary incontinence, stress incontinence, overflow incontinence and urge syndrome. Clinical suggestions are presented for the daily practice.

[An update on clinical and therapeutic aspects of nocturnal enuresis]. / Aggiornamento sugli aspetti clinici e terapeutici dell'enuresi notturna.

Justification of early treatment of nocturnal enuresis is founded in the negative psychological impact on the child. In fact nocturnal enuresis delays early autonomy and socialisation by decreasing in self-esteem and self-confidence. Nocturnal enuresis classification is the preliminary step to correct therapy. Enuresis must be classified as primary (never acquired nocturnal control) or secondary (at least 6 months of dry nights). A child is also classified as having monosymptomatic enuresis if she/he experienced only night wetting and symptomatic enuresis if she/he experienced night wetting associated with diurnal voiding symptoms (urinated > or = 7 times a day, urgency, damp pants, squatting, holding the perineum, sitting on one heel). Monosymptomatic patients must be treated with desmopressin nasal spray at the daily dose of 20 micrograms at bed time. If the reduction of at least the 50% of the basal number of the wet nights is not achieved, the dosage must be increased until 40 micrograms. For patients affected by rhinitis or asthma, desmopressin is now available in tablets. In symptomatic patients desmopressin therapy must be associated to oxybutinin (5 mg x 2). Therapy interruption must be gradual with desmopressin reduction of 10 micrograms every 30 days. In symptomatic patients oxybutinin must be introduced only at bed time. The efficacy of the drugs depends on the therapy length. The highest percentage of success is obtained if the treatment is protracted for at least six months. Antidepressants are also used for nocturnal enuresis especially imipramine. The dosage varies between 0.5-1.5 mg/ kg/daily. As plasmatic levels are achieved only in 30% of treated patients, a 3-5 fold increase in suggested. Nevertheless these levels result in near toxic threshold concentration. Sporadic treatment purposes include amytriptiline, diclofenac sodicum, viloxsazine and methilphenidate if giggle incontinence is present. Non responders may be treated with alarm. If after 16 weeks of treatment no success is obtained alarm use must be interrupted.

Functional daytime incontinence: pharmacological treatment.

The basis for the treatment of functional daytime incontinence in children is the bladder regimen, i.e. to teach the children to void regularly by the clock. Drug treatment may be needed as an adjunct to the regimen in children with gross detrusor instability. There is no evidence from properly controlled studies that tricyclic antidepressants or anticholinergic drugs are of value for the child with daytime wetting. Terodiline is a new drug combining anticholinergic and calcium-blocking effects. In two randomized, double-blind studies of terodiline compared with placebo in children with urge incontinence (i.e. functional day wetting), continence improved significantly over placebo in the terodiline group. Only a few mild adverse reactions were noted. Children with symptomatic urinary tract infection and day wetting should receive chemotherapy, but covert bacteriuria should best be left untreated. There is no evidence that eradication of the bacteriuria improves continence. Instead, there is a great risk of symptomatic recurrence of the urinary tract infection after antibacterial treatment.

[Effect of obstructive malformations on the gastrointestinal tract on bilirubin levels in newborn infants]. / Influenza delle malformazioni ostruttive del tubo gastro-intestinale sui livelli bilirubinemici del neonato.

The authors have reviewed their cases of neonatal obstructive malformations of the intestinal tract and analyzed the incidence of association with indirect hyperbilirubinemia. 39 patients in four years are considered. In 23 of them there is a bilirubin level greater than 5 mg/100 ml. A great number of high bilirubin levels (greater than 15 mg/100 ml) is associated with volvulus, malrotations and intestinal atresias. Bilirubin levels between 11 and 15 mg/100 ml are often connected with meconium ileus while ano-rectal atresias have a low bilirubin level (less than 5 mg/100 ml). The reported data allow to conclude that the jaundice is an early, but unfortunately, not specific symptom of congenital intestinal obstruction. The entero-hepatic circulation seems to be an important cause of the neonatal hyperbilirubinemia.

Quality indicators to detect pre-analytical errors in laboratory testing.

The identification of reliable quality indicators (QIs) is a crucial step in enabling users to quantify the quality of laboratory services. The current lack of attention to extra-laboratory factors is in stark contrast to the body of evidence pointing to the multitude of errors that continue to occur, particularly in the pre-analytical phase. The ISO 15189: 2012 standard for laboratory accreditation defines the pre-analytical phase, and recognizes the need to evaluate, monitor and improve all the procedures and processes in the initial phase of the testing cycle, including those performed in the phase of requesting tests and collecting samples, the so-called "pre-pre-analytical phase". Therefore, QIs should allow the identification of errors and non-conformities that can occur in all steps of the pre-analytical phase. Traditionally, pre-analytical errors are grouped into identification and sample problems. However, appropriate test requesting and complete request forms are now recognized as fundamental components in providing valuable laboratory services. The model of QIs developed by the Working Group of the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) includes indicators related to both identification and sample problems as well as all other pre-analytical defects, including those in test requesting and request forms. It, moreover, provides the framework (with objective criteria) necessary for promoting the harmonization of available QIs in the pre-analytical phase.

Audit in laboratory medicine.

Laboratory medicine is at a crossroads that provides great opportunities to improve the efficacy of the service and its role in healthcare. Many of the new roles for laboratory staff will be outside the boundaries of the traditional laboratory. These roles include increased emphasis on consultative activities, participation in interdisciplinary teams, and efforts to assure appropriate test utilization. Audit in laboratory medicine may be defined as a process of review and assessment of laboratory performance, and its purpose should be to improve patient care by enhancing laboratory performance and making better use of resources. Here we discuss the rationale of audit in laboratory medicine, its goals as well as its topics. The suggested conduct for an audit and the involvement of personnel are also reviewed.

Dexamethasone does not affect vasopressin release in bronchopulmonary dysplasia.

Elevated levels of vasopressin (AVP) have been found in premature infants with bronchopulmonary dysplasia (BPD), and may be related to abnormalities of water handling, and to non-pulmonary signs of edema. Dexamethasone treatment improves pulmonary function in infants with BPD, and is frequently associated with a significant increase in diuresis and a decrease in weight gain. To determine whether this diuresis is primarily the result of AVP inhibition (potentially induced by steroid treatment), we measured endogenous AVP levels in nine premature babies with BPD [birth weight 802 +/- 141 (SD) g; gestation 26 +/- 2 weeks, age 26 +/- 17 days], before initiation, and 3 and 7 days after the start of dexamethasone therapy (0.5 mg/kg/day). All study infants required mechanical ventilation, and none was receiving diuretics or cardiac inotropes during the study. Results indicated that premature infants with BPD have functionally unmodified AVP levels after 3 and 7 days of dexamethasone therapy (pre-dexamethasone 5.9 +/- 2.1 ng/l vs post-dexamethasone 7.0 +/- 3.0 and 8.0 +/- 1.9 ng/l at 3 and 7 days, respectively). Pulmonary function improved with oxygenation indexes decreasing (pre-dexamethasone 14 +/- 7 vs post-dexamethasone 9 +/- 7 and 7 +/- 4 at 3 and 7 days, respectively). A concurrent reduction in weight gain occurred (pre-dexamethasone 12 +/- 10 g/kg/day vs post-dexamethasone 7 +/- 3 g/kg/day and 3 +/- 1.5 g/kg/day on days 3 and 7, respectively). These data suggest that the improvement in lung function with dexamethasone treatment for BPD in premature infants does not correlate with a diuresis that results from vasopressin inhibition, and potentially induced by dexamethasone.

Evoked potentials in pediatrics: economic audit.

In the present era of resource management, there is increasing emphasis on the need to make the best possible use of available resources. We therefore measured the productive factors directly involved in performance of 59 evoked potential examinations (brainstem auditory evoked potentials, BAEPs; flash visual evoked potentials, F-VEPs; and electroretinograms, ERGs) in different pediatric age groups. In order to ascertain the gap between the costs of instrumental examinations performed in our service on children and the fees reimbursed by the Italian national health service (NHS) a breakdown was made of the costs of tests and their scheduling in relation to the different age variables involved. It was found that the fees reimbursed do not cover the real costs, because they underestimate the actual consumption of resources. The findings recorded indicate that for pediatric tests the economic audit should be graded according to the ages of the children examined and should include an analysis of different test phases. The economic audit should also be considered a preliminary step in clinical audit. It is concluded that it is financially punitive to reimburse a pediatric service with a fee based on the examination of adults, because in pediatrics the variable "age" influences the duration and complexity of tests and also their interpretation.

Nocturnal enuresis in the adolescent: a neglected problem.

OBJECTIVE: To assess the features of adolescent bedwetters, as few data are available on enuresis in this age group. PATIENTS AND METHODS: A specific database for adolescents and young adults was created with the collaboration of various specialists (paediatricians, urologists, gynaecologists, psychiatrists). Questions focused on family and personal history, stressful events, age of attaining urinary and fecal control, characteristics of enuresis (primary vs secondary, monosymptomatic vs enuresis associated with daytime urinary symptoms), school performance, diagnostic examination and physical examinations, and treatment and its response. RESULTS: Data were collected from 107 enuretic adolescents (mean age 15.3 years, median 14, range 13-23; 63 males and 44 females). A positive family history for enuresis was recorded in 82%. Enuresis was primary in 79 patients (74%), secondary in 28 (26%), monosymptomatic in 76 (71%) and associated with daytime urinary symptoms in 31 (29%). In males monosymptomatic enuresis was significantly more frequent than in females (P < 0.01). Urinary tract infections were reported by 13 patients, all females; eating disorders (anorexia, polyphagia) were present in six. In 85 patients (80%) enuresis was considered severe (> or = three nights/week). Of the 107 patients, 27 (20%) had never consulted a doctor about their problem and 43 (40%) had received no therapy; 66 received desmopressin monotherapy, with a good response (half the number of wet nights) in 44 (79%). There was no relation between response to desmopressin and gender, age, type and severity of enuresis or positive family history of enuresis. Eight patients were provided with a nocturnal alarm but this was not tolerated by two. Altogether, 25 patients refused any therapy or did not comply with the given therapy. CONCLUSIONS: Enuresis can persist into adolescence and be a significant problem; 80% of these patients had severe enuresis and 31% also had associated daytime urinary symptoms, with 40% receiving no previous therapy. The treatment of enuresis can be particularly difficult at this age; 22% of patients did not respond to desmopressin and 23% had low compliance with the given therapy. Enuresis in adolescents requires further study; hopefully more enuretic children will receive adequate treatment before reaching adolescence.

Primary nocturnal enuresis and left-handedness.

To date, no previous studies have described the association between primary nocturnal enuresis and left-handedness. In our series of enuretic patients, the prevalence of left-handedness was significantly higher than the control group. These data suggest a new correlation which needs further investigation.