Epidemiological surveillance of West Nile neuroinvasive diseases in Italy, 2008 to 2011.

We describe the geographical and temporal distribution of West Nile neuroinvasive diseases (WNND) cases in Italy from 2008 to 2011. The increasing number of confirmed human cases from eight in 2008 to 18 in 2009 and the occurrence of the virus in a larger geographical area in 2009 (moving from east to west) prompted the Ministry of Health to publish, in spring 2010, a national programme for WNND human surveillance, comprising veterinary and vector surveillance. Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (chikungunya, dengue and West Nile disease) was issued. Between 2008 and 2011, 43 cases of WNND were reported from five regions in Italy with a case fatality rate of 16%. The incidence of WNND during the entire study period was 0.55 per 100,000 population (range: 0.06­0.23 per 100,000). During 2011, two new regions (Friuli-Venezia Giulia and Sardinia) reported confirmed cases in humans. Integrated human, entomological and animal surveillance for West Nile virus is a public health priority in Italy and will be maintained during 2012.

Does clonidine 50 microg improve cervical plexus block obtained with ropivacaine 150 mg for carotid endarterectomy? A randomized, double-blinded study.

STUDY OBJECTIVE: To evaluate the effects of adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block in patients undergoing elective carotid endarterectomy (TEA). DESIGN: Randomized, double-blind study. SETTING: Departments of Anesthesia and Vascular Surgery of a university hospital. PATIENTS: 40 ASA physical status II and III patients undergoing elective TEA during superficial cervical plexus block. INTERVENTIONS: Superficial cervical plexus block was placed using 20 mL of 0.75% ropivacaine alone (Ropi group, n = 20) or with the addition of 50 microg clonidine (Ropi-Clonidine group, n = 20). If required, analgesic supplementation was given with local infiltration with 1% lidocaine and intravenous fentanyl (50-microg boluses). Nerve block profile, need for intraoperative analgesic supplementation, and time to first analgesic request were recorded. MEASUREMENTS AND MAIN RESULTS: Median (range) onset time was 10 minutes (5-25 min) in the Ropi group and 5 minutes (5-20 min) in the Ropi-Clonidine group (P < 0.05). Intraoperative consumption of both 1% lidocaine and fentanyl was higher in patients of the Ropi group (15 mL [0-25 mL] and 250 microg [50-300 microg]) than in patients of the Ropi-Clonidine group (8 mL [0-20 mL] and 0 microg [0-150 microg]; P < 0.05 and P < 0.05, respectively). First postoperative analgesic request occurred after 17 hours (10-24 hrs) in the Ropi group and 20 hours (10-24 hrs) in the Ropi-Clonidine group (P > 0.05). CONCLUSIONS: Adding 50 microg clonidine to 150 mg ropivacaine for superficial cervical plexus block shortened the onset time and improved the quality of surgical anesthesia in patients undergoing elective TEA.

Heterotopic mesenteric ossification ('intraabdominal myositis ossificans'): report of five cases.

Intraabdominal heterotopic ossification is a very uncommon disorder. We report five new cases, review the previous literature, and discuss the clinical and pathologic features of these lesions. The clinical features of the current cases and of those previously reported are remarkably similar. All patients were middle-aged to elderly men (range, 43-80 years; mean, 61 years) who had small bowel obstruction associated with heterotopic bone formation in the small bowel mesentery, often after one or more abdominal operations. In one case, an initial diagnosis of extraosseous osteosarcoma was considered. This unusual reactive process shares many of the clinical and pathologic features of myositis ossificans, as classically described in somatic soft tissues. We propose to designate this condition heterotopic mesenteric ossification.

Hepatic artery aneurysm: an ever present danger.

Hepatic artery aneurysms are infrequent vascular lesions, difficult to diagnose preoperatively manifesting themselves usually by acute rupture. We report our experience in both diagnosis and surgical treatment of 3 cases. The selective angiograph of the celiac tripod and of superior mesenteric artery, is an indispensable means able, not only to put forward a certain diagnosis, but also to supply precious notions on the possibilities of compensation on the side of the collateral circle and of consequence, to suggest operative tactics. Surgical management may range from the simple binding to the reconstruction of the hepatic arterial axis by means of prosthesis grafts and if possible to the simple excision and termino-terminal regraft.

Neuropathy as the only symptom of common carotid artery spontaneous rupture. Case report.

We describe a case of a false aneurysm of the common carotid artery, caused by spontaneous carotid rupture, with atypical clinical presentation. The patient came to the our Hospital complaining of left shoulder pain and functional impairment of her left arm, during the past 20 days. The diagnostic work-up, color Doppler ultrasound, MR and angiography, evidenced a cervical false aneurysm; the electromyography showed denervation of the deltoid muscle, caused by cervical nerve roots compression. The therapeutic stages were initially an endovascular stent placement; then a surgical stage with evacuation for the hematoma and reconstruction of the carotid artery with saphenous graft.

Some questions about Eurocollins solution used for lung preservation.

Currently, Eurocollins' (EC) solution (high-potassium concentration) is the most widely clinically used pulmonary perfusate. However, recently, experimental studies have reported an increase of the lung ischemic period using low-potassium solutions. The purpose of our study, is to investigate the influence of the EC ionic composition and the effect of hyperosmolarity due to the glucose concentration on isolated alveolar type II epithelial cells. Pneumocytes type II were isolated from pathogen free Wistar rats using the modified Dobbs' method. Cells were incubated for 6 hours at 4 degrees C in EC, Collins (CL) and Ringer Lactate (RL) solutions. After that, cellular viability was evaluated by analysis of the protein synthesis assay by measuring the 35 S methionine uptake during an incorporation period of one hour at 37 degrees C (picomol 35 S met/mg proteins/h). Mean +/- standard deviation and Student "t"-test were used for data presentation and results comparison. Cellular viability at time 0 (control) before cellular incubation was 3.93 +/- 0.38. After 6 hours at 4 degrees C the results were respectively as follows: EC = 2.16 +/- 0.13; CL = 2.63 +/- 0; RL = 3.21 +/- 0.04. Our results suggest that the low-potassium extracellular type solution (RL) shows a protection on isolated type II epithelial cells statistically significant (p < 0.05) if compared with EC solution. Moreover CL solution, that has the same ionic composition EC but without glucose, presents a less cytotoxic effects on incubated cells than EC, confirming a deleterious influence of solution hyperosmolarity.

A new extracellular type solution for lung preservation: "in vitro" comparison with Beltzer, low potassium Dextran and Euro-Collins solutions by means of human lung fibroblasts.

UNLABELLED: The attempt to synthesise efficacious solution to prolong lung preservation is, at present one of the most interesting challenges in transplant research. Recently, several issues emphasise the central role of ionic composition of lung-flush solutions, underlining, however, that colloid-free solutions are clearly detrimental. We have been studying a complex extracellular type solution (SPAL UP) synthesised to minimise the pathological events that occur during both preservation and reperfusion period. We report the results of toxicity of SPAL UP on normal human fibroblasts obtained from foetal lung (WI-38). WI-38 cells were seeded at 1.4 x 10(4)/cm2 in disposable plastic 12-well plates. After 3 days, cells were incubated in SPAL UP, Beltzer (UWS), Low Potassium Dextran (LPD) and Eurocollins (ECS) solutions for 6 hours at 10 degrees C. Cellular viability was evaluated by the rate of protein synthesis exploiting the incorporation of 35S-Methionine (2 microCi/ml) in growth medium with 10 mM unlabelled Methionine during 30 minutes incubation at 37 degrees C. The results were expressed as nmol. 35S-Methionine/mg of proteins/minute, and presented as means +/- SD of data of three (n = 3) well for each solution studied. RESULTS: the viability at time 0 before incubation (considered as control) was 1.65 +/- 0.1; after hypothermic preservation the data were respectively as follow: SPAL UP 0.51 +/- 0.09; UW 0.24 +/- 0.02; ECS 0.19 +/- 0.01; LDP 0.19 +/- 0.05. CONCLUSIONS: in this "in vitro" model SPAL UP solution provides a significantly (p < 0.05) better cell preservation than regular UW, ECS and LPD solutions.

A multicentre study on LMW-heparin effectiveness in preventing postsurgical thrombosis.

A multicentric study was carried out involving six italian departments of general surgery to assess the efficacy of a low molecular weight (LMW) heparin called Fluxum compared to standard calcium heparin in low doses for prevention of postoperative thromboembolic complications (deep vein thrombosis and pulmonary embolism). 610 patients were treated; 308 (50.5%) of whom were treated with Fluxum at doses of 4,000 or 8,000 I.U. Axa once a day by subcutaneous injection and 302 (49.5%) with heparin calcium at doses of 5,000 I.U. two or three times a day by subcutaneous injection. We observed a total of 29 deep vein thrombosis (4.7%); 10 (3.2%) from the group treated with LMW heparin and 19 (6.3%) from the comparative group. During the study 4 (0.65%) pulmonary embolism were found, 1 (0.32%) in the group treated with LMW heparin and 3 (1%) in the group treated with calcium heparin. None serious hemorrhagic accident was reported during the study. The antithrombotic prophy laxis carried out with Fluxum was on the whole better tolerated than the treatment of the other group, registering a lower frequency of hematomas at the injection and surgical wound sites.

[Traumatic chylothorax. A further indication for total parenteral nutrition]. / II chilotorace traumatico. Una ulteriore indicazione alla nutrizione parenterale totale.

Successful and rapid resolution of a serious cases of traumatic chylothorax by means of conservative management with TPN is reported. This method is clearly indicated as a mean of making up the calorie and amino acid need when litres of chyle are being lost every day. In addition, by resting the digestive tract it brings about a massive decrease in the production of lymph in the mesenteric district and thus leading to easier and earlier sufficiency of the collateral lymph drainage routes. The rapid decrease in quantity and the change over from chylous to serous chest drainage liquid after TPN are evidence of its soundness. An immediate lymphographic control revealed complete section of the duct. Two months later, collateral diaphragmatic and azygos circulation was observed. It is felt, therefore, that TPN extends the range of conservative management of posttraumatic and postoperative chylothorax.

[A middle esophageal ring]. / L'anello esofageo medio.

The Authors, having observed a case of middle oesophageal web giving rise to severe dysphagia, discuss the aetiopathogenesis, the diagnosis and therapy of these rare oesophageal lesions. Because of its pathological feature, the reported case was succesfully treated by surgical resection of the ring, using a transthoracic approach.

[Surgical treatment of cancer of the pancreas]. / La terapia chirurgica del cancro del pancreas.

A series of 145 patients with cancer of the pancreas is presented. Radical surgery was performed in 23 cases. An assessment is made of anatomical and clinical factors likely to interfere with the results of surgery, particularly radical surgery. The mean survival after palliative operations was 5.5 months and after duodenocephalopancreatectomy 16.1 months. After resection, operative mortality as a whole was 21.6%, though in the last 5 years it had fallen to 8.8%. Actuarial survival after 1 yr was 56.3% and after 2 yr 18.8%. The average duration of the symptom picture was long due to the difficulty of making an early diagnosis. This has an adverse influence on the operability of cancer of the pancreas. On average, survival after resection was less in cases with infiltration of the lymph nodes, but not in those with extension of the neoplasia to neighbouring organs, such as the duodenum. The results of radical management were much the same as those reported in the literature and are regarded as unsatisfactory, even though better than those achieved with palliative surgery. Their improvement is discussed in the light of the technical features of duodenocephalopancreatectomy. It is felt that extensive lymphadenectomy is required and that this should be planned and performed in accordance with strict anatomical and surgical criteria.

[Reinterventions for arterial reconstruction in anastomotic aneurysm]. / I reinterventi di ricostruzione arteriosa per aneurismi anastomotici.

We reviewed our experience on the surgical treatment of anastomotic false aneurysms from 1979 through 1990: two groups of patients were identified. Group 1 (31 patients) included patients who had been previously operated on at our Institute and then routinely followed-up with physical examination and ultrasonographic studies. The incidence of anastomotic aneurysm in this group was 4.03%; the interval between insertion of the prosthesis and detection of the false aneurysm varied from 5 to 144 months, with a median interval of 58 month. The surgical treatment of choice (false aneurysm resection and graft interposition) has been successfully performed (97% of cases) without mortality. Group 2 (8 patients) included patients with complications of false aneurysm (emergency operations); in this group radical treatment was not always applicable; mortality and amputations rate were significantly increased (respectively 25% and 37%). We conclude that, after prosthetic reconstructions, only a careful long-term follow-up (also with use of ultrasonic and/or CT-scan studies) may allow reduction in morbidity and improvement in late survival.

[Infected aneurysms of the abdominal aorta. Personal case reports]. / Aneurismi infetti dell'aorta addominale. Casistica personale.

Two cases of infected aneurysms of the subrenal abdominal aorta observed in the last year are reported. In this study some specific aspects of this unusual pathology are analyzed: the high mortality rate, the difficulties involved in the diagnosis and the surgical solutions.

[Consumption coagulopathy associated with a case of an abdominal aortic aneurysm]. / Coagulopatia da consumo in associazione con un caso di aneurisma dell'aorta addominale.

Consumption coagulopathy with clinical symptoms reveals aortic arterial aneurysms in less than 5% of cases. The authors report a case of abdominal aortic aneurysm: surgical repair is able to remove the hemostasis abnormalities for a long time. Implications of the consumption coagulopathy are analyzed: diagnosis, preoperative correction of the coagulopathy, surgical technique.

[Pseudo-occlusions of the internal carotid artery]. / Le pseudo-occlusioni della carotide interna.

The pseudo-occlusion (P.O.) of the internal carotid artery is defined as an atheromatous lesion causing a high-grade stenosis, which describes a peculiar angiographic finding ("string sing" or "slim sign"). The authors report their experience with 6 P.O. (angiographically diagnosed) that had been found in 16 months. In all these cases, whenever there was a clinical e/or B-scan ultrasound suspect, angiographic recommendations for the detection of that lesion have been applied. One of these 6 patients, clinically asymptomatic, refused surgery, remaining asymptomatic for cerebral ischemia during the successive 16 months; angiographic control evidenced an unmodified P.O. The other 5 patients, clinically symptomatic, underwent surgical correction: in one, intraoperative finding was a total carotid occlusion. In the other 4 patients the P.O. was confirmed and an endoarterectomy has been done. No immediate or later complications have been noted (clinical and ultrasonographic average follow-up time was 12 months). The experience described by the authors leeds to some considerations: a) the carotid P.O. is not so rare; specially if adequate angiographic technique has been employed; b) the non-invasive studies could not reliably distinguish a P.O; c) intraoperative findings do not confirm, always, angiographic ones but a fibrous, chronic and totally occluded internal carotid artery; d) the evolution of P.O. in a complete carotid occlusion is very probable but not obligatory, and if this happens it needs long period of time; consequently the surgical correction of P.O. could be justified but not urgently; e) the surgical correction of the P.O. can be done without particular difficulty and its outcome is so similar to those obtained from the routine carotid surgery.

[A subclavian vein lesion due to the positioning of a chest tube via thoracostomy]. / Lesione della vena succlavia da posizionamento di drenaggio endopleurico per via toracotomica.

The authors describe an unusual complication of chest tube placement: subclavian vein lesion. After a literature review concerning complications of chest tube placement, the authors conclude that associated risks may be best minimized with a strict adherence to standardized technique and management protocol.

[An unusual case of a double location of arteriosclerotic aneurysms of the ulnar artery and anterior tibial artery]. / Un caso insólito de doble localización de aneurismas arterioscleróticos: arteria ulnar y arteria tibial anterior.

Multiple peripheral arteriosclerotic aneurysms are relatively rare. This is a report of a case of two arteriosclerotic aneurysms in unusual sites: ulnar artery and anterior tibial artery. Surgical treatment was: simple resection for the ulnar aneurysm; resection with restoration of arterial continuity for the tibial aneurysm.

Circulation of West Nile virus lineage 1 and 2 during an outbreak in Italy.

In 2011, from 26 September to 16 October, a small outbreak of West Nile virus (WNV) disease occurred on the island of Sardinia (Italy). According to the national case definition, six cases with acute neurological disease were confirmed in hospitalized patients, and four of them died; one of these was only 34 years old. In two case, WNV RNA was detected in urine, suggesting renal involvement. Sequence analysis showed lineage 1 and 2 circulation.