Endoscopic failure for foreign body ingestion and food bolus impaction in the upper gastrointestinal tract: an updated analysis in a European tertiary care hospital.

OBJECTIVE: Harmfulness of foreign body ingestion and food bolus impaction (FBIs) varies according to geographical area, population, habits, and diet. Therefore, studies may not draw generalizable conclusions. Furthermore, data regarding FBIs management in Europe are limited and outdated. This study aimed to analyze the endoscopic management and outcomes of FBIs in an Italian tertiary care hospital to identify risk factors for endoscopic failure. METHODS: We retrospectively reviewed patients who underwent upper gastrointestinal endoscopy for FBIs between 2007 and 2017. Baseline, clinical, FBIs, and endoscopic characteristics and outcomes were collected and reported using descriptive statistics and logistic regression analyses. RESULTS: Of the 381 endoscopies for FBIs, 288 (75.5%) were emergent endoscopy and 135 (35,4%) included underlying upper gastrointestinal conditions. The study population included 44 pediatric patients (11.5%), 54 prisoners (15.8%), and 283 adults (74.2%). The most common type and location of FBIs were food boluses (52.9%) and upper esophagus (36.5%), respectively. While eight patients (2.1%) developed major adverse events requiring hospital admission, the remainder (97.9%) were discharged after observation. No mortality occurred. Endoscopic success was achieved in 263 of 286 (91.9%) verified FBIs endoscopies. Endoscopic failure (8.04%) was associated with age, bone, disk battery, intentional ingestion, razor blade, prisoners, and stomach in the univariate analysis. Multivariate logistic regression revealed that intentional ingestion was associated with endoscopic failure (odds ratio: 7.31; 95% confidence interval = 2.06-25.99; P  = 0.002). CONCLUSION: Endoscopy for FBIs is safe and successful, with low hospital admission rate in children, prisoners, and adults. Intentional ingestion is a risk factor of endoscopic failure.

Glioblastoma: from volumetric analysis to molecular predictors.

BACKGROUND: Decades of therapeutic and molecular refinements, the prognosis of patients with glioblastoma (GBM) still remains unfavorable. Integrative clinical studies allow a better understanding of the natural evolution of GBM. To assess independent predictors of overall survival (OS) and progression free survival (PFS) clinical, surgical, molecular and radiological variables were evaluated. A novel preoperative volumetric magnetic resonance imaging (MRI) Index for tumor prognosis in GBM patients was investigated. METHODS: A cohort of 195 cases of patients operated for newly GBM were analyzed. Extent of tumoral resection (EOR), tumor growth pattern, expressed by preoperative volumetric ΔT1-T2 MRI Index, molecular markers such as O6-methylguanine-DNA methyltransferase (MGMT) methylation and isocitrate dehydrogenase 1/2 (IDH1/2) mutation, were analyzed. Analysis of survival was done using Cox-proportional hazard models. RESULTS: The 1-, 2- years estimated OS and PFS rate for the whole population were 61% and 27%, 38% and 17%, respectively. A better survival rate, both in terms of survival and tumor progression, was observed in patient with higher EOR (P=0.000), younger age (P=0.000), MGMT methylation status (P=0.001) and lower preoperative ΔT1-T2 MRI Index (P=0.004). Regarding the tumor growth pattern a cut-off value of 0.75 was found to discriminate patient with different prognosis. Patients with a preoperative ΔT1-T2 MRI Index <0.75 had a 1-year estimated OS of 67%, otherwise patients with a preoperative ΔT1-T2 MRI Index >0.75 had a 1-year estimated OS of 34%. CONCLUSIONS: In this investigation longer survival is associated with younger age, EOR, promoter methylation of MGMT and preoperative tumor volumetric features expressed by ΔT1-T2 MRI Index The preoperative ΔT1-T2 MRI Index could be a promising prognostic factor potentially useful in GBM management. Future investigations based on multiparametric MRI data and next generation sequences analysis, may better clarify this result.

Fattori che influenzano lo screening nutrizionale nei pazienti ricoverati in ospedali per acuti: un'indagine di prevalenza regionale (2017).

BACKGROUND: the prevalence of malnutrition among hospitalized patients varies between 19.8% and 50%, with approximately 31% of all hospital patients considered malnourished or at nutritional risk, both in European and in Italian hospitals. Nutritional screening is necessary to identify nutrition-related problems, but it is not largely performed at the admission or during hospitalization. OBJECTIVES: to identify factors associated with the probability of performing nutritional screening during hospitalization and to describe BMI among inpatients in acute facilities of Friuli Venezia Giulia (FVG) Region (Northern Italy). DESIGN: point prevalence survey. SETTING AND PARTICIPANTS: the study was conducted in all the 18 hospitals of the FVG regional healthcare system; 58 trained surveyors collected data from 2nd to 30th October 2017. MAIN OUTCOME MEASURES: weight and height, presence of parenteral and enteral nutrition data of 2,553 patients were collected. RESULTS: BMI was determinable for 77.2% of people under study. Negative predictors for BMI screening were: spoke hospital (p<0.001), age over 65 years (p=0.005), both 'ultimately fatal' (p<0.001) and 'rapidly fatal' (p<0.001) McCabe score, presence of minimally invasive surgery (p=0.02); major surgery was a positive predictor (p<0.001). Prevalence of parenteral and enteral nutrition prescription was 4.0% and 3.6%, respectively; statistical differences were found according to care units and McCabe score (p<0.001). CONCLUSIONS: globally, BMI for inpatients in the surveyed hospitals is often assessed, but more investigations are needed to understand the reasons why the reported differences exist.

Multimodal integrated approaches in low grade glioma surgery.

Surgical management of Diffuse Low-Grade Gliomas (DLGGs) has radically changed in the last 20 years. Awake surgery (AS) in combination with Direct Electrical Stimulation (DES) and real-time neuropsychological testing (RTNT) permits continuous intraoperative feedback, thus allowing to increase the extent of resection (EOR). The aim of this study was to evaluate the impact of the technological advancements and integration of multidisciplinary techniques on EOR. Two hundred and eighty-eight patients affected by DLGG were enrolled. Cases were stratified according to the surgical protocol that changed over time: 1. DES; 2. DES plus functional MRI/DTI images fused on a NeuroNavigation system; 3. Protocol 2 plus RTNT. Patients belonging to Protocol 1 had a median EOR of 83% (28-100), while those belonging to Protocol 2 and 3 had a median EOR of 88% (34-100) and 98% (50-100) respectively (p = 0.0001). New transient deficits with Protocol 1, 2 and 3 were noted in 38.96%, 34.31% and 31,08% of cases, and permanent deficits in 6.49%, 3.65% and 2.7% respectively. The average follow-up period was 6.8 years. OS was influenced by molecular class (p = 0.028), EOR (p = 0.018) and preoperative tumor growing pattern (p = 0.004). Multimodal surgical approach can provide a safer and wider removal of DLGG with potential subsequent benefits on OS. Further studies are necessary to corroborate our findings.

Critical Involvement of Calcium-Dependent Cytosolic Phospholipase A2α in Aortic Valve Interstitial Cell Calcification.

The involvement of calcium-dependent cytosolic phospholipase A2α (cPLA2α) in aortic valve calcification is not exhaustively elucidated. Here, cPLA2α expression in aortic valve interstitial cell (AVIC) pro-calcific cultures simulating either metastatic or dystrophic calcification was estimated by qPCR, Western blotting, and counting of cPLA2α-immunoreactive cells, with parallel ultrastructural examination of AVIC calcific degeneration. These evaluations also involved pro-calcific AVIC cultures treated with cPLA2α inhibitor dexamethasone. cPLA2α over-expression resulted for both types of pro-calcific AVIC cultures. Compared to controls, enzyme content was found to increase by up to 300% and 186% in metastatic and dystrophic calcification-like cultures, respectively. Increases in mRNA amounts were also observed, although they were not as striking as those in enzyme content. Moreover, cPLA2α increases were time-dependent and strictly associated with mineralization progression. Conversely, drastically lower levels of enzyme content resulted for the pro-calcific AVIC cultures supplemented with dexamethasone. In particular, cPLA2α amounts were found to decrease by almost 88% and 48% in metastatic and dystrophic calcification-like cultures, respectively, with mRNA amounts showing a similar trend. Interestingly, these drastic decreases in cPLA2α amounts were paralleled by drastic decreases in mineralization degrees, as revealed ultrastructurally. In conclusion, cPLA2α may be regarded as a crucial co-factor contributing to AVIC mineralization in vitro, thus being an attractive potential target for designing novel therapeutic strategies aimed to counteract onset or progression of calcific aortic valve diseases.

Cognitive Functions in Repeated Glioma Surgery.

Low-grade gliomas (LGG) are slow-growing brain tumors infiltrating the central nervous system which tend to recur, often with malignant degeneration after primary treatment. Re-operations are not always recommended due to an assumed higher risk of neurological and cognitive deficits. However, this assumption is relatively ungrounded due to a lack of extensive neuropsychological testing. We retrospectively examined a series of 40 patients with recurrent glioma in eloquent areas of the left hemisphere, who all completed comprehensive pre- (T3) and post-surgical (T4) neuropsychological assessments after a second surgery (4-month follow up). The lesions were most frequent in the left insular cortex and the inferior frontal gyrus. Among this series, in 17 patients the cognitive outcomes were compared before the first surgery (T1), 4 months after the first surgery (T2), and at T3 and T4. There was no significant difference either in the number of patients scoring within the normal range between T3 and T4, or in their level of performance. Further addressing the T1-T4 evolution, there was no significant difference in the number of patients scoring within the normal range. As to their level of performance, the only significant change was in phonological fluency. This longitudinal follow-up study showed that repeated glioma surgery is possible without major damage to cognitive functions in the short-term period (4 months) after surgery.

A Novel Comprehensive Clinical Stratification Model to Refine Prognosis of Glioblastoma Patients Undergoing Surgical Resection.

Despite recent discoveries in genetics and molecular fields, glioblastoma (GBM) prognosis still remains unfavorable with less than 10% of patients alive 5 years after diagnosis. Numerous studies have focused on the research of biological biomarkers to stratify GBM patients. We addressed this issue in our study by using clinical/molecular and image data, which is generally available to Neurosurgical Departments in order to create a prognostic score that can be useful to stratify GBM patients undergoing surgical resection. By using the random forest approach [CART analysis (classification and regression tree)] on Survival time data of 465 cases, we developed a new prediction score resulting in 10 groups based on extent of resection (EOR), age, tumor volumetric features, intraoperative protocols and tumor molecular classes. The resulting tree was trimmed according to similarities in the relative hazard ratios amongst groups, giving rise to a 5-group classification tree. These 5 groups were different in terms of overall survival (OS) (p < 0.000). The score performance in predicting death was defined by a Harrell's c-index of 0.79 (95% confidence interval [0.76-0.81]). The proposed score could be useful in a clinical setting to refine the prognosis of GBM patients after surgery and prior to postoperative treatment.

Efficacy and Safety of Trabeculectomy Versus Nonpenetrating Surgeries in Open-angle Glaucoma: A Meta-analysis.

PURPOSE: The purpose of this study was to conduct a meta-analysis on the efficacy and safety of trabeculectomy (TE) and nonpenetrating glaucoma surgery (NPGS) techniques in patients with primary open-angle glaucoma, pseudoexfoliation glaucoma, pigmentary glaucoma, and normal-tension glaucoma. METHODS: All studies were identified by searching electronic sources (PubMed, Medline, Scopus, and Embase) until February 5, 2018. Primary outcome was mean intraocular pressure (IOP) reduction at 6, 12, and 24 months. Complications, number of antiglaucomatous medications, and visual outcomes were also evaluated. RESULTS: Twenty-one studies were included. Ten studies compared TE with deep sclerectomy (DS), 5 with viscocanalostomy (VC), 1 study with both DS and VC, and 5 with canaloplasty (CP). TE was superior to DS, VC, and CP in reducing IOP at 6 and 12 months, and to DS at 24 months. When comparing TE to VC and to CP at 24 months, there was no significant difference in IOP reduction. Hypotony, choroidals, anterior chamber shallowing or flattening, and cataract formation or progression were more associated with TE than with NPGSs. TE was more effective in reducing antiglaucomatous medications than VC and CP. CONCLUSIONS: TE is more effective in reducing IOP. TE presents a higher risk of complications as compared with NPGS, except for hyphema.

A Prospective Accuracy Study of Prostate Imaging Reporting and Data System Version 2 on Multiparametric Magnetic Resonance Imaging in Detecting Clinically Significant Prostate Cancer With Whole-mount Pathology.

OBJECTIVE: To assess the accuracy of Prostate Imaging Reporting and Data System version 2 (PI-RADS v2) in detecting clinically significant prostate cancer (csPCa) on multiparametric magnetic resonance imaging (mpMRI) using whole-mount sections after radical prostatectomy (RP) as reference standard. METHODS: Forty-eight patients undergoing mpMRI before RP were prospectively enrolled. Two experienced radiologists independently scored and mapped imaging findings according to PI-RADS v2. One experienced uropathologist mapped cancers detected on whole-mount sections using the PI-RADS v2 sector scheme. Per-lesion and per-patient analyses were run. Primary outcomes were sensitivity and false discovery rate (FDR) in detecting csPCa using PI-RADS v2 score ≥3 and ≥4 as thresholds. Secondary outcome was inter-reader agreement. RESULTS: On the per-lesion analysis, sensitivity and FDR at the PI-RADS v2 threshold score ≥3 were 0.75 and 0.17 for Reader 1, and 0.67 and 0.13 for Reader 2, respectively. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower, and FDR nearly halved for both readers. On the per-patient analysis, sensitivity for csPCa at the PI-RADS v2 threshold score ≥3 was 0.85 for Reader 1, and 0.78 for Reader 2. At the PI-RADS v2 threshold score ≥4, sensitivity was slightly lower for both readers. Inter-reader agreement was substantial (k 0.72 and 0.65 for PI-RADS v2 threshold score ≥3 and ≥4, respectively). CONCLUSION: In our prospective study with pathology after RP as standard of reference, PI-RADS v2 showed good sensitivity in detecting csPCa on mpMRI with substantial agreement between 2 experienced readers. Threshold score ≥4 had lower FDR.

"Dark corridors" in 5-ALA resection of high-grade gliomas: combining fluorescence-guided surgery and contrast-enhanced ultrasonography to better explore the surgical field.

BACKGROUND: Increasing the extent of resection (EOR) is considered a main goal in high grade glioma (HGG) surgery. Significant advancements have been recently made to assist surgery: namely the use of 5-aminolevulinic acid (5ALA) and the application of contrast-enhanced ultrasound (CEUS) embody two of the most recently introduced tools in the neuro-oncology field. A combined approach including the two techniques has been suggested in literature. Our primary aim is to identify in which conditions CEUS final survey has a real impact in a 5-ALA guided context and assess which preoperative tumor characteristics, with specific attention to working corridors can predict strains of the fluorescence guided procedure and hence recommend the use of the combined technique. METHODS: Forty-nine HGG glioma surgeries were performed at our institution with the abovementioned protocol between January 2016 and June 2016. Based on preoperative MRI, we stratified glioma characteristics according to three determinants: localization (deep versus superficial), size (<3.5 versus >3.5 cm) and shape (regular versus irregular). RESULTS: CEUS modified 5-ALA guided resection in 11 cases (22.45%): this appeared to be associated with statistically significance to deep tumor localization (P=0.04) and irregular/multi-lobulated margins (P=0.003). On the other hand, tumor size alone did not appear as a statistically significant determinant. CONCLUSIONS: When dark corridors are presents or when overlying brain parenchyma hinders illumination, drawbacks to the 5-ALA assistance can be expected, hence CEUS final survey has a crucial role of 'refinement'. In those selected cases, an integrated 5ALA+CEUS protocol was shown as advisable in EOR improvement.

An easy, prompt and reproducible methodology to manage an unexpected increase of incident reports in surgery theatres.

OBJECTIVES: Surgery is a high-risk hospital area for adverse events (AEs) occurrence. This study aims to develop an effectiveness and reactive methodology to manage an unexpected increase of AEs in the operating rooms (ORs) of a large Academic Hospital providing about 30 000 surgeries per year. METHODS: The study included three phases: 1. analysis of the AEs collected through the hospital incident reporting system from 2014 to 2015; 2. development of a programme to improve the surgical patient's safety and 3. application and evaluation of the programme effectiveness. RESULTS: In 2014, all hospital AEs were 825 (10.3% in ORs), while in the first 5 months of 2015, they were 645 (17.7% in ORs) [relative risk (RR) 2015 vs 2014=1.7; 95% CI=1.3 to 2.2; p<0.0001] with two sentinel events. Due to this increase, 177 real-time observations were planned in 12 ORs with external staff (n.25) during 1 week in June, July and November 2015 using a checklist with 14 items related to the patient's pathway (surgical site, time-out, medical records and sponges count). After the observations, the AEs decreased from 11.4×1000 surgeries (January-June 2015) to 8.6×1000 (July-December 2015) (RR=0.7, 95% CI=0.6 to 0.9, p<0.05). Compliance to the correct procedures applied by ORs staff has improved during the year for all items. CONCLUSIONS: The methodology of this study has been revealed effective to control an unexpected increase in AEs and to improve the healthcare workers' adherence to correct procedures and it could be translated in other patients' safety settings.