A prospective study comparing two methods of pre-hospital triage for trauma.

We conducted a prospective study comparing two different pre-hospital triage tools for trauma: the American College of Surgeons Committee on Trauma (ACS-COT) field triage decision scheme and the TRENAU score. The main objective was to evaluate which triage tool was more appropriate in the setting of Lombardy's trauma system. Data were collected from the population of trauma patients admitted to Niguarda hospital in Milan from January to June 2021. RStudio and Excel were used for data analysis. For each triage tool performance measures, Receiver Operating Characteristics (ROC) curves, and overtriage and undertriage rates were obtained. A total of 1439 injured patients admitted through 118 pre-hospital Emergency Medical Services (EMS) were included in the study. The ACS-COT triage tool showed a good accuracy but an excessive overtriage rate (59%). The TRENAU triage tool had a moderately good accuracy and a low overtriage rate (23%) while maintaining an acceptable undertriage rate (3.9%). The TRENAU triage tool proved to be efficient in optimizing the use of resources dedicated to trauma care while resulting safe for the injured patient. In a modern trauma system such as Lombardy's it would be more appropriate to adopt the TRENAU score over the ACS-COT field triage decision scheme.

Mediation of the Cardioprotective Effects of Mannitol Discovered, with Refutation of Common Protein Kinases.

The osmodiuretic agent Mannitol exerts cardioprotection against ischemia and reperfusion (I/R) injury when applied as a pre- and/or postconditioning stimulus. Previously, we demonstrated that these properties are mediated via the activation of mitochondrial ATP-sensitive potassium (mKATP) channels. However, considering Mannitol remains in the extracellular compartment, the question arises as to which receptor and intracellular signaling cascades are involved in myocardial protection by the osmodiuretic substance. Protein kinase B (Akt) and G (PKG), as part of the reperfusion injury salvage kinase (RISK) and/or endothelial nitric oxide (eNOS)/PKG pathway, are two well-investigated intracellular targets conferring myocardial protection upstream of mitochondrial potassium channels. Adenosine receptor subtypes have been shown to trigger different cardioprotective pathways, for example, the reperfusion injury. Further, Mannitol induces an increased activation of the adenosine 1 receptor (A1R) in renal cells conferring its nephroprotective properties. Therefore, we investigated whether (1) Akt and PKG are possible signaling targets involved in Mannitol-induced conditioning upstream of the mKATP channel and/or whether (2) cardioprotection by Mannitol is mediated via activation of the A1R. All experiments were performed on male Wistar rats in vitro employing the Langendorff isolated heart perfusion technique with infarct size determination as the primary endpoint. To unravel possible protein kinase activation, Mannitol was applied in combination with the Akt (MK2206) or PKG (KT5823) inhibitor. In further groups, an A1R blocker (DPCPX) was given with or without Mannitol. Preconditioning with Mannitol (Man) significantly reduced the infarct size compared to the control group. Co-administration of the A1R blocker DPXPC fully abolished myocardial protection of Mannitol. Interestingly and in contrast to the initial hypothesis, neither administration of the Akt nor the PKG blocker had any impact on the cardioprotective properties of Mannitol-induced preconditioning. These results are quite unexpected and show that the protein kinases Akt and PKG-as possible targets of known protective signaling cascades-are not involved in Mannitol-induced preconditioning. However, the cardioprotective effects of Mannitol are mediated via the A1R.

Infectious complications of extra-peritoneal pelvic packing in emergency room.

PURPOSE: The Extra-Peritoneal Pelvic Packing (EPP) is a procedure used in emergency conditions to control pelvic hemorrhage. This procedure can be performed in Emergency Room (ER) if the patient is too unstable to be transported into the operating room (OR), with a possible increased risk of infections linked to a less sterile environment. METHODS: All patients who underwent EPP from 2009 to 2018 were selected from the trauma registry. The patients were divided into two groups according to where EPP was performed (ER or OR). A Propensity Score Matching was realized. EPP was removed in all patients in the OR after obtaining hemodynamic stabilization within 24-48 h and surgical pads were sent to the laboratory for microbiological analysis. RESULTS: Eighty-four patients underwent EPP during the period of the study. After PSM, 26 couples of patients were selected. No differences were observed between the two groups in the development of pelvic infection. Patients managed in OR showed a higher rate of associated abdominal injuries (p = 0.027) and an increasing need for external fixation (p = 0,005) as well as an increased proportion of laparotomies (p = 0.023), orthopedic interventions (p = 0.005) and a higher systolic blood pressure on admission (p = 0.003). CONCLUSIONS: The EPP is a safe procedure, even when performed out of OR. The EPP in ER allows an earlier control of bleeding in patients in extremis. To minimize the risk of infection, EPP should be removed early, as soon as hemodynamics have been stabilized.

A genome-wide association study identifies an association between variants in EFCAB4B gene and periodontal disease in an Italian isolated population.

BACKGROUND AND OBJECTIVE: Periodontitis in one of the most prevalent dental diseases. Despite numerous studies have investigated its aetiopathogenetic factors, few works have focused on its genetic predisposition and most of them took into account only candidate genes. Therefore, we conducted a Genome Wide Association Study in an Italian isolated population aimed at uncovering genetic variants that predispose to this disorder. METHODS: Diagnosis of chronic periodontitis was made following the criteria of the American Academy of Periodontology. Patients with chronic periodontitis were grouped into different categories: slight, severe, localized and generalized. A control group composed by people without signs of periodontitis or gingivitis was defined. DNA was genotyped using 370k Illumina chips. Linear mixed model regression was used to test the association between each single nucleotide polymorphism (SNP) (independent variable) and the periodontitis status (dependent variable), controlling for confounders sex, age and smoking. The genomic kinship matrix was also used as random effect. RESULTS: Four SNPs on the gene EFCAB4B resulted significantly associated to localized periodontitis (P < 5 × 10-8 ), with the best hit on the rs242016 SNP (P = 1.5 × 10-8 ). CONCLUSION: We have identified a novel significant association between the EFCAB4B gene and localized periodontitis. These results open a new perspective in the understanding of genetic factors contributing to this common disorder.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis.

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis.

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of "high risk" patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Predicting haemorrhage in pre-hospital traumatic patients: evaluation of the novel heart-to-arm time index.

BACKGROUND: Early recognition of hypovolaemia in trauma patients is very important. However, the most often used clinical signs, such as hypotension and tachycardia, lack specificity and sensitivity. METHODS: We propose a non-invasive index of hypovolaemia, the heart to arm time (iHAT), based on a modified pulse transit time indexed to heart rate. Pulse transit time is the sum of pre-ejection period and vascular transit time. Following pre-load reductions due to hypovolaemia, ventricular diastolic filling time increases causing an increase in pre-ejection-period, pulse transit time, and hence iHAT. One hundred and four consecutive patients with suspected major trauma were enrolled. The primary aim was to evaluate the use of the iHAT for detecting haemorrhage in major trauma. The secondary end point was to compare the specificity and sensitivity of iHAT compared to commonly used indexes. RESULTS: iHAT was calculated in 84 subjects, 11 of whom were haemorrhagic. iHAT discriminated haemorrhagic from non-haemorrhagic group (46.8% vs. 66.9%, P < 0.0001). The cut-off for iHAT with the best compromise between sensitivity (90.9%) and specificity (100%) was reached at the 58.78% level. Comparing haemorrhagic and non-haemorrhagic patients, the area under the ROC curve was 0.952 for iHAT, 0.835 for heart rate, and 0.911 for systolic blood pressure, showing no significant differences. CONCLUSIONS: iHAT is a non-invasive index that can identify haemorrhage in trauma patients with high sensitivity and specificity. These data should be considered as an exploration, but any conclusion should be validated in a new set of consecutive patients.

The IOL-Vip System: a double intraocular lens implant for visual rehabilitation of patients with macular disease.

PURPOSE: To investigate the efficacy of a new surgical and rehabilitative procedure designed to improve vision in patients with central scotoma due to macular diseases. DESIGN: Case series of 40 consecutive surgical and rehabilitative procedures. PARTICIPANTS: Forty eyes of 35 consecutive patients with a stable central scotoma due to macular disease underwent phacoemulsification cataract surgery with the implant of the IOL-Vip System. METHODS: The IOL-Vip System consists of a biconcave high minus-power intraocular lens (IOL) in the capsular bag and a biconvex high plus-power IOL in the anterior chamber, reproducing an intraocular Galilean telescope with x1.3 magnification for distance. Selection of the candidate patients was carried out by means of a low-vision diagnostic and rehabilitative program (IOL-Vip software) that evaluates the residual visual function of patients and prognosis for visual improvement based on simulation of the postoperative condition. The software also designs the rehabilitation strategies based on preoperative and postoperative training of the preferred retinal locus. MAIN OUTCOME MEASURES: Best-corrected visual acuity (BCVA), evaluated by means of the Early Treatment Diabetic Retinopathy Study charts and procedure; reading magnification; and reading distance. RESULTS: All patients showed an improvement of visual acuity (VA) due to the surgical and rehabilitative procedure, confirming or exceeding the preoperative expected results. Mean postoperative BCVA was 0.77 (logarithm of the minimum angle of resolution), compared with 1.28 preoperatively. The mean postoperative best reading magnification gain was x6.2, and the mean postoperative reading distance gain was 7.66 cm. No cases of intraoperative or postoperative complications were detected, and the implant was subjectively well tolerated in both monocular and binocular procedures. CONCLUSION: In this pilot study, the IOL-Vip System was shown to be effective and apparently well tolerated in improving the vision of patients with macular disease. Best-corrected VA, reading magnification, and reading distance improved in all cases of this low-vision patient series.

Laparoscopic splenectomy: A retrospective review of 75 cases.

Laparoscopic splenectomy (LS) is considered a safe procedure for spleens of normal size as well as for larger spleens. Seventy-five consecutive patients underwent LS. Splenomegaly was defined by diameter >15 cm and by weight >400 g. Thirty patients had splenomegaly. The outcomes with spleens <15 cm and spleens >15 cm were compared. LS was successfully completed in 73 cases (97.4%). Spleens >15 cm required longer operating time and were associated with greater blood loss (P < 0.001), longer hospital stay, and more complications. Two patients needed blood transfusion. No overwhelming postsplenectomy infection was registered, and operative mortality was zero.

Laparoscopic treatment of sigmoid diverticulitis: a retrospective review of 103 cases.

BACKGROUND: Laparoscopic treatment of sigmoid diverticulitis is commonly accepted in Hinchey cases I and II, whereas it is debated in the case of purulent peritonitis, and not indicated for fecal peritonitis. METHODS: A single-center experience of 103 patients treated for Hinchey I-III sigmoid diverticulitis was reviewed. One-stage laparoscopic resection and primary anastomosis constituted the planned procedure. Abscesses in patients with Hinchey IIa were drained percutaneously before surgery. Patients with Hinchey III underwent surgery in emergency. A four-trocar approach with left iliac fossa minilaparotomy was used. Fistulas were treated laparoscopically with Harmonic Scalpel dissection. RESULTS: Laparoscopic treatment was successfully completed for 100 patients. Intraoperative complications occurred in 2.9% of the cases. Postoperative procedure-related morbidity was 8%, occurring mainly in Hinchey I patients. A longer hospital stay was recorded among Hinchey IIb patients treated for colovescical fistula. No mortality was observed. CONCLUSIONS: Laparoscopic surgery for sigmoid diverticulitis in experienced hands can be a safe and effective gold standard procedure also for patients with fistula or purulent peritonitis.

[Smooth-muscle-cell tumors of the gastroenteric tract. A review of cases]. / I tumori a cellule muscolari lisce del tratto gastroenterico. Revisione casistica.

Smooth muscle tumors of the gastrointestinal tract are difficult to evaluate and to stage. Twenty-four patients surgically treated during the last ten years have been evaluated using a TGM staging to identify the more rational criteria for the therapeutic choice. Six gastric leiomyomas, 1 ileal leiomyoma, 4 gastric leiomyosarcomas, 1 esophageal leiomyosarcoma, 4 ileal leiomyosarcomas, 2 rectal leiomyosarcomas and 6 gastric leiomyoblastomas were included. 62.5% of cases presented acute clinical features. Preoperative histological diagnosis was adequate in 29% of cases. We performed 7 excisions, 6 gastric subtotal resections, 3 total gastrectomies, 1 esophageal resection, 5 ileal resections, 2 rectal low anterior resection. Fourteen patients were staged I/II, 8 staged III and 2 staged IV. The overall median survival time was 27.5 months (56, 20 and 5 months concerning stage I/II, III and IV respectively; p < 0.01). In relation to T and G factors overall survival was statistically significant. TGM staging was highly significant to predict long-term survival. Radical surgical procedure was highly effective to guarantee long-term survival. Extended follow up is requested because recurrences after many years seem to be possible also with low histologic grade at first presentation.

Complement activation and polymorphonuclear neutrophil leukocyte elastase in sepsis. Correlation with severity of disease.

Complement activation is necessary for an adequate immune and inflammatory response to infections. Activation releases anaphylatoxins that cause vasodilation, increase vascular permeability, and trigger release of polymorphonuclear neutrophil leukocyte (PMN) lysosomal enzyme and oxygen radicals. Under normal circumstances, an orderly progression of such events has a beneficial antimicrobial effect. The same mechanism, however, when uncontrolled, may damage host tissues. To provide information about the clinical importance of such events in sepsis, different complement parameters (C3, C4, and the desarginated forms of C3a [C3a(des)-Arg] and C5a [C5a(des)-Arg]), PMN elastase, and malondialdehyde (a by-product of membrane peroxidation by oxygen radicals) were measured daily in 26 septic patients and correlated with two objectively assessed and previously validated severity scores (acute physiology and chronic health evaluation [APACHE II] and Sepsis Severity Score [SSS]). Nonsurvivors (n = 12) had significantly greater and longer lasting complement activation than that in survivors, as reflected by higher levels of catabolic peptides (C3a(des)-Arg) and lower levels of native proteins (C3 and C4). C3a(des)-Arg, C3, C4, and the C3a(des)-Arg-C3 ratio were correlated with Sepsis Severity Scores. Polymorphonuclear neutrophil leukocyte elastase levels were higher in nonsurvivors and were correlated with C3a(des)-Arg and the C3a(des)-Arg-C3 ratio. Malondialdehyde levels were significantly higher in all patients than in controls, without, however, any relationship to severity of disease or clinical outcome. Since the higher and more persistent the complement activation and polymorphonuclear neutrophil leukocyte stimulation, the worse the patient's prognosis, we conclude that these mechanisms may be important in the clinical development of sepsis.

Role of hepatic histologic findings in the prognosis and treatment of bleeding esophageal varices.

In the period from 1976 to 1986, we performed 329 hepatic needle biopsies using a posterior extraperitoneal approach in patients with bleeding esophageal varices. The histologic findings subdivided according to a four-stage classification were correlated significantly with immediate survival. Specifically, 21 of 23 stage IV patients with severe degenerative and necrotic parenchymal lesions died after immediate emergency surgery, whereas 26 of 48 stage IV patients who did not undergo emergency surgery survived. Stage IV patients appeared unable to withstand major surgery. According to our data, histologic stage and Child's class are independent parameters, especially in emergency situations, since they quantify different aspects of functional liver failure. Therapeutic implications are presented based on cumulative analysis of histologic stages and Child's classes.

Hypermetabolic response after hypothermic cardiopulmonary bypass.

Sixteen patients undergoing hypothermic cardiopulmonary bypass for open heart surgery were studied prospectively. Oxygen consumption and CO2 production showed a marked increase during the first 6 h postoperatively. Consequently, the measured resting energy expenditure was markedly elevated compared to the predicted energy expenditure. This hypermetabolic response occurred simultaneously with maximum spontaneous rewarming after the end of surgical procedures. Ventricular function was low throughout the postoperative period, and no cardiac response to increased energy requirements was recorded. On the contrary, marked increases in arteriovenous oxygen and CO2 difference were observed during the period of highest resting energy expenditure. We conclude that the first hours after hypothermic cardiopulmonary bypass represent the period of highest risk for decompensation. The continuous monitoring of CO2 production is suggested as a useful clinical method to detect postoperative changes in metabolic rate.