Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state.

Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.

Caracterización imagenológica de la sinovitis vellonodular pigmentada y el tumor de células gigantes de la vaina sinovial / Radiological features of pigmented villonodular synovitis and giant cell tumor of tendon sheath

OBJETIVO: Mostrar los hallazgos imagenológicos en la resonancia magnética (RM) de la sinovitis vellonodular pigmentada (SVP) y el tumor de células gigantes de la vaina sinovial (TCGVS), dado que son entidades que representan un diverso grupo de alteraciones en la proliferación de la sinovial. MATERIALES Y MÉTODOS: Entre mayo de 2011 y junio de 2013, se estudiaron en nuestra institución 25 casos con diagnóstico histológico de proliferación de la sinovial. Se destacaron los distintos tipos de presentación en imágenes a través de una RM 1.5 Tesla. Los resultados fueron analizados y comparados con la literatura. RESULTADOS: La RM mostró características similares para esta patología en todos los pacientes. No obstante, se distinguieron 4 patrones principales de presentación, dependiendo de la morfología, la localización de la lesión y las características radiológicas diferenciales. Estos fueron: como dominante, el tumor de células gigantes de la vaina sinovial (n = 10), todos de localización extraarticular; la sinovitis vellonodular pigmentada de localización bursal (n = 2); la sinovitis vellonodular pigmentada de forma intraarticular focal (n = 5); y la sinovitis vellonodular pigmentada difusa (n = 8). CONCLUSIÓN: La sinovitis vellonodular pigmentada y el tumor de células gigantes de la vaina sinovial se consideran entidades similares desde el punto de vista anatomopatológico. La RM fue de gran utilidad para objetivar tanto las características radiológicas comunes como las diferenciales. Estas últimas, junto con la localización, nos permitieron clasificar 4 patrones de presentación. Su reconocimiento posibilita un adecuado seguimiento de la patología y un óptimo manejo terapéutico.

PURPOSE: To show the resonance magnetic imaging (MRI) findings of pigmented villonodular synovitis (PVNS) and giant cell tumor of the tendon sheath (PVNTS), entities with similar histology but differences in clinical and some radiological manifestations. MATERIALS AND METHODS: We studied 25 cases with histologically benign synovial proliferation in intra and extraarticular location of the extremities. It highlighted with a 1.5T MRI unit the different types of images presentation. The results were analyzed and compared with the literature. RESULTS: MRI displayed very specific imaging features in all patients. However, we were able to distinguish 4 main patterns of presentation depending on the morphology, location of the lesion and radiological differential. These were: as dominant presentation, pigmented villonodular synovitis localized form (n=10); pigmented villonodular synovitis bursal form (n=2); pigmented villonodular synovitis focal (n =5); and pigmented villonodular synovitis diffuse (n = 8). CONCLUSION: Both pigmented villonodular synovitis as well as giant cell tumor of the tendon sheath are considered similar from the point of view of the histological findings. MRI was useful to objectify both radiological features in common, such as the differential, which along with the location, allow us to classify patterns into 4 individual presentations. This recognition involves adequate radiological evaluation and is important for optimal management.

Giant adrenal myelolipoma: report of a case and review of the literature.

Myelolipoma of the adrenal gland is a benign, endocrinologically inactive neoplasm composed of mature adipose tissue and a variable amount of hematopoietic elements. Rarely giant adrenal myelolipomas have been reported in literature and they are very unusual clinical entities. We describe a case in a 72 year-old woman observed at our Department of Urology for nausea, flank and abdominal pain. The surgical resected mass measured 16.5x11.5x10 cm and weighted 1 250 g. A survey of the literature on this topic is made.

Laparoscopic repair of Morgagni hernia and cholecystectomy in a 40-year-old male with Down's sindrome. Report of a case.

Morgagni-Larrey hernia (MH) is an unusual diaphragmatic hernia of the retrosternal region. Few cases of MH, treated laparoscopically, associated with Down's syndrome (DS) have been reported in literature. On October 2004, a DS 40-year-old male was admitted to our Department with mild abdominal pain and nausea. Hematochemical tests were within the normal range. Ultrasonography showed biliary sludge and multiple gallstones. Chest X-ray revealed a right-sided paracardiac mass that appeared as MH after a thoraco-abdominal computed tomography (CT). Four trocars were placed as a routinary cholecystectomy. Abdominal exploration confirmed the presence of a voluminous hernia through a wide diaphragmatic defect (12 cm) on the left side of the falciform ligament, containing the last 20 cm ileal loops and right colon with the third lateral of transverse. After retrograde cholecystectomy and reduction of the herniated ileo-colonic tract from multiple adherences, the defect was repaired with an interrupted 2/0 silk suture and then a running 2/0 polypropylene suture. Postoperative course was complicated by pulmonary edema but subsequently the patient was discharged without further complications and has no recurrence after 2 years. In conclusion, surgery is necessary for symptomatic MH and to prevent possible severe complications. We preferred laparoscopy for the reduced morbidity compared to laparotomy, even if in our case the postoperative course was not uneventful. There are still few comparative data about the modality of closure of the defect between primary repair with nonabsorbable suture material, in case of small defects, or continuous monofilament suture or prosthesis in case of large defects.

A double Meckel's diverticulum as obscure gastrointestinal bleeding cause. Report of a case.

Meckel's diverticulum is the most common developmental anomaly of the gastrointestinal tract, affecting 1-4% of the general population. It is usually an incidental finding during laparotomy for other causes; occasional complications are bleeding, obstruction, diverticulitis and perforation. Up to 60% of Meckel's diverticula harbor heterotopic mucosa (mostly gastric or pancreatic), neoplastic degeneration occurs in 1-5% of cases. We report herein a case of obscure gastrointestinal bleeding in a 25-years-old man, due to a double Meckel's diverticulum, both located into jejunum and ileum, harboring ectopic gastric mucosa, diagnosed by a small bowel double contrast enema and managed laparoscopically with a tangential resection. To the best of our knowledge this is an unfrequent case of such a variant of Meckel's diverticulum with ectopic gastric mucosa diagnosed by double contrast enema.

[Management of obese patients: surgical therapy]. / Management del paziente obeso. Terapia chirurgica.

At present, the management of obesity includes integration of therapeutic strategies such as diet, physical training, behaviour therapy and pharmacologic therapy. An increased number of selected patients with morbid obesity, where medical therapy was ineffective, have been surgically treated in the last years due to less invasive surgical techniques, such as laparoscopic surgery. Main operations include gastroplasty, adjustable gastric banding, gastric bypass, bilio-pancreatic diversion. A less invasive procedure is intragastric balloon, i.e. a temporary device which is removed after few months. Surgery shows efficacy to induce weight loss and duration in time. All obese patients can't be treated by the same operation. Available surgical techniques are different and have to be chosen in each case according to the patient's clinical conditions.

Metabolic changes during recovery in normothermic versus hypothermic patients undergoing surgery and receiving general anesthesia and epidural local anesthetic agents.

BACKGROUND: Mild hypothermia is accompanied by metabolic changes. Epidural local anesthetic agents attenuate the surgical stress response, but it is not known whether they modulate thermal stress. METHODS: Thirty patients undergoing colorectal surgery, performed by one surgical team, received epidural 0.5% bupivacaine to achieve T3-S5 sensory block. They were then assigned randomly to two groups of 15 patients each. The control or unwarmed group was left to cool during surgery, whereas active warming was used in the warmed group. General anesthesia was induced by thiopentone, vecuronium, fentanyl, nitrous oxide in oxygen, and enflurane. At the end of surgery, both groups received epidural 0.25% bupivacaine to maintain a T5-L3 sensory block. Aural canal (core) and skin surface (15 sites) temperatures; oxygen consumption; pain visual analogue score; and concentrations of epinephrine, norepinephrine, glucose, cortisol, lactate, and free fatty acids in plasma were measured before epidural blockade, 30 min after epidural blockade, at the end of surgery, and for 4 h after surgery. Patients and those measuring the outcomes were unaware of group allocation. RESULTS: Core and mean skin temperatures decreased significantly in the control group (P < 0.001) but not in the warmed group. Catecholamine concentrations in plasma decreased significantly after epidural block, and although concentration of epinephrine in plasma increased from baseline sharply in the control group at the end of surgery (P = 0.004), it decreased in the warmed group (P = 0.007). During recovery, there was no difference between the two groups for norepinephrine concentrations in plasma, body weight-adjusted oxygen consumption, pain visual analogue score, and metabolites. CONCLUSIONS: The postoperative metabolic changes obtained with epidural block were similar except for an attenuated concentration of epinephrine in normothermic patients compared with those who were mildly hypothermic.

[T1G3 bladder tumors]. / I tumori vescicali T1G3.

Bladder tumors T1G3 are aggressive and difficult for their staging. Out of 176 p. with tumor pT1, 16 (9%) presented pT1G3. Among the latter 4 were submitted to TUR and chemioimmunotherapy; 5 to surgical partial resection and radiotherapy; 7 to radical cystectomy. After a mean interval of 21.6 months free of relapse, 5 p. had recurrent T1 tumor below G3: 1 out of 4 after TUR; 1 out of 5 after surgical resection; 1 out of 7 after cystectomy. Clinical T1G3 8 revealed a greater pathological staging: 7 (50%) had a relapse in spite of an aggressive therapy (2 TUR; 4 surgical resection; 8 cystectomy); 5 out of the 7 relapsed revealed a greater pathological staging than T1; 2 died by metastasis. The therapeutical choice should be demolitive from the beginning. Should conservative therapy be decided, the convenience of surgical bladder resection has to be considered because, besides being effective, has some advantages over TUR: easier and unfailing staging possibility of contemporary lymphadenectomy healing of bladder by first intention.

[Radical versus conservative therapy in prostatic adenoma. Open adenomectomy]. / Terapia demolitiva versus terapia conservativa nell' adenoma prostatico. Adenomectomia a cielo aperto.

Our technical procedure for surgical adenomectomy of prostate is the Hey-Delinotte one. Indications for this type of procedure are large adenomas with a volume, estimated by ultrasonography, more than 50 cc. and with significant obstruction and urinary retention. In our experience during the past 3 years, in patients without severe operating risk, it was utilized a little more frequently than transurethral resection. We hope that in the future the new procedures will be as useful and resolutive as traditional ones.

[Instrumental chemolysis of cystine calculi]. / La chemiolisi strumentale dei calcoli di cistina.

ESWL and PCN have modified the urinary stones therapy. Nevertheless these therapeutic procedures are not much effective in cystine stone because of its protein structure and frequent recurrences; these procedures need to be combined to achieve the best results. In cystine stones the lithochemolysis, performed following recent technique has shown excellent results, without complications and easy to apply.

[Treatment of symptomatic bone metastases of prostatic carcinoma using strontium chloride (Sr-89)]. / Trattamento delle metastasi ossee sintomatiche da carcinoma prostatico con Cloruro di Stronzio (Sr-89).

Until now, patients with a progressive prostatic cancer, in whom all therapies failed and the disease spread locally and distally, was considered "a lost patient"; because it did not exist an effective therapy easily to be used. The skeletal pain control is a serious problem and it is a great responsibility also for the Urologists especially if the patient has not a short survival time and the quality of life is very poor. Physicians feel the need for a systemic, well tolerated and effective therapy also for a long time, uniform and repeatable, able to be efficient for these patients. Strontium 89 chloride seems to offer all these possibilities and to be the best procedure for Urologist, Radiotherapists and Nuclear Specialists in order to satisfy the patients requirements. International research has shown Sr-849 Chloride is a powerful new therapy. Sr-89 Chloride is a radiopharmaceutical product for the treatment of painful metastases from prostatic cancer. It is a new treatment but its effectiveness is well documented and results are reported in the most important international literature. In our Department a clinical research has started and our purpose is to produce more data for a clinical and biological evaluation of the results, hoping that a similar research will extend as a multicenter study.

[Treatment of symptomatic bone metastases of prostatic carcinoma with strontium (Sr-89) chloride: initial experience]. / Trattamento delle metastasi ossee sintomatiche da carcinoma prostatico con Cloruro di Stronzio (Sr-89), esperienza iniziale.

Until now, patients with a progressive prostatic cancer, in whom all therapies failed and the disease spread locally and distally, was considered "a lost patient"; because it did not exist an effective therapy easily to be used. The skeletal pain control is a serious problem and it is a great responsibility also for the Urologists especially if the patient has not a short survival time and the quality of life very poor. Physicians feel the need for a systemic, well tolerated and effective therapy also for a long time, uniform and repeatable, able to be efficient for these patients. Strontium 89 chloride seems to offer all those possibilities and to be the best procedure for Urologist, Radiotherapists and Nuclear Specialists in order to satisfy the patients requirements. International research has shown Sr-89 Chloride is a powerful new therapy. Sr-90 Chloride is a radiopharmaceutical product for the treatment of painful metastases from prostatic cancer. It is a new treatment but its effectiveness is well documented and results are reported in the most important international literature. In our Department a clinical research has started and our purpose is to produce more data for a clinical and biological evaluation of the results hoping that a similar research will extend as a multicenter study.

[Treatment of ureteral calculi with extracorporeal lithotripsy. Comparison between the original Dornier HM3 and the modified lithotriptor]. / Trattamento della calcolosi ureterale con litotrissia extracorporea. Confronto tra il litotritore Dornier HM3 originale e modificato.

From January 1985 till June 1989, 222 patients with ureteral stones, underwent ESWL treatment. 109 patients were treated with the original Dornier HM3 under general or epidural anaesthesia and 113 patients were treated with the modified Dornier HM3 under anglosedation. 156 stones were in the upper ureter, 15 in the middle ureter, 51 in the lower ureter. We performed a total of 269 ESWL treatments. Out of 109 patients treated with the original HM3 and 113 patients treated by the modified HM3 12 (11%) and 28 (24.7%) needed, respectively, two or more ESWL sessions. In 89.9% and 88.5% of the patients, respectively, has been performed an ureteral manipulation before the treatment to push up or to localize the stone. The treatment was unsuccessful in 10 patients of whom 3 underwent anterograde lithotripsy by percutaneous access, 4 transureteral lithotripsy and 3 surgery. At three months the percentage of patients stone free was as follows: original HM3 patients 88% modified HM3 patients 92.9%. The extracorporeal lithotripsy is now-day the treatment of choice for the ureteral stone without any limitation, due to the stone localisation. The clinical use of modified HM3 on ureteral stones didn't low our success rate, but increased the shock wave out of session.

Produccion de glucosa-isomerasa por Streptomyces phaeochromogenes. / Production of glucose-isomerase from Streptomyces phaeochromogenes

Se estudio la produccion de glucosa-isomerasa utilizando una cepa de Streptomyces phaeochromogenes NRRL B-3559. Se considero la influencia de la composicion del medio cultivo y de las condiciones de aeracion.De tres tipos de colonias bien diferenciadas que el microorganismo es capaz de desarrollar, las grises fueron de la mayor produccion enzimatica. Con el objeto de evitar la variabilidad de la poblacion microbiana y obtener resultados sobre la composicion del medio, se vio que la concentracion de cobalto es critica en cuanto a los niveles de enzima alcanzados.Empleando una concentracion de Cl2Co.6H2 de 0,18 g/l se obtuvieron 1600 UE/l. Los estudios de aeracion realizados en fermentadores con agitacion mecanica del tipo convencional, mostraron que es posible obtener valores de actividad enzimatica similares a los producidos en erlenmeyers agitados, operando a 550 rpm y un flujo de aire de 1 1/1.min. Se demostro que el cultivo estaba adecuadamente aerado en razon de que los valores de consumo y demanda celular de oxigeno fueron semilares

Influente de una mutante deficiencia respiratoria de levadura en la produccion de biomasa. / The influence of a respiratory defficient yeast mutant on biomass production

Se estudio la influencia de mutantes respiratorias de una Saccharomyces fragilis en la produccion de biomasa. Se considero el efecto de distintas proporciones de una mutante con capacidad respiratoria nula en poblaciones de celulas de levadura en relacion al rendimiento celular. Los resultados obtenidos en estas esperiencias muestran que para procesos donde se utiliza el 100% de celulas normales (RC) es posible obtener 5,6 g/l de masa celular mientras que operando con el 100% de mutantes respiratorias (RD) solo se alcanza una concentracion de 1,6 g/l para iguales condiciones de cultivo. Estos estudios muestran la importancia del conocimiento de la distribucion de la poblacion de celulas, ya que el rendimiento en biomasa esta directamente relacionado a su composicion

[Production of soy bean inoculants. Behavior of supports based on peat from Tierra del Fuego sterilized by vapor and ethylene oxide]. / Obtención de inoculantes para soja. Comportamiento de soportes a base de turbas de Tierra del Fuego esterilizadas por vapor y óxido de etileno.

The survival of Rhizobium japonicum was studied in neutralized and sterilized peats from Ushuaia and Rio Grande. The carriers were sterilized by ethylene oxide and by autoclaving. Similar counts for Rhizobium (5 x 10(8) cel/g) were obtained in peat-cultures sterilized by both methods, after eight months. A good nodulation and nitrogen fixation capacity was observed with inoculated soybean plants. Using the strain Rhizobium japonicum E-45, no appreciable difference in symbiotic effectiveness was found between the inoculants prepared with the two peats.

[A case of epidermodysplasia verruciformis with neoplastic degeneration and demonstration of viral particles in warts (author's transl)]. / Caso di epidermodisplasia verruciforme con degenerazione neoplastica d dimostrazione di un virus nelle lesioni verrucose

A case of epidermodysplasia verruciformis, already described by Borelli in 1946, was presented. The electron microscopy showed viral intranuclear particles in the verrucous lesions. A Bowen-like tumor was found on the forehead. The connections are described between virus and tumor.