The Museum of the Department of Public Health and Infectious Diseases, Sapienza University of Rome.

This paper illustrates in detail the birth of the Museum of Public Health of the Sapienza University of Rome, which has been one of the most successful achievements of Prof Carmine Melino in the last few years of his academic career. Backed by a very thin group of enthousiastic coworkers and colleagues, he recuperated all the instruments which had been used by the research groups active since 1880 at the former Institute of Hygiene, to which he added samples of the different pieces of laboratory furniture, ancient reagents, etc. The goal was not to simply collect, restore and maintain the documents of the Institute's past, but to rebuild a vintage laboratory, as it was inhabited by the hygienists of the past and to describe the kinds of research being performed during a period more than a century long. Beginning from the days when Hygiene became a scientific discipline, he tried to demonstrate that only the transformation of Hygiene into an experimental discipline made it possible the numberless achievements, including the improvements of the environmental conditions, the reduction of infectious diseases and the successful fight against the chronic, degenerative diseases of the present times.

Totally implantable catheter migration and its percutaneous retrieval: case report and review of the literature.

Totally subcutaneous intravascular portals have been increasingly used to administer long-term chemotherapy and parental nutrition. The reported complications are rare. Accidental endovascular rupture of a fragment of catheter is one of the most formidable complications of the central vein catheterization. The Authors report a case of deployment of a Port-a-Cath catheter and its percutaneous retrieval. The catheter accidentally detached and migrated from the reservoir of the port-a-cath placed in the left subclavian vein to the right heart cavities through the blood stream. A review of the Literature is also given, focusing on the possible factors responsible for this unusual complication.

Neoplastic sigmoid-uterine fistula. An exceptional complication of large intestine cancer.

Neoplastic sigmoid-uterine fistula is an extremely rare condition because the uterus is a thick and muscular organ. A 74-year-old woman was admitted to the First Aid Station suffering from abdominal pain and foul smelling vaginal discharge. Gynaecological examination showed fecal drainage from the cervical orifice, while the uterus was regular in size but very firm and painful. Ovaries and fallopian tubes were not palpable owing to abdominal tenderness. Ultrasounds reveled inhomogeneous thickening of uterine cavity, without detecting fistula. Contrast Medium CT (CMCT) showed Douglas' recto-uterine pouch occluded. The sigmoid wall was very thin exception a site where a fistula was suspected. At the surgery severe adhesions of the sigma-rectum with the posterior uterine wall were observed. After adhesiolysis, 18 cm colon-sigma-rectum was removed. Total hysterectomy with salpingooophorectomy was performed. Lymphadenectomy ended the procedure. Anatomical specimen confirmed sigmoid-uterine fistula. At histology a mildly differentiated adenocarcinoma of sigma-rectum was shown. Postoperative course was uneventful. Such a case of neoplastic sigmoiduterine fistula has not been reported so far.

Nutritional information and health warnings on wine labels: Exploring consumer interest and preferences.

This paper aims to contribute to the current debate on the inclusion of nutritional information and health warnings on wine labels, exploring consumers' interest and preferences. The results of a survey conducted on a sample of Italian wine consumers (N = 300) show the strong interest of respondents in the inclusion of such information on the label. Conjoint analysis reveals that consumers assign greater utility to health warnings, followed by nutritional information. Cluster analysis shows the existence of three different consumer segments. The first cluster, which included mainly female consumers (over 55) and those with high wine involvement, revealed greater awareness of the links between wine and health and better knowledge of wine nutritional properties, preferring a more detailed nutritional label, such as a panel with GDA%. By contrast, the other two clusters, consisting of individuals who generally find it more difficult to understand nutritional labels, preferred the less detailed label of a glass showing calories. The second and largest cluster comprising mainly younger men (under 44), showed the highest interest in health warnings while the third cluster - with a relatively low level of education - preferred the specification of the number of glasses not to exceed. Our results support the idea that the policy maker should consider introducing a mandatory nutritional label in the easier-to-implement and not-too-costly form of a glass with calories, rotating health warnings and the maximum number of glasses not to exceed.

Topical hemostasis in laparoscopic surgery.

A major goal during any surgical intervention is minimization of blood loss, which reduces the need for blood transfusion. In open surgery, the possibility for the surgeon to use the hands directly in contact with the bleeding tissues for hemostasis, makes mechanical methods, such as compression, ligatures or sutures, important to achieve proper hemostasis. In laparoscopic surgery, where the intervention is performed by means of small incisions through which the surgeon's hand cannot directly achieve the tissues, the problem of hemostasis is critical and needs more attention. Either in open or in laparoscopic surgery, significant bleeding during surgery is controlled through vessel ligation, suturing, and electrocautery. Topical hemostatic agents are useful adjuncts to surgical hemostasis for controlling non-specific bleeding. The introduction of different devices and topical agents has made possible to perform more complex interventions also in laparoscopy. The Authors discuss about the type, the field of application, the side effects of the hemostatic devices and of the topical hemostatic agents.

How to prevent mesh erosion in transobturator Tension-Free Incontinence Cystocoele Treatment (TICT): a comparative survey.

BACKGROUND: Tension-Free Incontinence Cystocoele Treatment (TICT) was introduced by Leanza-Gasbarro-Caschetto in 2001, on the basis of experimental and clinical investigations to obtain a physiologic mechanism of closure and opening of the urethra in the event of genuine stress urinary incontinence (S.U.I.) and cistocoele. TICT took origin from the previous retropubic tension-free vaginal tape (TVT) based on the integral theory according which mid-urethra has a main role for urinary continence but differs in that the former restores the anatomy and physiology of the entire anterior compartment. Simultaneously Delorme in 2001 spread the TOT (Trans-Obturator Tape) technique, emphasizing the needle passage across the obturator foramen which represents a new and less invasive route in comparison with the retropubic one. Trans-obturator TICT exploits the advantages of TOT, adding the anatomical repair of bladder prolapse. Introduction of mesh for treatment of pelvic defects gives a lower rate of recurrence, but introduces new complications due to the extraneous materials, among which the most common is represented by mesh erosion. At present the rate of mesh erosion reported is 4.7% in the TOT. Aim of our survey was to verify a technique allowing post-operative erosion prevention. PATIENTS AND METHODS: 230 women with urodynamic stress incontinence and cystocoele after diagnostic phase were allocated to 2 treatment groups (A end B-group), with open alternative method. Agroup women underwent transobturator TICT procedure after preparation of anterior compartment by means of a transversal incision taking care to preserve the integrity of the vaginal skin in the site where the mesh would be allocated. Conversely, B-group transobturator TICT was carried out in a classical way, through a longitudinal incision of anterior vaginal skin and suturing after placing the mesh. Each of the two groups was initially constituted by 115 subjects. There were 14 preoperative dropouts among which 6 (115-6=109) in A-group and 8 (115-8=107) in B-group and, after, 16 postoperative dropouts including 7 (109-7=102) in the former and 9 (107-9=98) in the latter. Other pelvic defects were solved during the same operation for a complete repair of pelvic floor. RESULTS: A-group: subjectively SUI was cured in 87/102 (85.3%) objectively, SUI was cured in 88/102 (86.3%) of patients; cystocoele in 87/102 (85.3%). B-group: subjectively SUI was cured in 86/98 (87.7%) and objectively in 87/98 (88.8%) of patients; cystocoele was solved in 86/98 (87.7%). Between the two groups both anti-incontinence end cystocoele treatment was superimposable (p value > 0.05). Nevertheless regarding mesh erosion, a percentage of 5.1% (5/98) was found among B-group while none among A-group patients where integrity of vaginal skin beneath the mesh was preserved. CONCLUSION: Integrity of the vagina beneath the mesh is the right.key to prevent ad externum mesh erosion.

A rare case of myeloid sarcoma presenting as anal fissure.

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.

Hydronephrosis and utero-vaginal prolapse in postmenopausal women: management and treatment.

INTRODUCTION: Pelvic organ prolapse is a multifactorial disease. Aim was to evaluate the effect of the whole surgical correction of pelvic floor on hydronephrosis due to severe prolapse. PATIENTS AND METHODS: A retrospective case study on 250 patients presenting with severe uterovaginal prolapse was carried out. RESULTS: Hydronephrosis was found in 32/234 (13.7 %). All patients underwent hysterectomy, vaginal apex axial suspension, posterior and anterior repair, vaginally. Prepubic TICT (Tension free Incontinence Cystocoele Treatment) was done in 38 cases (3 with hydronephrosis). Of the 32/234 (13.7 %) patients with hydronephrosis, 18/32 (56.25%) had complete resolution of hydronephrosis after treatment, 14/32 (43.75%) had a reduction of calico-pyelic dilatation, among them 8 patients had a second degree and 6 a first degree of hydronephrosis. CONCLUSIONS: Vaginal-hysterectomy, axial apex suspension, anterior and posterior repair resulted in either complete resolution or improvement of hydronephrosis. Prepubic TICT did not interfere on mechanical obstruction and maintained postoperative continence in the event of occult Stress Urinary Incontinence (SUI).

Surgical reconstructive procedures for treatment of ischial, sacral and trochanteric pressure ulcers.

BACKGROUND: Pressure ulcers are frequent complications for long term hospitalized bed-ridden patients which are not able to move or move very little. In fact, the lesion forms in a skin and muscle region which undergoes a constant pressure between an underlying bone protrusion and a support structure such as a bed or a wheelchair. Initially only the outer layers are involved but in time, the ulcer can spread to the deeper structures and reach the bone. PATIENTS AND METHODS: In our work we described the anatomical areas that are most often subject to developing a pressure ulcer and we considered the surgical treatment and reconstructive procedures which are applied using a logical and rigorous sequence. RESULTS: We considered 4 clinical cases (2 ischiatic sores, 1 sacral sore and 1 gluteal-trochanteric sore) which demonstrate the surgical treatment and the reconstructive procedures. CONCLUSIONS: It is crucial to cover the defects with a thick flap to give more support and protection to the areas which undergo pressure and to lower the incidence of recurrences.

Surgical drain after open or laparoscopic splenectomy: is it needed or contraindicated?

OBJECTIVE: The Authors report their experience with the routine use of surgical drainage in a large series of splenectomies. SUMMARY OF BACKGROUND DATA: Benefits and risks related to surgical drains have been always discussed, with some surgeons in favor of them and skeptic others considering not physiological their use. After splenectomy, their use is also largely debated, especially because of susceptibility of operated patients to infections. PATIENTS AND METHODS: Two thousand nine cases have been reviewed. Indications for splenectomy, performed either by open or laparoscopic approach, included idiopathic thrombocytopenic purpura in 137 patients (65,4%), splenic lymphoma in 36 (17,2%), hereditary spherocytosis in 15 (7,4%), ß-thalassemia in 8 (3,7%), other diseases in 13 (6,1%). RESULTS: "Active" or "passive" drains were placed in 80% and 20% of cases, respectively. Drains were removed 2-3 days after surgery in 90,2%, within 10 days in 4,3%, within 2 months in 0,4% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient developed a subphrenic abscess, successfully treated by a percutaneous drainage. One case of pancreatic fistula was observed. CONCLUSIONS: In Authors' experience, the use of drains after splenectomy does not affect the risk of subsequent infectious complications, independently on the type of the drainage system used. Early removal of drains in this series might have played an important role in the very low incidence of abdominal infections reported. The use of surgical drains after splenectomy might play an important role to early detect post-operative bleeding, as it happened in 2 cases of this series.

Single-Incision Laparoscopic Cholecystectomy: our experience and review of literature.

AIM: After the revolution in the surgery of gallbladder stones represented by the laparoscopic cholecystectomy, we tried a new technique that further maximize the aesthetic results and that at the same time is of easy learning for young surgeons. PATIENTS AND METHODS: From January 2011 to December 2012 we performed at our department 320 cholecystectomy: 27 in laparotomy and 293 in laparoscopy. Of these, 88 underwent to Single Incision Laparoscopic Surgery (SILS), namely the Single Incision Laparoscopic Cholecystectomy (SILC), in recruited patients aged between 19-65 years; 56 patients were females and 32 were males. RESULTS: The laparoscopic cholecystectomy with the SILS methodology is a safe technique. Respect to multi-port Laparoscopic Cholecystectomy (LC), we have cosmetic advances. The pain is less in extraumbilical sites, and the major umbilical pain can be prevented by local anaesthesia. The times are slightly longer, especially at the beginning of training, but after a few of operations it is reduced to about one hour. We didn't found any other difference in vantage and advantage between the two technics, only a case of postoperative umbilical hernia in SILS. CONCLUSION: We found the SILS a safe and effective technique for the cholecystectomy.

Subcutaneous cervical emphysema and pneumomediastinum due to a diastatic rupture of the cecum.

Pneumomediastinum usually occurs after esophageal or chest trauma. Subcutaneous cervical emphysema as a presentation of non-traumatic colonic perforation following colorectal cancer or diverticulitis, is very rare. We report a case of a patient with rectal cancer who developed a diastatic cecum retroperitoneal perforation with a secondary pneumomediastinum and cervical emphysema. The patient was in treatment with a neoadjuvant chemo-radiotherapy for a low rectal cancer. Treatment consisted in an emergency right hemi-colectomy with ileostomy and performance of distal colonic fistula. The Authors discuss the occurrence of pneumomediastinum and cervical emphysema complicating rectal cancer, pointing out ethiopathogenesis, clinical presentation, diagnosis and treatment. The importance of performing a diverting colostomy when neoadjuvant chemotherapy is scheduled in patients with stenotic rectal cancer, although not clinically occluded.

Colorectal cancer in aged patients. Toward the routine treatment through laparoscopic surgical approach.

AIM: Colorectal cancer is one of the most common malignancies in general population. The incidence seems to be higher in older age. Surgery remains the treatment of choice and laparoscopic approach offers numerous benefits. We report our personal experience in elderly patients operated on for colorectal cancer with laparoscopic resection. PATIENTS AND METHODS: From January 2003 to September 2013, out of 160 patients aged 65 years or older and operated with minimally invasive techniques, 30 cases affected by colorectal cancer and operated on with laparoscopic approach were analyzed in this study. RESULTS: Male/female ratio was 1.35 and mean age 72 years. Constipation, weight loss, anemia and rectal bleeding were the most commonly reported symptoms. Lesions involved descending-sigmoid colon in 53% of cases, rectum in 37% and ascending colon in 10%. Among laparoscopic colo-rectal operations laparoscopic left colectomy was the most frequently performed, followed by right colectomy, abdominoperineal resection and Hartmann procedure. Operative times ranged from 3 to 5 hours depending on surgical procedure performed. Mean hospital stay was 6 days (range 4-9). Conversion to open approach occurred only in a case of laparoscopic right colectomy (3%) for uncontrolled bleeding. A single case of mortality was reported. In two cases (7%) anastomotic leakage was observed, conservatively treated in one patient and requiring reoperation in the other one. CONCLUSIONS: Laparoscopic colorectal surgery is feasible and effective for malignancies in elderly population offering several advantages including immunologic and oncologic ones. However an experienced surgical team is essential in reducing risks and complications.

Comparison between three mini-sling surgical procedures and the traditional transobturator vaginal tape technique for female stress urinary incontinence.

OBJECTIVES: To compare mini-sling and traditional tension-free operations for female stress urinary incontinence. STUDY DESIGN: A systematic review of articles in the Literature published between 2002 and 2012, was conducted. A Pubmed search was performed. Primary outcomes were subjective and objective cure rates at 12 months comparing the three single-incision mini-slings techniques (TVT-Secur, MiniArc and Monarc systems) with the standard midurethral sling procedure TOT (Transobturator Vaginal Tape). Secondary outcomes included peri-operative (vaginal and/or bladder perforation, urine retention, urinary tract infection, bleeding, pain) and post-operative (mesh exposure, de novo urgency, and dyspareunia) complications. RESULTS: In term of objective cure rate at 12 month after surgery, it is evident that TOT at first, and MiniArc are the most effective procedures. The incidence of post-operative urgency and UTI was lower in TOT technique, while vaginal perforation was described in equal frequency both in TOT and in MiniArc procedures. The advantages of the three above described mini-invasive techniques seem to consist into lower cases of urinary retention, pain and bleeding. Furthermore, bladder perforation and bleeding are not described in the Literature for TVT-Secur and Monarc systems. CONCLUSIONS: Some single-incision slings look promising and as effective as conventional sub-urethral slings at short term evaluation. However, at this moment a clear statement in favor of the widespread use of single-incision slings cannot be made. More studies must define the efficacy of these techniques.

Mini-invasive tension-free surgery for female urinary incontinence.

The Authors describe the techniques they perform of prepubic, retropubic and transobturator mini-invasive anti-incontinence surgical procedures and point-out some technical details. The state of art and the results of these three main surgical procedure are compared and discussed. Data from the Literature have been reviewed in order to evaluate the efficacy of the techniques. A Medline search has been performed, and 65 relevant articles from 1996 to 2012 were selected. Literature showed similar cure rates among retropubic (71,4-91%), trans-oburator (77,3-95%) and prepubic (81-87,2%) anti-incontinence procedures. Cystoscopy was considered necessary in the retropubic, optional in transobturator and in the prepubic techniques. Intra-operative cough stress test was believed useful only in the retropubic and prepubic procedures. Obstruction symptoms prevailed in the retropubic, were rare in the transobturator and missing in the prepubic technique. Erosion rate was very low and similar for all the three techniques. Intra-operative vascular and perforating risks prevailed in the retropubic technique, due to the danger present in the retropubic space, whereas late infective complications overcame in the transobturator procedure. Severe complications in the prepubic procedure were not reported, but the procedure is performed only in few centers.

Breast cancer and sentinel lymph node micrometastases: indications for lymphadenectomy and literature review.

An increasingly early diagnosis for discovering breast cancer, an improvement of surgical procedures with refining techniques for research and study of sentinel node, currently allow a more conservative surgical approach. Association with suitable chemo-radiotherapy allows a good control of breast disease. Our study, although modest, was carried out on 63 patients suffering from breast cancer, who underwent surgical treatment with assessment of sentinel lymph node. Aim of study was to establish the most correct strategy in the presence of isolated tumor cells (ITC) and/or micro-metastases of sentinel lymph node. Many studies have been carried out to find which was the most appropriate treatment, nevertheless, in the absence of univocal guidelines, we prefer to proceed to axillary dissection, though the topic is very debated and controversial. Following this strategy we obtained quite satisfactory results.

Surgical repair of rectocele. Comparison of transvaginal and transanal approach and personal technique.

Rectocele is defined as a herniation of the rectal wall inside the vagina due to a defect of the recto-vaginal septum. It is traditionally considered a posterior compartment damage with weakness of posterior vaginal wall support resulting in a bulging of the rectum into the vaginal cavity. One of the main causes of rectal prolapse is the operative vaginal birth, although the evidence of the defect may occur after many years The treatment of rectocele is surgical, and the approach can be transperineal, transvaginal, and transanal or, in selected cases, transperitoneal through open or laparoscopic techniques. In this study we compare two transvaginal surgical techniques - i.e. the perineal body anchorage to the posterior septum and the traditional Denonvilliers' transversal suture after removing of the vaginal skin, with the mostly performed transanal procedure, the STARR - comparing the data from the literature on their results. Mean hospital stay, rectal symptoms, dyspareunia, quality of life, recurrence rate and postoperative complications have been considered. Both transvaginal and transrectal surgical techniques are effective to solve posterior compartment defect and to improve the quality of life. Vaginal approach may interfere with the sexual activity; furthermore it is associated with minimal postoperative pain than the transanal approach. Better anatomic results are assured after endovaginal surgery, while better rectal function prevail after the transanal approach. Vaginal techniques are more suitable to gynecologists, whereas the transrectal ones are usually performed by colo-proctologists or general surgeons.

Laparoscopic-endoscopic rendez-vous resection of iuxta-cardial gastric GIST.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and they often require a surgical removal. Gastrointestinal stromal tumors can originate from any part of the gastrointestinal tract but gastric location is the most common. In the past the risk of rupture of pseudocapsula and peritoneal dissemination have discouraged surgeons from making a minimally invasive surgical treatment. Recently laparoscopic wedge resection has been proposed. Performance of this mini-invasive technique is however difficult in some gastric location of gastrointestinal stromal tumors, such as iuxta-cardial region. The Authors report and discuss a new technique they used to remove a gastrointestinal stromal tumor located just below the cardia, using a rendez-vous endoscopic and laparoscopic technique.

Laparoscopic removal of a giant paratubal cyst complicated by hydronephrosis.

Paratubal cysts represent approximately 10% of all adnexal masses. In most cases they are very small, but very few cases are reported in the literature where they exceed 15 cm of diameter. Furthermore, giant paratubal cysts complicated by bilateral hydronephrosis are unique. The Authors describe a case of a huge paratubal cyst (30 cm in diameter), in a 14 year old obese girl, treated by complete laparoscopic enucleation.

Measuring consumer effort in circular economy initiatives in the food domain: An exploratory analysis.

The transition towards a Circular Economy (CE) system requires a change in consumers' behavioural pattern that implies a certain level of effort which, in turn, could affect initiatives' success. Although consumers' role in CE is increasingly drawing the attention of scholars, limited knowledge is available on the evaluation of consumer's effort in CE initiatives. The current research provides an identification and measurement of the core parameters affecting consumer effort, offering a comprehensive Effort Index applied to 20 CE companies operating in food domain. Companies were classified in 5 categories (Quantity of food, Appearance of food, Edibility of food, Living with food and Local and sustainable food); the analysis of the companies revealed 14 parameters building the Effort Index. Results showed that initiatives ascribable to the category "Local and sustainable food" require higher levels of consumer effort; in contrast, case studies belonging to "Edibility of food" group are less effort-requiring.