Bringing door-to-needle times within the European benchmarks results in better stroke patients outcomes in a spoke hospital from the Apulian Region.

INTRODUCTION: Door-to-needle time (DNT) is a key factor in acute stroke treatment success. We retrospectively analysed the effects of a new protocol aimed at reducing treatment delays in our single-centre observational series over a 1-year period (from October 1st 2021 to September 30th 2022). METHODS: The time frame was divided into two semesters as a new protocol was started at the beginning of the second semester to ensure a rapid evaluation, imaging, and intravenous thrombolysis in all stroke patients attending our spoke-hospital serving 200,000 inhabitants. Logistics and outcome measures were obtained for each patient and compared before and after implementation of the new protocol. RESULTS: A total of 215 patients with ischemic stroke attended our hospital within a 1-year period (109 in the first semester, 96 in the second semester). Seventeen percent and 21% of all patients underwent acute stroke thrombolysis in the first and second semesters, respectively. DNTs were strongly reduced in the second semester (from 90 to 55 min), bringing this value below the Italian and European benchmarks. This resulted in better short-term outcomes (an average of 20%) as measured by both Δ NIHSS scores at 24 h and at discharge with respect to baseline.

Treatment of Large Non-Muscle-Invasive Bladder Cancer: The Potential Role of Neoadjuvant Intravesical Chemotherapy.

INTRODUCTION: The endoscopic resection of large and bulky bladder cancers represents a challenge. To reduce the tumor and make it more easy to resect, we used neoadjuvant short and intensive intravesical mitomycin (MMC) therapy. METHODS: Patients with large bladder tumors were evaluated for this study. At cystoscopy, the surgeon evaluated the feasibility of complete resection. In patients where this was not possible, biopsies from the tumor, bladder mucosa, and prostatic urethra were taken. These patients then underwent a short and intensive cytoreductive schedule of intravesical MMC. This was then followed by TUR-BT. RESULTS: Fifteen patients were included in our study. The mean age was 74 years (range: 56-82; SD ±6 years). Mean tumor size was 51 mm (range: 35-65; SD ±8 mm). After neoadjuvant treatment, complete resection was then feasible in all patients. The mean tumor volume after the chemo-resection had reduced to 34 mm (range: 10-50; SD ±13 mm). No adverse effects were reported. CONCLUSION: Intravesical cytoreductive neoadjuvant MMC as an initial treatment of large NMIBC can be considered safe, effective, and feasible.

Preconception Thyrotropin Levels and Thyroid Function at Early Gestation in Women With Hashimoto Thyroiditis.

CONTEXT: Preconception optimization of thyroid function in women with Hashimoto thyroiditis (HT) is highly recommended to prevent/reduce the risk of thyroid insufficiency at early gestation. OBJECTIVE: This work aimed to evaluate the prevalence of first-trimester thyroid insufficiency in HT women with preconception thyrotropin (T0-TSH) values consistently less than or equal to 2.5 mIU/L with or without levothyroxine (LT4) treatment, and to calculate T0-TSH cutoffs that best preconceptionally identified HT women requiring first-trimester LT4 adjustment/prescription. METHODS: Serum TSH was obtained at 4- to 6-week intervals from 260 HT pregnant women (122 on LT4 [Hypo-HT]; 138 euthyroid without LT4 [Eu-HT]), prospectively followed from preconception up to pregnancy term. Receiver operating characteristic (ROC) curves were plotted to identify T0-TSH cutoffs best predicting first-trimester TSH levels greater than 2.5 mIU/L (diagnostic criterion [DC] 1) and greater than 4.0 mIU/L (DC 2). RESULTS: At first trimester, TSH was greater than 2.5 mIU/L in approximately 30% of both Hypo-HT and Eu-HT women, and greater than 4.0 mIU/L in 19.7% Hypo-HT and 10.1% Eu-HT women (P = .038). The optimal ROC-based T0-TSH cutoffs found were 1.24 mIU/L/1.74 mIU/L in Hypo-HT, and 1.73 mIU/L/2.07 mIU/L in Eu-HT women, for DC 1 and DC 2, respectively. T0-TSH values exceeding these cutoffs resulted in a statistically significantly increased risk of first-trimester thyroid insufficiency (odds ratio [OR] [95% CI)] 15.92 [5.06-50.15] and 16.68 [5.13-54.24] in Hypo-HT; 16.14 [6.47-40.30] and 17.36 [4.30-70.08] in Eu-HT women, for DC 1 and DC 2, respectively). CONCLUSION: The preconception TSH cutoffs that guaranteed a first-trimester TSH less than 2.5 mU/L in hypothyroid- and euthyroid-HT women were, respectively, almost 50% (1.24 mU/L) and 30% (1.73 mU/L) lower than this gestational target, and 1.74 mU/L and 2.07 mU/L in hypothyroid- and euthyroid-HT women, respectively, for a gestational target of 4.0 mU/L.

Trabecular bone score, bone marrow fat and vertebral fractures in cushing syndrome.

OBJECTIVE: Prediction of fragility fractures in Cushing syndrome (CS) is a challenge since dual energy X-ray absorptiometry (DXA) measurement of bone mineral density (BMD) does not capture all the alterations in bone microstructure induced by glucocorticoid excess. In this study we investigated the relationship between trabecular bone score (TBS), bone marrow fat (BMF) and vertebral fractures (VFs) in endogenous CS. DESIGN: Cross-sectional. METHODS: Thirty subjects (7 M and 23 F, mean age 44.8 ± 13.4 yrs, range: 25-71) with active hypercortisolism were evaluated for VFs by quantitative morphometry, BMD and TBS by lumbar spine DXA and BMF by single-voxel magnetic resonance spectroscopy of vertebral body of L3. RESULTS: Subjects with VFs (17 cases; 56.7%) had higher BMF (P = 0.014) and lower BMD T-score (P = 0.012) and TBS (P = 0.004) as compared to those without VFs. Prevalence of VFs resulted to be significantly higher in individuals with impaired TBS as compared to those with normal TBS (77.8% vs. 25.0%; P = 0.008). Among patients with VFs, only 6 (35.3%) had either osteoporosis or "low BMD for age". In logistic regression analysis, impaired TBS maintained the significant association with VFs [odds ratio (OR) 6.60, 95% C.I. 1.07-40.61; P = 0.042] independently of BMF (OR 1.03, 95% C.I. 0.99-1.08; P = 0.152). CONCLUSIONS: TBS might be more accurate than BMF in identifying subjects with active CS and skeletal fragility at risk of VFs. SIGNIFICANCE STATEMENT: Excess in glucocorticoids is associated with alterations in bone remodeling and metabolism, leading to fragility fractures regardless of bone mineral density, making more challenging for the clinician the identification of high-risk population and the definition of preventing strategies. In this context, instrumental parameters suggestive of bone quality alterations and predictive of increased fracture risk are needed. In this study, we found CS patients to have bone quality alterations as indicated by the decreased trabecular bone score and increased bone marrow fat, as measured by DEXA and MRI respectively. Both parameters were associated with high risk of VFs, and were inversely correlated, although TBS seems to be more accurate than BMF in fractures prediction in this clinical setting.

Global incidence and prevalence of differentiated thyroid cancer in childhood: systematic review and meta-analysis.

Objective: Differentiated thyroid cancer (DTC) is rare in childhood and adolescence although it represents the most frequent endocrine malignancy in this population. DTC includes both papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). Most pediatric DTCs are PTCs, while FTCs are rare. To date, no systematic reviews on the global epidemiology of pediatric and adolescent DTC have been published. This systematic review and meta-analysis aims to estimate the overall incidence and prevalence of DTCs in patients aged 0-19 years. Methods: The systematic research was conducted from January 2000 to December 2021 through MEDLINE via PubMed, Cochrane Library, and Embase databases. Two separate meta-analyses were performed for PTC and FTC. Results: After the selection phase, a total of 15 studies (3,332 screened) met the inclusion criteria and are reported in the present systematic review. Five studies were conducted in Europe, five in North America, two in South America, one in Asia, one reported data for 49 countries and territories across the five continents, and one from both the USA and Africa. Most of the studies (n = 14) reported data obtained from national registries, and only one provided information collected from hospital medical records. Beyond the actual trend over time, our study reported a pooled global incidence rate (IR) of PTC and FTC in the pediatric age of 0.46 (95% CI: 0.33-0.59) and 0.07 (95% CI: 0.02-0.12) per 100,000 person-years, respectively. The highest IRs were recorded among Caucasian girls, and the lowest in black or other races/ethnicities. Conclusion: Our data confirm that DTC in the pediatric population is a rare condition. The pooled IRs of the studies included in this meta-analysis are ~0.5 for PTC, which is the most common histological type when both genders and all age groups are considered. The implementation of a prospective international registry on pediatric DTC, as part of the wider European Registries for Rare Endocrine Conditions, has been recently proposed. In addition to providing relevant information on the clinical behavior of this rare disease, standardization of data collection will be pivotal to fill current gaps and allow an accurate estimation of the real incidence and risk factors of DTC.

Orgasm-associated incontinence (climacturia) after bladder neck-sparing radical prostatectomy: clinical and video-urodynamic evaluation.

INTRODUCTION: Orgasm-Associated Incontinence (OAI) or climacturia has been observed in male patients maintaining sexual potency after radical prostatectomy and cystectomy. AIM: We investigated the incidence and video-urodynamic aspects of this event in continent and potent patients after bladder neck-sparing (BNS) radical prostatectomy (RP). MAIN OUTCOME MEASURE: Comparing functional and morphological aspects between climacturic and non-climacturic patients to identify a possible explanation of this unusual kind of leakage that could seriously impact the sexual life after surgery. METHODS: In a pool of 84 men, potent and continent at least 1 year after BNS RP, 24 (28.6%) reported climacturia and 7 agreed to undergo video-urodynamic evaluation (group 1), which was performed also in 5 controls (group 2). Those 12 men were also evaluated with 24-hour pad test, 5-item International Index of Erectile Function and International Prostate Symptom Score questionnaires. RESULTS: Functional urethral length (FUL) was significantly lower in the climacturia group (P=0.02) and time to continence recovery was significantly longer (P=0.05). No other significant differences were found between the two groups. The radiological appearance of the vesicourethral junction at voiding cystourethrography was similar. CONCLUSIONS: To the best of our knowledge, this is the first functional and morphological evaluation of climacturia after RP. In our experience, this event is indirectly associated with a reduced FUL in the sphincter area, although both patients and controls were continent during daily activities. BNS technique seems to reduce time to continence recovery, although climacturic patients need longer time than control patients. Since in our series no rigidity of the vesicourethral anastomosis was radiographically evident, we believe that differences in FUL could explain OAI. Anatomical difference in membranous urethra length could explain the occurrence of this symptom in patients treated with the same surgical technique.

Ureteral reimplantation with psoas bladder hitch in adults: a contemporary series with long-term followup.

We retrospectively evaluated our experience with ureteral reimplantation and psoas bladder hitch to restore urinary tract continuity in patients with lower ureteral defects, since long-term data on the outcomes of this procedure have been relatively scarce in the last two decades. The procedure was performed in 24 patients (7 male, 17 female) with a mean age of 54.6 years. The mean ureteral defect length was 4.8 cm (range 3-10), the ureterovesical anastomosis was performed with simplified split-cuff technique in 18 patients, submucosal tunnel in 2, and direct anastomosis without antireflux technique in 2. Mean followup was 53 months (range 12-125), and there were no reinterventions. Postoperative renal imaging was normal in 22 cases (91.6%) and revealed decreased kidney size in 2, 3 patients presented intermittent flank pain, and 5 had sporadic episodes of lower tract UTI but no one pyelonephritis. Psoas hitch ureteral reimplantation can be successfully used for bridging defects of the lower ureter up to 10 cm in length in difficult clinical situations. It is relatively simple to perform, compared to other procedures of ureteral reconstruction, and it provides adequate protection of the upper urinary tract.

Orthotopic bladder substitute in renal transplant recipients: experience with Studer technique and literature review.

Renal transplant recipients with high-risk bladder cancer following cystectomy need a urinary diversion preserving the renal function and possibly maintaining body image, while still offering the best oncological outcome. The aim of this report is to describe our experience of radical cystectomy and orthotopic ileal neobladder with Studer technique in this population, and to review the literature. We performed radical cystectomy and Studer ileal neobladder in four male patients (median age 67 years) after median time of 9.5 years following renal transplantation. Pathology revealed pT1HGN+ transitional cell carcinoma in one case, pT1HGN0 in two and pT3aHGN0 in one. Two patients presenting aggressive disease (N+ and pT3a) died of tumour progression after 20 and 14 months, respectively, while the other two are alive after 56 and 36 months of follow-up with no evidence of disease, stable serum creatinine (2.29 and 1.6 mg/dl) and mild metabolic acidosis. Day and night-time urinary continence were satisfactory in all patients. Good functional outcomes have been reported in the 20 cases of ileal orthotopic neobladder with different techniques published so far and the global experience of 24 cases with a median follow-up of 39 months documents a cancer specific survival of 62.5%.

Candida bezoars with urinary tract obstruction in two women without immunocompromising conditions.

More than half of the cases of fungal infections of the urinary tract are caused by Candida sp., but occurrence of obstructive uropathy caused by mycetomas or fungus balls (urobezoars) is extremely rare. The latter are conglomerates of fungal hyphae. Diabetes mellitus, immunosuppression, chronic disease, and malignancies are known predisposing factors. Preoperative imaging is not pathognomonic; blood clots, radiolucent urinary calculi, air bubbles, and inflammatory debris can mimic urobezoars. We report on two otherwise healthy women presenting with urinary tract obstruction caused by candidal mycetomas of the renal pelvis that mimicked matrix lithiasis.

Nutritional iodine status and obesity.

Iodine is an essential component of the thyroid hormones, thyroxine and triiodothyronine. Its availability strictly depends on iodine content of foods, which may vary from very low to very high. Inadequate iodine intake (deficiency or excess) may affect thyroid function resulting in hypothyroidism or hyperthyroidism. Based on median urinary iodine concentrations, epidemiological criteria have been established for the categorization and monitoring of nutritional iodine status of a population (or subgroups of populations). Additional methods for iodine intake assessment include measurement of thyroid size (by thyroid palpation or ultrasonography) and of biochemical parameters, such as neonatal thyroid stimulating hormone, thyroglobulin and thyroid hormones.Recent studies carried out in overweight/obese children and adults provide evidence that body mass index (BMI) may significantly influence the above indicators, thus theoretically affecting the epidemiological evaluation of nutritional iodine status in populations.In this short review, we analyze current knowledge on the effects of overweight and obesity on indicators of adequacy and monitoring of iodine status, namely urinary iodine excretion and thyroid volume and echogenicity.Data on urinary iodine excretion in overweight/obese children are divergent, as both increased and reduced levels have been reported in overweight/obese children compared to normal-weight controls.Whether gastrointestinal surgery may affect iodine absorption and lead to iodine deficiency in patients undergoing bariatric surgery has been evaluated in a limited number of studies, which excluded iodine deficiency, thus suggesting that supplements usually recommended after bariatric surgery do not need to include iodine.Albeit limited, evidence on thyroid volume and obesity is consistent with a direct relationship between thyroid volume and BMI, irrespective of nutritional iodine status. Finally, a higher frequency of thyroid hypoechoic pattern has been described in overweight/obese children. This finding has been recently related to an increased adipocyte infiltration and thyroid parenchyma imbibition mediated by inflammatory cytokines and should be considered when the frequency of thyroid hypoechoic pattern is used as non-invasive marker to indirectly assess thyroid autoimmunity in monitoring Universal Salt Iodization programs. Further studies, specifically addressing the role of schoolchildren body mass index as a factor potentially influencing iodine intake indicators are needed.

Latrodectism in Italy: First report of successful treatment of L. tredecimguttatus envenomation using L. mactans antivenom from North America.

INTRODUCTION: Latrodectism is a rare, but potentially severe, clinical syndrome caused by spider of the genus Latrodectus. L. tredecimguttatus is widespread in Italy and its bite cause the injection of α-latrotoxin that cause depletion of acetylcholine at motor nerve endings and release of catecholamines at adrenergic nerve endings. We describe the first clinical case of L. tredecimguttatus poisoning successfully treated with L. mactans antivenom from North America. CASE REPORT: A healthy 60-year-old patient was admitted to the emergency department after unknown insect sting or arachnid/snake bite. In the early morning, the patient was working in the countryside when he felt a sting-like pain in the medial area of the right lower leg, associated with an intense burning sensation. An hour later he developed agitation, hoarseness, sweating, abdominal distress and intense pain in his right leg. In the emergency room vital signs showed a hypertensive crisis, tachycardia and peripheral oxygen desaturation. ECG was normal and ABE showed mixed acid-base disorder. Blood tests showed leukocytosis with neutrophilia, high levels of myoglobin, with normal coagulation and normal plasmatic cholinesterase. Neck, thorax and abdomen CT scan, with and without contrast medium, was negative. Four hours after admission hypertension worsened with board like rigid abdomen and onset of fasciculations, tremors, miosis and intense regional sweating. The definitive diagnosis of poisoning by L tredecimguttatus was based on the clinical picture. Within short time the antidote was provided by the Poison Centre and administered. A marked improvement of the symptomatology was noted after 30 minutes, and 1 hour later all symptoms were under control. The patient was discharged after 2 days. CONCLUSIONS: The clinical presentation of a patient suffering from latrodectism places the clinician in front of a challenging differential diagnosis. Following the suspicion, the first-line doctor is invited to discuss the case with a toxicologist, in order to confirm or exclude the diagnosis and implement all therapeutic measures. In our clinical case, the absence of organic lesions, laboratory tests not suggestive for other causes, and the presence of typical clinical feature suggested the diagnosis of L tredecimguttatus poisoning. This hypothesis was then supported by the close temporal relation between antivenom administration and symptoms improvement. With this case, we report the first use of L mactans antivenom from North America to treat L.tredecimguttatus poisoning and we confirm its effectiveness in counteracting latrodectism caused by this spider.

The role and extension of lymphadenectomy in bladder cancer: a review of the current literature.

Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the gold standard for high grade and muscle invasive bladder cancer. Although consensus exists on the need for node dissection, its extent and role are still matter of debate. However, an ever-growing body of data supports an extended dissection since it may provide a survival advantage in both node positive and node negative patients without significantly increasing morbidity and mortality. Besides dissection extent, the modality of specimen submission and node retrieval have a key role in the quality of node assessment. Moreover the stage of primary bladder tumor, the total number of lymph nodes removed, the lymph node tumor burden, the extracapsular extension and the lymph node density have been demonstrated to be important prognostic variables in patients undergoing cystectomy with node metastases and could be useful to accurately stratify patient risk in order to identify those who may benefit from adjuvant therapies. Even if evidence from the literature is only based on retrospective studies, an extended dissection at the time of cystectomy appears to provide a more accurate staging and enhance survival; future prospective studies taking into account the new prognostic factors are needed.

Thulium laser enucleation of the prostate (ThuLEP): Results, complications, and risk factors in 139 consecutive cases.

OBJECTIVES: To report our experience with the emerging technique of thulium laser enucleation of the prostate (ThuLEP) for the treatment for prostate hyperplasia. PATIENTS AND METHODS: Our inclusion criteria were an International Prostate Symptom Score (IPSS) of >15 and a quality-of-life (QoL) score of >3 in patients with confirmed bladder outflow obstruction, no longer responsive to medical therapy, with a significant post-void residual urine volume (PVR; >100 mL), with or without recurrent urinary tract infection and/or acute urinary retention. Patients with neurogenic bladder, urethral strictures, bladder stones, and previously failed transurethral prostate surgery were excluded. RESULTS: In all, 139 men were included in the study. The mean age was 67.8 years. The IPSS and QoL score improved by 17.6 and 2.6, respectively. The flow rate increased from a mean of 9.6 mL to 31.2 mL and the PVR decreased from a mean of 131 mL to 30 mL. On univariate and multivariate analyses, operating time was a predictive factor for haemoglobin drop during the operation. Heparin prophylaxis was the only risk factor identified for postoperative bleeding. Two patients (0.01%) required blood transfusion. One patient (0.007%) required re-intervention for bleeding control, and two patients developed urethral and bladder neck strictures (0.01%). CONCLUSION: ThuLEP is safe and reproducible. Whilst it significantly reduces intraoperative bleeding as compared to transurethral resection of the prostate, operating time and perioperative heparin prophylaxis may still lead to a Hb drop and constitute a risk factor for postoperative bleeding. Therefore, a potential risk of deep vein thrombosis requiring heparin prophylaxis should be carefully considered and balanced with the expected clinical benefit of the operation.

Renal cell carcinoma with caval involvement: contemporary strategies of surgical treatment.

OBJECTIVES: We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition. MATERIALS AND METHODS: From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration. RESULTS: Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6-90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418). CONCLUSIONS: Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.

Pseudodiverticula of ureter: radiologic and histologic findings.

A 70-year-old man with previous history of TUR-BT presented positive urinary cytology at one year follow-up. Cystoscopy with bladder mapping was negative, and IVP revealed multiple outpouchings of the right upper ureter without hydronephrosis. Ureteroscopy failed because of an underlying stricture. Surgical excision of the strictured segment and of 2.5 cm of cranial ureter was performed. Histopathology demonstrated focal hyperplasia of the urothelium with outpouchings involving only the mucosa, compatible with the diagnosis of pseudodiverticula.