Hard-to-heal peripheral wounds infected with Corynebacterium striatum: a prospective study.

OBJECTIVE: To investigate Corynebacterium striatum as a nosocomial pathogen infecting hard-to-heal peripheral wounds, such as skin wounds, soft tissue abscesses and osteomyelitis. As of 2023, the medical community were alerted against the risk of emerging systemic and central infections; on the other hand literature on peripheral cutaneous regions is still scarce. METHOD: In this study, two groups of patients with similar lesions which were infected were compared: one group with the presence of the coryneform rod, the other without. RESULTS: In total, Corynebacterium striatum was cultured from 62 patients and 131 samples. Corynebacterium striatum infection correlated well with the presence of: foot ulcer; venous leg ulcer; altered ambulation and/or altered foot loading; peripheral vascular and arterial disease; hospitalisation; malignancy; spinal cord injury; and recent administration of antibiotics (p<0.05 for all associations). Patients with Corynebacterium striatum had a lower overall survival rate compared to patients in the non-Corynebacterium striatum group (28.6 versus 31.6 months, respectively; p=0.0285). Multivariate analysis revealed that Corynebacterium striatum infection was an independent factor for poor prognosis (p<0.0001). CONCLUSION: In view of the findings of our study, Corynebacterium striatum appears to be an important opportunistic pathogen infecting peripheral tissues and complicating wound healing. Given its numerous and worrying virulence factors (such as multidrug resistance and biofilm production), particular attention should be given to this pathogen by professional wound care providers in nosocomial and outpatient environments.

Clear cell carcinoma of the stomach: a rare tumor variant imparting poor prognosis.

INTRODUCTION: Clear cell gastric cancer (CCGC) represents an extremely rare variant of adenocarcinoma of the stomach. It can be mistaken for a clear cell metastatic lesion arising from other anatomic parts, especially renal cell carcinoma. PATIENTS AND METHODS: We describe the case of a 66-year-old woman who was operated for a pyloric adenocarcinoma which resulted to be a CCGC at definitive histology. Moreover, we offer a systematic review of the current pertinent literature on CCGC. RESULTS: Our case represents the 160th example of CCGC. Clear cell aspect is due to the intracytoplasmic accumulation of glycogen in most cases, followed by mucin, lipid or water; the reason of the underlying biochemical process is still unclear. Paralleling other epithelial clear cell malignancies (as ovarian, bladder, urothelial or pancreatic cancers), also CCGC shows a more aggressive clinical behavior over conventional neoplastic counterparts. CONCLUSIONS: Differently from clear cell carcinomas involving other organs, CCGC has been rarely investigated by the literature. Since, compared to non clear cell cancers, this particular phenotype of gastric cancer appears to be associated with poorer prognosis, further studies are needed in order to corroborate its real adverse prognostic significance and standardize the correct management and treatment.

Blood stream infections during the first wave of COVID-19. A short microbiological retrospective picture at Papa Giovanni XXIII Hospital, Bergamo, Italy.

This paper aims to describe the etiology of bloodstream infections in COVID-19, Papa Giovanni XXIII Hospital, Bergamo, Italy. Two periods were evaluated: February 22-May 21, 2019/2020. We considered: the number of patients and blood culture sets, species of isolates (bacteria, specifically those indicated by EARS criteria; CoNS; Candida albicans) and their antibiotic sensitivity. In 2020 Escherichia coli and Carbapenemase-producing Klebsiella pneumoniae disappeared. Candida albicans and MDR Pseudomonas aeruginosa, Enterococcus faecium and Acinetobacter baumannii were largely present. The analysis shows: 1. BSIs number was the same; 2. In the first month of the COVID-19 period, BSIs were uncommon; 3. Microbial etiologies were different; 4. MDR isolates were less common.

Down-regulated miRs specifically correlate with non-cardial gastric cancers and Lauren's classification system.

BACKGROUND AND OBJECTIVES: Gastric cancers are usually characterized using Lauren's classification into intestinal and diffuse types. We previously documented the down-modulation of miR31, miR148a, miR204, and miR375 in gastric cancers. We aimed this manuscript to investigate these miRs with the end-points of diagnosis, Lauren's classification and prognosis. METHODS: A total of 117 resected non-cardial adenocarcinomas were evaluated for miRs' expressions. The performance of miRs' expressions for cancer diagnosis was tested using ROC curves. Logistic regression was conducted with the end-point of Lauren's classification. Kaplan-Meier and Cox analyses were performed for OS, DFS, and DSS. miRs' targets were reviewed using PRISMA method and BCL-2 was further investigated in cell lines. RESULTS: ROC curves documented that miRs' down-modulation was significant in differentiating cancer versus normal tissues. Diffuse type cancers were associated with female sex, young age, and miR375 higher expression. We confirmed BCL-2 as a miR204 target. However, survival analyses confirmed the pathologic criteria (advanced stages, LNR, and low LNH) as the significant variables correlated to worse prognosis. CONCLUSIONS: The down-modulation of miR31, miR148a, miR204, and miR375 is significantly associated with non-cardial gastric cancers and miR375 is specifically linked to Lauren's classification. Nevertheless, standard pathological features display as the independent variables associated with worse prognosis.

Early onset pancreatic cancer: risk factors, presentation and outcome.

BACKGROUND: About 10% of pancreatic cancer patients are aged ≤50 at diagnosis and defined as Early Onset Pancreatic Cancer (EOPC). There is limited information regarding risk factors for EOPC occurrence and their outcome. AIM: To investigate risk factors, presentation features and outcome of EOPC patients. METHODS: Consecutive, histologically confirmed, pancreatic cancer patients enrolled. Data regarding environmental and genetic risk factors, clinical and pathological information, treatment and survival were recorded. EOPC patients (aged ≤50 at diagnosis) were compared to older subjects. RESULTS: Twenty-five of 293 patients (8.5%) had EOPC. There was no difference regarding sex distribution, medical conditions and alcohol intake between EOPC and older subjects. EOPC patients were more frequently current smokers (56% vs 28% p = 0.001) and started smoking at a significantly lower mean age (19.8 years, 95%CI 16.7-22.9) as compared to older patients (26.1, 95%CI 24.2-28) (p = 0.001). Current smoking (OR 7.5; 95%CI 1.8-30; p = 0.004) and age at smoking initiation (OR 0.8 for every increasing year; 95%CI 0.7-0.9; p = 0.01) were significant and independent risk factors for diagnosis of EOPC. There were no differences regarding genetic syndromes and pancreatic cancer family history. EOCP presented less frequently with jaundice (16% vs 44%, p = 0.006) and had a higher rate of unresectable disease, albeit not significantly (84% vs 68%, p = 0.1). EOPC patients were more frequently fit for surgery or chemotherapy than their counterpart, resulting in similar stage-specific survival probability. CONCLUSION: EOPC seems related to active and early smoking but not to familial syndromes. Young patients display aggressive disease but not worse outcome.

Technical characteristics can make the difference in a surgical linear stapler. Or not?

BACKGROUND: Anastomotic leak (AL) after gastrointestinal surgery is a severe complication associated with relevant short- and long-term sequelae. Most of the anastomosis are currently performed with a surgical stapler that is required to have appropriate characteristics to guarantee good performances. The aim of our study was to evaluate, in the laboratory, pressure resistance and tensile strength of anastomosis performed with different surgical linear staplers, available in the market. MATERIALS AND METHODS: We have been studying three linear staplers, with diverse cartridges and staple heights, of three different companies, used for gastrointestinal anastomosis and gastric or intestinal closure. We performed 50 anastomosis for each device, with the pertinent different cartridges, on fresh pig intestine, for a total of 350 anastomosis, then injected saline solution and recorded the pressure that provokes a leak on the staple line. There were no statistically significant differences between the mean pressure necessary to induce an AL in the various instruments (P > 0.05). For studying the tensile strength, we performed a total of 350 anastomosis with the different linear staplers on a special strong paper (Tyvek), then recorded the maximal tensile force that could open the anastomosis. RESULTS: There were no statistically significant differences between the different staplers about the strength necessary to open the staple line (P > 0.05). CONCLUSIONS: we demonstrated that different linear staplers of three companies available in the market give comparable anastomotic pressure resistance and tensile strength. This might suggest that small dissimilarities between different devices are not involved, at least as major parameters, in AL etiology.

Epididymal-testicular fusion anomalies in cryptorchidism are associated with proximal location of the undescended testis and with a widely patent processus vaginalis.

Past studies documented the presence of epididymal/testicular fusion anomalies and persistence of a patent processus vaginalis in a small case-series of cryptorchid and/or hydrocele patients. The primary aim of this study was to determine the prevalence of the epididymal/testicular anomalies in a series of more than 1000 cryptorchid patients compared with controls. Secondary aims were: (i) to investigate the association between the cryptorchidism and the patency of p. vaginalis; and (ii) to correlate the epididymal/testicular fusion anomalies with the position of the testis and with the patency of the p. vaginalis. The clinical and surgical data of 1002 cryptorchid patients and 230 controls were retrospectively retrieved and analysed. Epididymal/testicular fusion anomalies were classified as: (i) normal anatomy; (ii) minor anomalies; and (iii) major anomalies. Statistical analysis was performed using the Student's t-test and Chi-square tests. The prevalence of the epididymal/testicular fusion anomalies was higher in the cryptorchid group compared with that of the control group (minor and major anomalies in cryptorchids vs. controls, respectively: 42.2 vs. 5.6% and 9.3 vs. 1.6%, P < 0.0001). Moreover, we documented a correlation of these anomalies with a more proximal localization of the testis (minor and major anomalies in proximal vs. distal location of the testis, respectively: 62.5 vs. 34.8% and 19.1 vs. 6.3%, P < 0.0001) and with the persistence of a widely patent p. vaginalis (minor and major anomalies in widely patent p. vaginalis vs. narrow duct, respectively: 51.7 vs. 42.2 and 11.9% vs. 7.8%, P < 0.001). In conclusion, the epididymal/testicular fusion anomalies were strongly associated with cryptorchidism and the persistence of a widely patent peritoneal vaginal duct. Although it remains unclear whether these anomalies cause non-descent of the testis or, conversely, result from the cryptorchidism or from the persistence of a widely patent duct, our data re-enforce this association.

Is EUS-FNA of solid-pseudopapillary neoplasms of the pancreas as a preoperative procedure really necessary and free of acceptable risks?

BACKGROUND: Solid-pseudopapillary neoplasms (SPNs) of the pancreas are infrequent tumors since, as of 2014, only 2744 patients have been described. Its rarity, unclear histogenesis, pleomorphic aspect on radiology (cystic, solid or mixed) and unpredictable biological behavior with an insidious high-grade malignant potential make SPN difficult to recognize preoperatively even in its target patient population which is predominantly composed of young women (about 87% of cases). METHODS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) showed to improve the preoperative diagnostic yield for this tumor and obviate the risks formerly given by percutaneous biopsy. RESULTS: In light of our experience, such a procedure could not be so innocuous as generally acknowledged. CONCLUSION: We report the first case of rupture of pancreatic SPN following EUS-FNA and entertain both the actual and potential complications ensuing from this type of mishap.

Prognostic assessment of different lymph node staging methods for pancreatic cancer with R0 resection: pN staging, lymph node ratio, log odds of positive lymph nodes.

BACKGROUND AND AIMS: Survival after surgical resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumour grading have been identified. The aims of the present study were to evaluate and compare the prognostic assessment of different lymph nodes staging methods: standard lymph node (pN) staging, metastatic lymph node ratio (LNR), and log odds of positive lymph nodes (LODDS) in pancreatic cancer after pancreatic resection. MATERIALS AND METHODS: Data were retrospectively collected from 143 patients who had undergone R0 pancreatic resection for pancreatic ductal adenocarcinoma. Survival curves (Kaplan-Meier and Cox proportional hazard models), accuracy, and homogeneity of the 3 methods (LNR, LODDS, and pN) were compared to evaluate the prognostic effects. RESULTS: Multivariate analysis demonstrated that LODDS and LNR were an independent prognostic factors, but not pN classification. The scatter plots of the relationship between LODDS and the LNR suggested that the LODDS stage had power to divide patients with the same ratio of node metastasis into different groups. For patients in each of the pN or LNR classifications, significant differences in survival could be observed among patients in different LODDS stages. CONCLUSION: LODDS and LNR are more powerful predictors of survival than the lymph node status in patients undergoing pancreatic resection for ductal adenocarcinoma. LODDS allows better prognostic stratification comparing LNR in node negative patients.

Lymph-node ratio classification strongly correlates with cancer survivals of patients who underwent r0 resection for gastric cancer with more than 15 nodes harvested.

BACKGROUND: During the last few years, the gastric cancer nodal staging has been extensively revised. Lately, a new system emerged in this field with the purpose of implementing the prognostic stratification: the lymph-node ratio (LNR). The aim of this study was to investigate the prognostic value of the LNR in relation to cancer survivors undergoing resection for gastric adenocarcinoma. METHODS: Off 227 patients undergoing surgical resection for gastric cancer at our Department, 129 curative gastric resections with more than 15 nodes harvested were selected. The LNR was calculated and patients were stratified into 6 subgroups based on the ratio values. The subgroups were compared for data analysis. Survivals were calculated by the Kaplan-Meier method, and the mean follow-up period was 40 months. ROC curves were calculated in order to analyze the performance of the LNR system. RESULTS: LNR stratification correlated with the stage of the disease, with the rate of patients undergoing chemotherapy and patients presenting with a relapse of disease at follow-up. Moreover, an increased ratio correlated with a worse overall, a disease-free and a disease-specific survival of the patients. The ROC curves documented a significant performance of the stratification system with the endpoints of disease-free and disease-specific survivals. CONCLUSION: LNR stratification correlated with cancer-related survivals in our case series. It is a reliable system that might improve current nodal staging and thereby the identification of patients with a higher risk of recurrence or cancer-related mortality.

Post-operative morbidity and mortality in pancreatic surgery. The role of surgical Apgar score.

BACKGROUND: Morbidity and mortality rates after pancreatic resection still remain high. The surgical Apgar score (SAS) has been recently introduced as predictive value of perioperative outcomes after pancreatic surgery. Aim of the study was to detect significant parameters affecting post-operative outcomes in pancreatic surgery, and to evaluate the role of SAS in predicting morbidity, pancreatic fistulas and mortality. MATERIALS AND METHODS: Data were collected from 143 patients who had undergone pancreatic resection for pancreatic and periampullary adenocarcinoma. Pre-operative and intra-operative parameters were statistically analyzed to evaluate their potential prognostic effects. RESULTS: A low SAS (p = 0.001), hypo-albuminemia (p = 0.003), and the need for blood transfusions (p = 0.05) were significant independent predictors of postoperative morbidity. The SAS was demonstrated to significantly predict major complications (p = 0.001) surgical site infections (p = 0.001) and mortality (p = 0.001). CONCLUSION: The SAS provides a simple, immediate, and objective means of measuring patient outcomes in surgery. This score should be used to identify patients at high risk of major complications and death after pancreatic surgery and may be useful to optimize the use of postoperative critical care beds and hospital resources.

Malnutrition and pancreatic surgery: prevalence and outcomes.

BACKGROUND: Pancreatic surgery is associated with severe postoperative morbidity. Identification of patients at high risk may provide a way to allocate resources objectively and focus care on those patients in greater need. The Authors evaluate the prevalence of malnutrition and its effect on the postoperative morbidity of patients undergoing pancreatic surgery for malignant tumors. METHODS: Data were collected from 143 patients who had undergone pancreatic resection for cancer. Prevalence of malnutrition was evaluated by several validated screening tools and correlated to the incidence of surgical site infection, overall morbidity, mortality, and hospital stay. RESULTS: Overall, 88% of patients were at medium-high risk of malnutrition. Patients at high risk of malnutrition presented a fourfold longer postoperative hospitalization period and a higher morbidity rate (53.2%) than those patients at low risk of malnutrition. Malnutrition, evaluated by MUST and NRI, was an independent predictor of overall morbidity using multivariate analysis (P = 0.00145, HR = 2.6581, 95% CI = 1.3589-8.5698, and P = 0.07129, HR = 1.9953, 95% CI = 0.9723-13.548, respectively). CONCLUSION: Malnutrition is a relevant predictor of post-operative morbidity and mortality after pancreatic surgery. Patients underwent pancreatic resection for malignant tumors are usually malnourished. Preoperative malnutrition screening is mandatory in order to assess the risk and to treat the malnutrition.

Prevention of congenital Chagas disease by screening of mothers and monitoring of serological tests of neonates: the seven years' experience.

Approximately 14000 immigrants coming from the Cochabamba area of Bolivia, with an increased risk of congenital Chagas Disease (CD), are currently living in Bergamo, Italy. According to the World Health Organization (WHO) recommendation (2011), prevention of congenital CD involves testing all pregnant women at risk of infection and performing follow-up of their newborns. In our study, all pregnant women of Latin American origin were tested for the presence of Trypanosoma cruzi antibodies and children, born to mothers found to be positive, were followed up after delivery. T. cruzi antibodies were detected using a chemiluminescence immunoassay. The test was also performed on siblings and fathers of children with CD, and women of childbearing age to prevent the congenital infection, as proposed by 2011 WHO recommendation. In the study period 1105 patients were tested for CD, using a serological test: 934 (85%) were females and 171 (15%) were males. Of the 62 newborns, from mothers who tested positive, 28 were females and 34 were males. The number of positive adults and siblings identified was 148 (14%). Among the adults and siblings born between 1991 and 2011 only 3 (2%) of females tested positive to serological test. All neonates, with the exception of one, were classified as non-infected according to the follow-up of index value of CD serology. This study confirms the usefulness of serological tests and of their index value as follow-up. The difference of positivity rate for CD antibodies between people born before and after 1990 should be further investigated to generate information that potentially improve the prevention and control of CD.

The glasgow prognostic score as a predictor of survival in patients with potentially resectable pancreatic adenocarcinoma.

BACKGROUND: Survival rates after resection of pancreatic adenocarcinoma are poor; however, several tumor-related prognostic factors have been identified. There is increasing evidence that additional patient-related prognostic factors, such as ongoing systemic inflammatory response, are associated with poor outcomes in patients with common solid tumors. The purpose of this study was to evaluate the prognostic significance of the modified glasgow prognostic score (mGPS) in resected pancreatic ductal adenocarcinoma. METHODS: Data were collected from 101 patients who had undergone pancreatic resection for ductal adenocarcinoma. Tumor and host factors were analyzed by Kaplan-Meier and Cox proportional hazard models to evaluate their potential prognostic effects. RESULTS: An elevated mGPS was associated with lower overall survival rate after pancreatic resection. The median actuarial survival rate for patients with an mGPS of 0, 1, or 2 was 37.2, 11.5, and 7.3, respectively (p = 0.0001). The Cox proportional hazards model, including all the parameters statistically significant at univariate analysis, demonstrated that mGPS, lymph node ratio (LNR), and positive resection margins were independent negative prognostic factors CONCLUSIONS: Margin involvement, LNR, and the preoperative mGPS were identified as independent predictors of survival in patients undergoing potentially curative pancreatic resection. Based on the present results and existing validation literature, the mGPS should be included in the routine assessment of patients with pancreatic cancer to better stratify patients for entry into therapeutic trials.

Number of harvested lymph nodes is the main prognostic factor in Stage IIa colorectal cancer patients.

BACKGROUND: Current international guidelines on colorectal cancer (CRC) treatment suggest performing adjuvant chemotherapy only in Stage II patients presenting with high-risk prognostic factors. Aim of the study was to a the impact of these parameters on the survival of Stage IIa CRC patients, focusing on the prognostic value of the number of harvested lymph nodes (NHLN). PATIENTS AND METHODS: Out of 651 CRC patients undergoing surgical resection, 204 T3-N0-M0 were selected and reviewed. Univariate and multivariate survival analyses were adapted for the evaluation of the prognostic factors. RESULTS: The 5 years actuarial DFS, DSS, and OS rates of patients with a NHLN >12 were significantly better compared to those of patients with a NHLN <12 (respectively: 72.8% vs. 50.4% P=0.001; 82% vs. 56% P=0.001; 78.5% vs. 53.1% P=0.001). Multivariate analysis revealed that a NHLN >12 was the only independent parameter of statistical significance influencing DFS, DSS, and OS. CONCLUSIONS: According to our findings, the NHLN is the main predictor of survival in Stage IIa CRC patients. This would appear to suggest the need of a better stratification of Stage IIa CRC patients, sub-dividing patients with more or less than 12 NHLN.

[New therapeutic prospects for renal transplant: extracorporeal photochemotherapy]. / Nuove prospettive terapeutiche per il trapianto di rene: la fotochemioterapia extracorporea.

Since 1960, different classes of immunosuppressive drugs have been used in the post-transplant follow-up. Each is assessed for its effectiveness in preventing rejection but also on the basis of the many side effects induced by prolonged treatment. To reduce these side effects, continuous development of knowledge and medical technology to create cutting-edge therapies in the field is necessary. One of these is extracorporeal photochemotherapy (ECP), an immunomodulatory therapy approved by the United States Food and Drug Administration in 1988 for the treatment of advanced forms of cutaneous T-cell lymphoma. EC P is a useful therapeutic tool for the development of immunomodulation supported by CD8+ clone-specific cytotoxic lymphocytes. The T cells targeted by EC P are modified by photoactivation and seem to develop marked immunogenicity with no suppression of the immune response. Recent studies suggest the possible utility of EC P in the treatment of glomerulonephritis and in countering rejection after transplantation of organs including the kidney.

Role of the lymph node ratio in pancreatic ductal adenocarcinoma. Impact on patient stratification and prognosis.

BACKGROUND: Survival after resection of pancreatic adenocarcinoma is poor. Several prognostic factors such as the status of the resection margin, lymph node status, or tumor grading have been identified. Aim of the study was to evaluate the prognostic significance of the lymph node ratio (LNR) for resected pancreatic ductal adenocarcinoma. MATERIALS AND METHODS: Data were collected from 101 patients who had undergone pancreatoduodenectomy for pancreatic ductal adenocarcinoma. Patients were divided into four groups according to the absolute LNR (0, 0-0.199, 0.2-0.399, >0.4). Kaplan-Meier and Cox proportional hazard models were used to evaluate the prognostic effect. RESULTS: The actuarial 3- and 5-year survival rates were 32 and 17%, respectively. The median survival was 19 months. Patients with LNR 0/0-0.199/0.2-0.399/>0.4 survived 40.2/30.5/18.1, and 13.6 months, respectively (P = 0.001). At the multivariate analysis, lymph node status was not found to be a significant prognostic factor; on the contrary LNR >0.2 (P = 0.007), positive resection margin (P = 0.001), and grading (P = 0.05) were significantly related to survival. CONCLUSION: LNR is a more powerful predictor of survival than the lymph node status in patients undergoing pancreaticoduodenectomy for ductal adenocarcinoma.

Gastrointestinal stromal tumors: correlation between symptoms at presentation, tumor location and prognostic factors in 47 consecutive patients.

BACKGROUND: Gastrointestinal stromal tumors (GIST) are mesenchymal tumors of the gastrointestinal tract, usually kit-positive, that are believed to originate from interstitial cell of Cajal, or their related stem cells. The most common clinical presentation of these tumors is gastrointestinal bleeding, otherwise they may cause intestinal obstruction, abdominal pain, a palpable mass, or can be incidentally detected during surgery or endoscopic/radiological procedures. Prognosis is related to the size of the tumor and to the mitotic rate; other prognostic factors are tumor location, tumor resection margins, tumor rupture, and c-kit mutation that may interfere with molecular target therapy efficacy. AIM: Primary aim of this study was to report our experience regarding GIST patients, correlating symptoms at presentation with tumor localization and risk factors. PATIENTS AND METHODS: 47 consecutive patients undergone to surgical resection for GISTs were enrolled in a prospective study from December 1999 to March 2009. Patient's clinical and pathological features were collected and analysed. RESULTS: The most common symptom was abdominal pain. Bleeding in the digestive tract and abdominal pain were more frequent in gastric GISTs (58% and 61%); acute abdominal symptoms were more frequent in jejunal and ileal GISTs (40% and 60%), p < 0.05. We reported a mild correlation between the mitotic rate index and symptoms at presentation (p 0.074): this correlation was stronger if GISTs causing "acute abdominal symptoms" were compared with GISTs causing "abdominal pain" as main symptom (p 0.039) and with "incidental" GISTs (p 0.022).We observed an higher prevalence of symptomatic patients in the "high risk/malignant group" of both the Fletcher's and Miettines's classification (p < 0.05). CONCLUSION: According with our findings symptoms correlate to tumor location, to class risk criteria as mitotic index and risk classifications, however we cannot conclude that symptoms are per se predictive of survival or patient's outcome.