Laparoscopic Heller-Dor is an effective long-term treatment for end-stage achalasia.

BACKGROUND: The end-stage achalasia is a difficult condition to treat, for the esophageal diameter and conformation of the gullet, that may progress to a sigmoid shape. The aim of this study was to examine the outcome of Laparoscopic Heller-Dor in patients with end-stage achalasia, comparing them with patients who had mega-esophagus without a sigmoid shape. METHODS: From 1992 to 2020, patients with a diagnosis of sigmoid esophagus, or radiological stage IV achalasia (the SE group), and patients with a straight esophagus larger than 6 cm in diameter, or radiological stage III achalasia (the NSE group), were all treated with LHD. The two groups were compared in terms of patients' symptoms, based on the Eckardt score, and on barium swallow, endoscopy and manometry performed before and after the treatment. The failure of the treatment was defined as an Eckardt score > 3, or the need for further treatment. RESULTS: The study involved 164 patients: 73 in the SE group and 91 in the NSE group. No intra- or postoperative mortality was recorded. The median follow-up was 51 months (IQR 25-107). The outcome was satisfactory in 71.2% of patients in the SE group, and in 89% of those in the NSE group (p = 0.005). CONCLUSIONS: SE is certainly the worst condition of the disease and the final outcome of LHD, in term of symptom control, is inferior compared to NSE. Despite this, almost 3/4 of the SE patients experienced a significant relieve in symptoms after LHD, which may therefore still be the first surgical option to offer to these patients, before considering esophagectomy.

Mumps clinical diagnostic uncertainty.

Background: During recent years, various mumps outbreaks have occurred among populations vaccinated for mumps worldwide. In Italy, improving routine coverage with two doses of measles, mumps and rubella (MMR) vaccine is one of the key strategies to eliminate measles and rubella. To monitor the effect of the vaccination programme on the population, the surveillance of these vaccine-preventable diseases has been implemented. This provided the opportunity to evaluate the accuracy of the clinical diagnosis of those diseases, including mumps. In fact, vaccinated children may develop a variety of diseases caused by a series of different viruses [Epstein-Barr virus (EBV), parainfluenza virus types 1-3, adenoviruses, herpes virus and parvovirus B19] whose symptoms (i.e. swelling of parotid glands) may mimic mumps. For this reason, laboratory diagnosis is essential to confirm clinical suspicion. Methods: The accuracy of clinical diagnosis of mumps was evaluated by differential diagnosis on EBV in Italy, a country at low incidence of mumps. This retrospective study investigated whether the etiology of 131 suspected mumps cases with a negative molecular/serological result for mumps virus, obtained from 2007 to 2016, were due to EBV, in order to establish a diagnosis. Results: Differential diagnosis revealed a EBV positivity rate of 19.8% and all cases were caused by EBV type 1. Conclusions: This study confirms the importance of a lab based differential diagnosis that can discriminate between different infectious diseases presenting with symptoms suggestive of mumps and, in particular, emphasize the importance to discriminate between mumps and EBV-related mononucleosis.

Effects of laparoscopic myotomy on the esophageal motility pattern of esophageal achalasia as measured by high-resolution manometry.

BACKGROUND: Esophageal achalasia can be classified on the grounds of three distinct manometric patterns that correlate well with final outcome after laparoscopic Heller-Dor myotomy (LHM). No analytical data are available, however, on the postoperative picture and its possible correlation with final outcome. The aims of this study were: (a) to investigate whether manometric patterns change after LHM for achalasia; (b) to ascertain whether postoperative patterns and/or changes can predict final outcome; and (c) to test the hypothesis that the three known patterns represent different stages in the evolution of the disease. METHODS: During the study period, we prospectively enlisted 206 consecutive achalasia patients who were assessed using high-resolution manometry (HRM) before undergoing LHM. Symptoms were scored using a detailed questionnaire. Barium swallow, endoscopy and HRM were performed, before and again 6 months after surgery. RESULTS: Preoperative HRM revealed the three known patterns with statistically different esophageal diameters (pattern I having the largest), and patients with pattern I had the highest symptom scores. The surgical treatment failed in 10 cases (4.9%). The only predictor of final outcome was the preoperative manometric pattern (p = 0.01). All patients with pattern I preoperatively had the same pattern afterward, whereas nearly 50% of patients with pattern III before LHM had patterns I or II after surgery. There were no cases showing the opposite trend. CONCLUSIONS: Neither a change of manometric pattern after surgery nor a patient's postoperative pattern was a predictor of final outcome, whereas preoperative pattern confirmed its prognostic significance. The three manometric patterns distinguishable in achalasia may represent different stages in the disease's evolution, pattern III and pattern I coinciding with the early and final stages of the disease, respectively.

Ongoing large measles outbreak with nosocomial transmission in Milan, northern Italy, March-August 2017.

A large measles outbreak has been ongoing in Milan and surrounding areas. From 1 March to 30 June 2017, 203 measles cases were laboratory-confirmed (108 sporadic cases and 95 related to 47 clusters). Phylogenetic analysis revealed the co-circulation of two different genotypes, D8 and B3. Both genotypes caused nosocomial clusters in two hospitals. The rapid analysis of epidemiological and phylogenetic data allowed effective surveillance and tracking of transmission pathways.

Measles in Italy: Co-circulation of B3 variants during 2014.

In 2013, the majority of the WHO/EUR countries reported an annual incidence of >1 case per one million population indicating that the elimination target is far from being met. Thus, there is the urgent need to uncover and analyze chains of measles virus (MV) transmission with the objective to identify vulnerable groups and avoid possible routes of introduction of MV variants in the European population. The analysis of molecular epidemiology of MV B3 strains identified in 2014 has shown that four different variants co-circulated in Italy, including the strain that caused a cruise-line ship outbreak at the beginning of the year.

Extensive Nosocomial Transmission of Measles Originating in Cruise Ship Passenger, Sardinia, Italy, 2014.

We report a measles outbreak in Sardinia, Italy, that originated in a cruise ship passenger. The outbreak showed extensive nosocomial transmission (44 of 80 cases). To minimize nosocomial transmission, health care facilities should ensure that susceptible health care workers are vaccinated against measles and should implement effective infection control procedures.

The esophageal pull-down technique improves the outcome of laparoscopic Heller-Dor myotomy in end-stage achalasia.

BACKGROUND: The treatment of patients with end-stage achalasia with a sigmoid-shaped esophagus is particularly challenging. A modified technique (pull-down technique) has been developed to straighten the esophageal axis, but only a limited number of studies on this topic are available in the literature. This study aimed to compare the outcome of patients who underwent the pull-down technique with that of patients who had a classical laparoscopic Heller-Dor (CLHD) myotomy. METHODS: All patients with a radiologic diagnosis of end-stage achalasia who underwent an LHD myotomy between 1995 and 2022 were considered eligible for the study. All patients underwent symptom score, barium swallow, endoscopy, and manometry tests before and after the procedure was performed. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score (ES) of >3 or the need for retreatment. RESULTS: Of the 94 patients who were diagnosed with end-stage achalasia (male-to-female ratio of 52:42), 60 were treated with CLHD myotomy, and 34 were treated with the pull-down technique. Of note, 2 patients (2.1%), both belonging to the CLHD myotomy group, developed a squamous cell carcinoma during the follow-up. The overall success of LHD myotomy was seen in 76 of 92 patients (82.6%). All patients in both groups achieved a lower ES after surgery. The failure rates were 27.6% (16/58) in the CLHD myotomy group and 5.9% (2/34) in the pull-down technique group (P < .01). CONCLUSION: Our findings confirm that LHD myotomy is an effective treatment of end-stage achalasia and that the pull-down technique further improves the outcome in patients with end-stage achalasia who are difficult to treat.

Manometric identikit of a functioning and effective fundoplication for gastroesophageal reflux disease in the high-resolution manometry ERA.

BACKGROUND: The pathophysiological and clinical value of performing High-Resolution Manometry (HRM) after laparoscopic fundoplication (LF) for gastroesophageal reflux disease (GERD) is still unclear and debated. OBJECTIVE: We sought to establish the HRM parameters indicative of functioning fundoplications, and whether HRM could distinguish them from tight or defective ones. METHODS: The study involved patients with GERD who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication between 2010 and 2022. HRM and 24-h pH monitoring were performed before and 6 months after surgery. The study population was divided into 5 groups: LN and LT patients with normal 24h-pH findings (LNpH- and LTpH-, respectively); LN and LT patients with pathological 24h-pH findings (LNpH+ and LTpH + groups, respectively); and patients with a postoperative dysphagia intensity score >2 (Dysphagia group). The novel Hiatal Morphology (HM) classification was applied, envisaging 3 different subtypes: HM1 (normal), HM2 (intrathoracic fundoplication), and HM3 (slipped fundoplication). RESULTS: Among the 132 patients recruited during the study period, 46 were in the LNpH- group, 51 in the LTpH- group, 15 in the LNpH + group, 7 in the LTpH + group, and 5 in the Dysphagia group. In multivariate analysis, postoperative abdominal lower esophageal sphincter length (p = 0.001) and HM2 (p < 0.001) were both independently associated with surgical failure. Integrated relaxation pressure was significantly higher in the Dysphagia group than in the LNpH- group. CONCLUSION: This study generated reference HRM values for an effective LF, and confirms that using HRM to assess the neo-sphincter and HM improves the clinical assessment in cases of symptom recurrence.

Molecular epidemiology of measles virus in Italy, 2002-2007.

BACKGROUND: The European Regional Office of the World Health Organization (WHO/Europe) developed a strategic approach to halt the indigenous transmission of measles in its 53 Member States by 2015. In view of the goal of measles elimination, it is of great importance to assess the circulation of wild-type measles virus (MV). Genetic analysis is indispensable to understand the epidemiology of measles. METHODS: Urine and saliva samples were collected between May 2002 and December 2007, in order to find the origins and routes of wild type measles virus circulation. RT-PCR was performed on a total of 414 clinical samples of patients from different Italian regions. The results confirmed the genome presence in 199 samples, out of which 179 were sequenced. The sequences were genotyped by comparing the fragment coding for the carboxyl terminus of the nucleoprotein (450 nucleotides) with that one of the WHO reference strains. RESULTS: From the year 2002 to the year 2007 phylogenetic analysis of measles sequences showed a predominant circulation of the D7 genotype in the Italian territory for the years 2002-2004. This genotype was replaced by D4 and B3 genotypes in the biennium 2006-2007. During the same period C2, A, D5 and D8 genotypes were also detected. CONCLUSIONS: Genetic characterization of wild-type MV provides a means to study the transmission pathways of the virus, and is an essential component of laboratory-based surveillance. Knowledge of currently circulating measles virus genotype in Italy will help in monitoring the success of the measles elimination programme and will contribute to evaluate the effectiveness of future vaccination campaigns.

SARS-CoV-2 infection: the environmental endurance of the virus can be influenced by the increase of temperature.

OBJECTIVES: To evaluate whether the increase of temperature can influence the environmental endurance of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). METHODS: Virus was inoculated on a plastic surface and harvested at predefined time-points in parallel at 20°C-25°C (room temperature; RT) and at 28°C (June temperature; JT). Samples were tested by TCID50 titres on Vero cells. RESULTS: Our results confirm that fomite transmission of the emerging SARS-CoV-2 is possible: the virus reserved its ability to infect cells for up to 84 hours at both RT and JT on a plastic surface, with TCID50 viral titres of 0.67 and 0.25 log10, respectively. At RT, an important reduction in the viral titre, from 4 log10 to 3 log10 TCID50, was observed during the first 24-36 hours. At JT, the same decay was observed more rapidly (between 8 and 12 hours), The rate of viral inactivation by D-value was 24.74 hours at RT and 12.21 hours at JT. CONCLUSIONS: This remarkable difference between the two temperatures suggests that virus vitality can be influenced by the environmental temperature and that the hot season could reduce the probability of COVID-19 transmission.

Laparoscopic Heller-Dor Is an Effective Treatment for Esophageal-Gastric Junction Outflow Obstruction.

BACKGROUND: The treatment of esophagogastric junction outflow obstruction (EGJOO) currently mirrors that of achalasia, but this is based on only a few studies on small case series. The aim of this prospective, controlled study was to assess the outcome of laparoscopic Heller-Dor (LHD) in patients with EGJOO, as compared with patients with esophageal achalasia. MATERIALS AND METHODS: Between 2016 and 2019, patients with manometric diagnosis of idiopathic EGJOO and patients with radiological stage I achalasia, both treated with LHD, were compared. The achalasia group was further analyzed by subgrouping the patients based on the manometric pattern. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3 or the need for retreatment. RESULTS: During the study period, 150 patients were enrolled: 25 patients had EGJOO and 125 had radiological stage I achalasia (25 pattern I, 74 pattern II, and 26 pattern III). The median follow-up was 24 months (IQR: 34-16). Treatment was successful in 96% of patients in the EGJOO group and in 96% of achalasia patients with pattern I, 98.7% in those with pattern II, and 96.2% of those with pattern III (p=0.50). High-resolution manometry showed a reduction in the LES resting pressure and integrated relaxation pressure for all patients in all 4 groups (p<0.001). CONCLUSION: This is the first comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. LHD emerged as an effective treatment for EGJOO, with an excellent success rate, comparable with the procedure's efficacy in treating early-stage achalasia.

Immunogenicity of Viral Vaccines in the Italian Military.

Military personnel of all armed forces receive multiple vaccinations and have been doing so since long ago, but relatively few studies have investigated the possible negative or positive interference of simultaneous vaccinations. As a contribution to fill this gap, we analyzed the response to the live trivalent measles/mumps/rubella (MMR), the inactivated hepatitis A virus (HAV), the inactivated trivalent polio, and the trivalent subunits influenza vaccines in two cohorts of Italian military personnel. The first cohort was represented by 108 students from military schools and the second by 72 soldiers engaged in a nine-month mission abroad. MMR and HAV vaccines had never been administered before, whereas inactivated polio was administered to adults primed at infancy with a live trivalent oral polio vaccine. Accordingly, nearly all subjects had baseline antibodies to polio types 1 and 3, but unexpectedly, anti-measles/-mumps/-rubella antibodies were present in 82%, 82%, and 73.5% of subjects, respectively (43% for all of the antigens). Finally, anti-HAV antibodies were detectable in 14% and anti-influenza (H1/H3/B) in 18% of the study population. At mine months post-vaccination, 92% of subjects had protective antibody levels for all MMR antigens, 96% for HAV, 69% for the three influenza antigens, and 100% for polio types 1 and 3. An inverse relationship between baseline and post-vaccination antibody levels was noticed with all the vaccines. An excellent vaccine immunogenicity, a calculated long antibody persistence, and apparent lack of vaccine interference were observed.

Description of two measles outbreaks in the Lazio Region, Italy (2006-2007). Importance of pockets of low vaccine coverage in sustaining the infection.

BACKGROUND: Despite the launch of the national plan for measles elimination, in Italy, immunization coverage remains suboptimal and outbreaks continue to occur. Two measles outbreaks, occurred in Lazio region during 2006-2007, were investigated to identify sources of infection, transmission routes, and assess operational implications for elimination of the disease. METHODS: Data were obtained from several sources, the routine infectious diseases surveillance system, field epidemiological investigations, and molecular genotyping of virus by the national reference laboratory. RESULTS: Overall 449 cases were reported, sustained by two different stereotypes overlapping for few months. Serotype D4 was likely imported from Romania by a Roma/Sinti family and subsequently spread to the rest of the population. Serotype B3 was responsible for the second outbreak which started in a secondary school. Pockets of low vaccine coverage individuals (Roma/Sinti communities, high school students) facilitated the reintroduction of serotypes not endemic in Italy and facilitated the measles infection to spread. CONCLUSIONS: Communities with low vaccine coverage represent a more serious public health threat than do sporadic susceptible individuals. The successful elimination of measles will require additional efforts to immunize low vaccine coverage population groups, including hard-to-reach individuals, adolescents, and young adults. An enhanced surveillance systems, which includes viral genotyping to document chains of transmission, is an essential tool for evaluating strategy to control and eliminate measles.

Extending Myotomy Both Downward and Upward Improves the Final Outcome in Manometric Pattern III Achalasia Patients.

Background: Achalasia is currently classified in three manometric patterns. Pattern III is the least common pattern, and reportedly correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome in pattern III achalasia patients after classic laparoscopic myotomy (CLM) as compared with a myotomy lengthened both downward and upward (long laparoscopic myotomy [LLM]). Materials and Methods: The study population consisted of 61 consecutive patients with a diagnosis of pattern III achalasia who underwent laparoscopic myotomy between 1997 and 2017. In CLM the total length of the myotomy was ≤9 cm, whereas myotomies extending both downward and upward to a length >9 cm were defined as LLM. Results: Of the 61 patients considered, 24 had CLM and 37 had LLM. The postoperative improvement in symptom score differed between the two groups: it dropped from 22 (17-26) to 4 (0-8) in the CLM group and from 20 (17-24) to 3 (0-6) in the LLM group (P < .001). There were 8 of 24 failures (33.3%) in the former group and 4 of 37 (10.8%) in the latter group (P < .05). An abnormal acid exposure was detected after the treatment of CLM in 4 patients and after the treatment of LLM in 3 patients (P = n.s.). Conclusions: Although with the intrinsic limitations of this study (retrospective, different time windows of the two procedures, and different lengths of follow-up), the results indicate that extending the myotomy both downward and upward improves the final outcome of laparoscopic Heller-Dor surgery in pattern III achalasia patients. A longer myotomy does not affect any onset of postoperative gastroesophageal reflux.

Traction on the septum during transoral septotomy for Zenker diverticulum improves the final outcome.

OBJECTIVE: Transoral diverticulostomy/septotomy has become a popular treatment for patients with Zenker diverticulum (ZD). To improve the results of transoral stapler-assisted septotomy, a modification of the technique has been introduced. In this study, we aimed to compare the final outcome of such a modified transoral septotomy (MTS) with the results of traditional transoral septotomy (TTS) in patients with ZD. METHODS: Fifty-two consecutive patients with ZD underwent transoral stapler-assisted septotomy between 2010 and 2018. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow, endoscopy, and manometry were performed before and after the procedure. RESULTS: Of the 52 patients forming the study population (male:female = 35:17), 25 had TTS and 27 had MTS. The patients' demographic and clinical parameters were similar in the two groups. No intraoperative mucosal lesions were detected, and the mortality was nil. The median time taken to complete the procedure was 25 minutes (interquartile range [IQR]: 22-35) for TTS, and 30 minutes (IQR: 25-36) for MTS (P < 0.07). The median follow-up was 69 months (IQR: 46-95) in the TTS group and 30 months (IQR: 25-35) in the MTS group. All patients in both groups had an improvement in their symptom score after the procedure, but the failure rates were 32% (8 of 25) after TTS and 3.7% (1 of 27) after MTS (P < 0.02). At univariate and multivariate analyses, the procedure was the only predictor of a positive final outcome. CONCLUSION: Albeit with the intrinsic limitations of the study (retrospective, different time window, and different follow-up), traction on the septum during transoral septotomy improves the final outcome of this treatment in patients with ZD. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:637-640, 2020.

Selective involvement of temporal regions in a case of flavivirus encephalitis.

Clinical manifestations of flavivirus infection may be various, from unapparent to severe meningoencephalitis. Our patient, 2 weeks after returning home from a holiday at Elba Island, developed biphasic fever, later associated with nausea and vomiting and followed by incoming seizures responsive to thiopental sodium only. Brain MRI showed bilateral hyperintensity (T2) in amygdale, hippocampus, left insular and temporal inferior cortex. Standard and microbiological CSF examination was normal, but microbiological serum analysis showed seroconversion for flavivirus. The patient came to our observation 6 months after disease onset and at that time he was affected by frequent seizures and severe cognitive impairment with behavioural disturbances; the patient also showed distal weakness with footstepping. EEG showed bitemporal epileptic foci. During the following months, seizures greatly decreased and cognitive status improved in response to a complex antiepileptic therapy. Flavivirus encephalitis should be taken into account in the differential diagnosis of encephalitis selectively involving temporal lobes.

Measles in Italy: Viral strains and crossing borders.

In 2017, Italy experienced one of the largest outbreaks of measles in recent years, with 5404 notified cases and 4347 confirmed cases. A further 2029 cases were notified during the first 6 months of 2018, and 1516 of them were laboratory-confirmed. The B3 and D8 genotypes were identified as those responsible for the outbreak. Possible transmission routes can be established by monitoring the circulating measles virus strains in support of the national health authorities to warn people and travellers.

Measles and rubella in Italy, e-learning course for health care workers.

INTRODUCTION: Since 2003, strategic plans for the elimination of measles and congenital rubella have been adopted in the World Health Organization European Region. In Italy, a network of reference laboratories for measles and rubella (MoRoNet) has been recently implemented to ensure high-quality laboratory investigation for the confirmation of cases and outbreaks. Training among health care workers (HCWs) is one of the tasks of MoRoNet and an e-learning course was produced to improve the knowledge on international and national elimination plans and laboratory surveillance for measles and rubella. METHODS: The course, based on the problem based learning methodology, was offered free of charge. Data about all participants and those who completed the course have been collected and analysed. RESULTS: 5822 participants enrolled and 3995 (69%) completed the course; comparison between pre- and post-test shows a significant improvement in knowledge. The average score obtained from the satisfaction questionnaire is 4.5 out of 5. DISCUSSION AND CONCLUSIONS: Course's results are satisfactory, and data show a significant improvement in knowledge among participants. Most of them were satisfied with content, learning methodology and platform. Moreover, this course represents one of the possible strategies to overcome resistance and mistrust about vaccinations among HCWs.

A Thousand and One Laparoscopic Heller Myotomies for Esophageal Achalasia: a 25-Year Experience at a Single Tertiary Center.

BACKGROUND: The aim of this study was to assess the long-term outcome of laparoscopic Heller-Dor (LHD) myotomy to treat achalasia at a single high-volume institution in the past 25 years. METHODS: Patients undergoing LHD from 1992 to 2017 were prospectively registered in a dedicated database. Those who had already undergone surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium swallow, endoscopy, and manometry were performed before and after surgery; and 24-h pH monitoring was done 6 months after LHD. RESULTS: One thousand one patients underwent LHD (M:F = 536:465), performed by six staff surgeons. The surgical procedure was completed laparoscopically in all but 8 patients (0.8%). At a median of follow-up of 62 months, the outcome was positive in 896 patients (89.5%), and the probability of being cured from symptoms at 20 years exceeded 80%. Among the patients who had previously received other treatments, there were 25/182 failures (13.7%), while the failures in the primary treatment group were 80/819 (9.8%) (p = 0.19). All 105 patients whose LHD failed subsequently underwent endoscopic pneumatic dilations with an overall success rate of 98.4%. At univariate analysis, the manometric pattern (p < 0.001), the presence of a sigmoid megaesophagus (p = 0.03), and chest pain (p < 0.001) were the factors that predicted a poor outcome. At multivariate analysis, all three factors were independently associated with a poor outcome. Post-operative 24-h pH monitoring was abnormal in 55/615 patients (9.1%). CONCLUSIONS: LHD can durably relieve achalasia symptoms in more than 80% of patients. The pre-operative manometric pattern, the presence of a sigmoid esophagus, and chest pain represent the strongest predictors of outcome.