Comparison of outcomes following intersphincteric resection vs low anterior resection for low rectal cancer: a systematic review.

BACKGROUND: Low Rectal Anterior Resection (LAR) is challenging when anal canal mucosa and/or internal sphincter are involved by very low tumors. In these cases, Intersphincteric resection (ISR) with the removal of the internal sphincter is designed to increase the distal margin of resection, thus preserving the external sphincter and pubo-rectalis muscle complex. Aim is to compare results after ISR with those of LAR, including subgroup analysis of open, laparoscopic and robotic ISR. METHODS: Studies published from January 1991 to January 2017 describing ISR and comparing results with LAR in adults were included irrespective of the technique. Tumor and surgical characteristics, clinical, functional and oncological results were collected. RESULTS: 25 non-randomized studies were included. Postoperative mortality ranged between 0% and 2.3%. The hospital stay ranged from 5 days to 40 days, lower in robotic ISR group if compared with laparoscopic ISR. Patients avoiding permanent stoma with ISR accept a lower continence level as satisfactory. Furthermore, anorectal function after ISR often tends to improve. ISR and LAR presented not statistically significant differences. Oncological outcomes were not statistically different Morbidity, blood loss and need for blood transfusions were lower in the laparoscopic ISR if compared with open approach. CONCLUSIONS: Morbidity could more frequently affect open ISR if compared with laparoscopic ISR. Functional outcomes were influenced by neoadjuvant CRT, but not by the surgical approach of reconstruction, while were positively influenced by partial ISR with respect to total ISR.

Do colorectal cancer patients diagnosed as an emergency differ from non-emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England.

BACKGROUND: More than 20% of colorectal cancers are diagnosed following an emergency presentation. We aimed to examine pre-diagnostic primary-care consultations and related symptoms comparing patients diagnosed as emergencies with those diagnosed through non-emergency routes. METHODS: Cohort study of colorectal cancers diagnosed in England 2005 and 2006 using cancer registration data individually linked to primary-care data (CPRD/GPRD), allowing a detailed analysis of clinical information referring to the 5-year pre-diagnostic period. RESULTS: Emergency diagnosis occurred in 35% and 15% of the 1029 colon and 577 rectal cancers. 'Background' primary-care consultations (2-5 years before diagnosis) were similar for either group. In the year before diagnosis, >95% of emergency and non-emergency presenters had consulted their doctor, but emergency presenters had less frequently relevant symptoms (colon cancer: 48% vs 71% (P<0.001); rectal cancer: 49% vs 61% (P=0.043)). 'Alarm' symptoms were recorded less frequently in emergency presenters (e.g., rectal bleeding: 9 vs 24% (P=0.002)). However, about 1/5 of emergency presenters (18 and 23% for colon and rectal cancers) had 'alarm' symptoms the year before diagnosis. CONCLUSIONS: Emergency presenters have similar 'background' consultation history as non-emergency presenters. Their tumours seem associated with less typical symptoms, however opportunities for earlier diagnosis might be present in a fifth of them.

Emotional responses to the experience of cancer 'alarm' symptoms.

OBJECTIVE: To qualitatively explore associations between emotional responses to experience of cancer 'alarm' symptoms and help-seeking in a community sample of adults. METHOD: Interviewees (n = 62) were recruited from a community sample (n = 2042) of adults aged ≥50 years, who had completed a health survey that included a list of cancer alarm symptoms. Participants who had reported an alarm symptom both at baseline and 3-month follow-up (n = 271), and who had consented to contact (n = 215), constituted the pool for invitations to interview. RESULTS: Over a third of participants (37%) described an emotional response to their symptom experience. In all these cases, there was evidence of awareness of the risk of cancer. Emotional responses were usually either classified as mild ('worry') or severe ('fear'). Worry was often described in the context of a desire to seek medical help, either to rule out cancer or to minimise patient delay. In contrast, the 'fear' group described associations with death, the perceived incurability of cancer, and the consequence of a cancer diagnosis. Where the emotional reaction was fear, medical contact was seen as something to be avoided either because it had no value or because it was preferable not to be told a diagnosis. CONCLUSION: In this community sample, worry about the possibility of cancer was associated with help-seeking, either for reassurance or as part of a 'sensible' strategy to deal with the risk. In contrast, fear was associated with avoiding help-seeking or even thinking about cancer, which could lead to prolonged help-seeking intervals.

A rare case of perforation of the subhepatic appendix by a toothpick in a patient with intestinal malrotation: laparoscopic approach.

Foreign body ingestion is not an uncommon problem in clinical practice. While most ingested foreign bodies pass uneventfully through the gastrointestinal tract, sharp foreign bodies such as toothpicks should cause intestinal perforation. We reported the case of a perforation of the appendix caused by a toothpick, which also pierced the liver without hepatic damages, in a male with an intestinal malrotation and subhepatic appendix. The patient was admitted to our hospital for abdominal pain in the right upper quadrant. An abdominal computed tomography scan revealed the anomalous position of the first portion of the large intestine with inflamed appendix. A laparoscopic appendicectomy and the exploration of the abdominal cavity was performed using minimally invasive technique.

Macro- and microvascular function in habitually exercising systemic lupus erythematosus patients.

OBJECTIVES: Vascular dysfunction is commonly observed in systemic lupus erythematosus (SLE) patients and may explain the accelerated cardiovascular disease (CVD) risk. It is unknown whether physical activity influences vascular function in SLE patients. We aimed to determine whether habitually exercising SLE patients also demonstrate a reduction in vascular function. METHOD: This study involved 41 young and middle-aged adults, including 15 healthy controls, 12 sedentary SLE patients, and 14 physically active SLE patients. RESULTS: Flow-mediated dilation (FMD), a measure of macrovascular function, was lower (3.6 ± 1.3 vs. 8.1 ± 1.2%; p < 0.05) and inflammatory markers [C-reactive protein (CRP), interleukin (IL)-12, and tumour necrosis factor (TNF)-α] were higher in sedentary SLE patients than in age-matched healthy controls (p < 0.05). Importantly, FMD and inflammatory markers were not different between physically active SLE patients and healthy controls. There were no group differences in skin reactive hyperaemia (RH) or minimal vascular resistance, both measures of microvascular function. Physically active SLE patients had lower intercellular adhesion molecule (ICAM)-1 concentrations and SLE disease activity scores than their sedentary peers. FMD was inversely associated with IL-6 and IL-10 (both p < 0.05). CONCLUSIONS: Significant SLE-associated macrovascular dysfunction was absent in physically active SLE patients. Additionally, vascular function was associated with inflammatory markers, suggesting that the favourable influence of physical activity may be mediated by its effect on inflammation.

Laparoscopic treatment of colovesical fistulas due to complicated colonic diverticular disease: a systematic review.

Colovesical fistulas originating from complicated sigmoid diverticular disease are rare. The primary aim of this review was to evaluate the role of laparoscopic surgery in the treatment of this complication. The secondary aim was to determine the best surgical treatment for this disease. A systematic search was conducted for studies published between 1992 and 2012 in PubMed, the Cochrane Register of Controlled Clinical Trials, Scopus, and Publish or Perish. Studies enrolling adults undergoing fully laparoscopic, laparoscopic-assisted, or hand-assisted laparoscopic surgery for colovesical fistula secondary to complicated sigmoid diverticular disease were considered. Data extracted concerned the surgical technique, intraoperative outcomes, and postoperative outcomes based on the Cochrane Consumers and Communication Review Group's template. Descriptive statistics were reported according to the PRISMA statement. In all, 202 patients from 25 studies were included in this review. The standard treatment was laparoscopic colonic resection and primary anastomosis or temporary colostomy with or without resection of the bladder wall. Operative time ranged from 150 to 321 min. It was not possible to evaluate the conversion rate to open surgery because colovesical fistulas were not distinguished from other types of enteric fistulas in most of the studies. One anastomotic leak after bowel anastomosis was reported. There was zero mortality. Few studies conducted follow-up longer than 12 months. One patient required two reoperations. Laparoscopic treatment of colovesical fistulas secondary to sigmoid diverticular disease appears to be a feasible and safe approach. However, further studies are needed to establish whether laparoscopy is preferable to other surgical approaches.

Participation, satisfaction and knowledge level of patients with cutaneous psoriasis or psoriatic arthritis.

There have been few studies about the participation in health care and the satisfaction of patients with psoriasis and with psoriatic arthritis. The objective of this study was to examine the attitudes of and satisfaction with decision-making of patients with psoriasis. The study was based on a self-completed questionnaire, given after a routine medical visit to a consecutive sample of 240 patients with psoriasis [207 with cutaneous psoriasis (CP) and 33 with psoriatic arthritis (PA)]. Of the patients with CP and PA, only about a third (27.3% and 28.1%, respectively) preferred to leave decisions entirely to their doctor, whereas the majority (72.7% and 71.9%, respectively) wanted to be involved in decision-making. However, the level of knowledge about the disease was not as high, with 17.0% and 21.4% of patient with CP and PA, respectively, having a good level of knowledge about psoriasis treatment. Participation, knowledge and overall satisfaction were not significantly different between patients with CP and those with PA. Information on treatment side-effects (OR = 5.11; 95% CI 2.5-15.0; P < 0.001) and information on treatment options (OR = 3.15; 95% CI 1.4-7.1; P = 0.006) were significantly associated with overall patient satisfaction.

Excimer laser ablation in the treatment of total chronic obstructions in critical limb ischaemia in diabetic patients. Sustained efficacy of plaque recanalisation in mid-term results.

This prospective study aims to evaluate the impact of the excimer laser technology as the first-line endovascular treatment of critical limb ischaemia (CLI) in diabetic patients. The protocol allowed the use of laser ablation of obstructive lesions when conventional endoluminal guidewire crossing of the plaque was unsuccessful. We extrapolate the data of consecutive patients treated, who completed at least 12 months of follow-up, extending the observation to a 26-month time frame. During this period, 67 diabetic patients with CLI were brought to the Cath Lab for 'operative angioplasty' and to be treated with endovascular techniques. Of the 67 cases, laser was used on 35 patients to treat 51 lesions. All patients had type C or D occlusive lesions, according to the TACS II classification, showing a single type D plaque or multiple tandem C/D occlusive plaques ranging from 4 to 23 cm in length. The immediate clinical success, defined as restored direct arterial flow to the foot, was 88.2%. The lesions were successfully crossed by laser in 45 out of 51 attempts. Stents were required in 25% of the patients with 21% lesions. Patency rates were assessed using the Kaplan-Meier survival curves. The patency rates of the successfully treated lesions (freedom from target lesion revascularisation) were 96.6% at 12 months and 82.7% at 24 months. Limb-salvage rate at 12 and 24 months were 100% and 94%, respectively. Our study showed that the excimer laser-assisted angioplasty, when feasible, is effective in granting event-free survival in CLI patients with diabetes, and that endoluminal-driven atherectomy allows long-term success in reducing the need of stents in the lower limb arteries.

[Psychological wellbeing in the hospital administrative personnel]. / Scarso benessere psicologico negli amministrativi di una struttura ospedaliera.

Job satisfaction and psychological well being of health care workers significantly influence the quality of care. The aim of this study was to evaluate job satisfaction and psychological well-being in the administrative personnel of a large hospital in Rome-Italy. The personnel self-completed two anonymous questionnaires: the General Health Questionnaire (GHQ-12) for minor psychiatric non psychotic diseases and a validated job satisfaction questionnaire. Descriptive analysis and multiple logistic regression analysis were performed. Response rate was 65%. 74 were the questionnaires analyzed. 37.8% of respondents showed a high likelihood to develop symptoms of depression/anxiety (OR = 3.57; 95% CI 1.17-10.85). Major determinants of job dissatisfaction were the lower autonomy and poor communication in the working Unit. Factors associated with overall dissatisfaction were: insufficient training opportunities (p = 0.033), low autonomy (p = 0.023), poor communication between hospital Units (p = 0.009), unclear aims of their working Unit (p = 0.029), low agreement between personal expectations and required competence (p < 0.001). Among administrative staff job dissatisfaction was associated with high likelihood of depression/anxiety, low autonomy and poor communication, independently of sex, age, years of employment. Possible targets to improve satisfaction of administrative personnel were identified.

Retained sponges in abdomen: an analysis of the judgments of the Italian Supreme Court.

The administration of justice in Italy includes first, second and third instance. The first and second instances are represented by the Court of First Instance and the Court of Appeal: these are judgment of Romamerit. The court of last appeal for both the civil and the criminal jurisdiction is the Court of Cassation, the Italian Supreme Court. It is a court of legitimacy that should provide for a consistent and uniform interpretation of the law and that only on points of law, not on factual evidence. The Court of Cassation can confirm the sentence of second instance, can dismiss it without referral, can deciding and closing the trial definitively, or dismiss it referring the case to the judge of merit that must decide according to the principles set out in the legitimacy. The aim of this study is to analyze the Supreme Cassation Court's judgments on the legal proceedings about retained sponges in abdomen.

Efforts to link declarations to actions: Italian experiences of shared decision making in clinical settings.

The Italian National Health Plan 2006-08 acknowledges the importance of patient/citizen participation, highlighting that health services have to involve patients by means of a shared decision-making (SDM) approach. The present study aims at examining the implementation of SDM in clinical settings in Italy, describing some experiences, practical difficulties and potential solutions. We found that the majority of patients want to participate in decision-making, but substantial knowledge gaps represent a barrier. Small proportions of patients express opinions and questions during the medical encounter, with a lack of facilitating questions by physicians, indicating a limited degree of involvement. The project Partecip a Salute is an initiative aiming at involving citizens, patient associations and scientific-medical professionals in the health and clinical research debate. The literature review on Italian SDM experiences has shown a limited number of publications, with the majority being commentaries or letters. In conclusion, in order to put SDM into practice more organizational and educational efforts are needed directed to both health professionals and patients/consumers. Documenting and sharing experiences is a fundamental prerequisite for progressing in the field.

Sentinel lymph node biopsy for high risk cutaneous squamous cell carcinoma: case series and review of the literature.

AIMS: Cutaneous squamous cell carcinoma (SCC) is the second most common skin cancer. The metastatic potential is generally low. However, there are subgroups of patients at higher risk, for whom sentinel lymph node biopsy (SLNB) might be useful. SLNB might allow the timely inclusion of high risk patients in more aggressive treatment protocols, sparing at the same time node-negative patients the morbidity of potentially unnecessary therapy. Our aim was to introduce the concept of SLNB for patients with high risk cutaneous SCC. PATIENTS AND METHODS: We examined a consecutive series of high risk cutaneous SCC patients undergoing SLNB at our large dermatological hospital, and performed a literature review and pooled analysis of all published cases of SLNB for cutaneous SCC. RESULTS: Among the 22 clinically node-negative patients undergoing SLNB at our hospital, one patient (4.5%) showed a histologically positive sentinel node and developed recurrences during follow-up. Sentinel node-negative patients showed no metastases at a median follow-up of 17 months (range: 6-64). The incidence of positive sentinel nodes in previous reports ranged between 12.5% and 44.4%. Pooling together patients from the present and previous studies (total 83 patients), we calculated an Odds Ratio of 2.76 (95% CI 1.2-6.5; p=0.02) of finding positive sentinel nodes for an increase in tumor size from <2 cm to 2.1-3 cm to >3 cm. CONCLUSIONS: Our case series and the pooled analysis support the concept that SLNB can be performed for high risk cutaneous SCC. Prospective multicenter studies are needed to examine the role, utility and cost-effectiveness of SLNB for this population.

[Job satisfaction, burnout and stress amongst nursing staff: a survey in two hospitals in Rome]. / Soddisfazione lavorativa, burnout e stress del personale infermieristico: indagine in due ospedali di Roma.

The job satisfaction and psychological well-being of health care workers may significantly influence the quality of care they provide. The aim of this study was to assess burnout and psychiatric disorders, such as anxiety and depression, as well as evaluate job satisfaction among nurses working at the IDI-Sanità in Rome. Nurses (n = 545) were invited to answer an anonymous, self-administered questionnaire, which consisted of the Maslach Burnout Inventory (MBI), the General Health Questionnaire (GHQ-12), and a validated questionnaire to examine job satisfaction. Descriptive analyses and multiple logistic regression analysis were performed. The section designed to evaluate job satisfaction was specifically examined by means of principal component factor analysis. Two hundred and forty-two nurses answered the questionnaire (response rate: 44%). Emotional exhaustion was observed in 38% of respondents. No significant difference was detected between mean values ( standard deviation) at each of the three MBI subscales and Italian normative data. About 33% of respondents showed a GHQ-12 score typical for disorders such as anxiety or depression. High levels of job satisfaction were found to be associated to a lower likelihood both of emotional exhaustion at MBI and psychiatric morbidity at GHQ-12. Factor analysis on items investigating job satisfaction identified 4 factors that globally accounted for 61% of the total variance. The factors obtained could represent possible targets for action aimed at improving nurse satisfaction.

Systematic review and meta-analysis of metal versus plastic stents for preoperative biliary drainage in resectable periampullary or pancreatic head tumors.

BACKGROUND: Preoperative biliary drainage (PBD) with stenting increases complications compared with surgery without PBD. Metallic stents are considered superior to plastic stents when considering stent-related complications. Aim of the present systematic review and meta-analysis is to compare the rate of endoscopic re-intervention before surgery and postoperative outcomes of metal versus plastic stents in patients with resectable periampullary or pancreatic head neoplasms. METHODS: We conducted a bibliographic research using the National Library of Medicine's PubMed database, including both randomized controlled trials (RCTs) and non-RCTs. Quantitative synthesis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Statistical heterogeneity was assessed using the I(2) tests. RESULTS: One RCT and four non-RCTs were selected, including 704 patients. Of these, 202 patients (29.5%) were treated with metal stents and 502 (70.5%) with plastic stents. The majority of patients (86.4%) had pancreatic cancer. The rate of endoscopic re-intervention after preoperative biliary drainage was significantly lower in the metal stent (3.4%) than in the plastic stent (14.8%) group (p < 0.0001). The rate of postoperative pancreatic fistula was significantly lower in the meta stent group as well (5.1% versus 11.8%, p = 0.04). The rate of post-operative surgical complications and of - post-operative mortality did not differ between the two groups. CONCLUSIONS: Although the present systematic review and meta-analysis demonstrates that metal stent are more effective than plastic stents for PBD in patients with resectable periampullary tumors, randomized controlled trials are needed in order to confirm these data with a higher level of evidence.

[Sexual behavior of Italian youths in connection to AIDS risk]. / Sexuelles Verhalten der italienischen Jugendlichen in Bezug auf das AIDS-Risiko.

The objective of this survey is to evaluate knowledge and sexual behaviour among young Italians (19 to 24 years). The project, began in 1993, is being carried out through an anonymous postal questionnaire, sent to a representative sample of the young Italian population (a total of 52,000 people from 363 Italian towns). In the present intermediate evaluation, we have analysed 6929 of the 18,132 questionnaires sent till now, with all Italian regions being proportionally included. Our data show that, after sexual activity has been started, it hardly seems to be limited to monogamy or to be always regulated by AIDS-preventing practices. Data show that the age of the first sexual intercourse is increasing (after age 18) and that condoms are used more frequently, particularly in occasional sex.

[Prevention focused on sexual behavior]. / La prevenzione mirata al comportamento sessuale.

In Italy, studies on the sexual behaviour of young persons are rare, especially those conducted among samples that are representative of the same-age general population. This report presents the preliminary results of a knowledge, attitudes and practices survey on sexual behaviour among a representative sample of individuals 18-26 years of age. The study was begun in 1994, and as of 30 June 1997, 8533 (32%) of the 26,536 questionnaires sent so far have been completed: 3947 (46%) by males and 4586 (54%) by females. 70% of the males and 64% of the females reported that they are sexually active; the median age at first sexual experience is 18 years for both genders. The proportion of respondents who use condoms with occasional sexual partners is low, and only half of the respondents demonstrated an adequate level of knowledge regarding the transmission of HIV.

[Treatment of pulmonary embolism. Current status and future prospects]. / Il trattamento dell'embolia polmonare. Attualità e nuove prospettive.

Although still severe, the prognosis of pulmonary embolism has recently improved due to considerable progress in the therapeutic field. This paper concerns the various therapeutic tools, both pharmacologic and surgical, which are already available or under evaluation. Despite the introduction of thrombolytic drugs, heparin remains an indispensable drug. The rationale for its use comes from the need of preventing further clot formation, while endogenous fibrinolysis or thrombolytic drugs are dissolving the already existing clots. Thrombolytic drugs, such as streptokinase, urokinase or rt-PA, have changed the therapeutic strategy of pulmonary embolism, due to their ability to accelerate the normal fibrinolytic mechanisms and to facilitate pulmonary reperfusion. This often allows an early disappearance of symptoms and a reduced incidence of invalidating complications involving the respiratory function. rt-PA seems to be most effective and fast in inducing reperfusion (angiographic signs of clot dissolution are obtained in 82% of the patients within 2 hours). The administration of rt-PA by intravenous bolus has recently been proposed, which would induce an even faster thrombolysis and fewer hemorrhagic complications. The role of surgical therapy has declined after the diffusion of thrombolytic drugs, being reserved only for the most serious cases. When anticoagulation is counter-indicated or not effective, the prevention of embolic relapses can be achieved by percutaneous insertion of caval filters of different types. Some new catheters provided with rotating metallic tips, which allow the mechanical fragmentation of the emboli, are presently under evaluation. Although some improvements are needed, this technique is expected to become soon of general use, especially in cases in which thrombolytic therapy is counter-indicated.

Immunologic changes in circulating leukocytes in the presence of atherosclerotic disease.

To assess the numeric and functional changes in circulating white blood cells in the presence of severe atherosclerosis, 25 subjects with marked, angiographically assessed, atherosclerotic lesions and 29 selected controls were studied. Of the differential leukocyte counts, only monocyte count was significantly higher in the atherosclerotic than in the control subjects (449.0 +/- 115.6 (1 S.D.) vs. 344.1 +/- 138.8/mmc; P = 0.0016). By flow-cytometry no significant differences concerning monocyte surface antigens were found, except a feeble decrease in beta 2-microglobulin in the atherosclerotic subjects. As to lymphocytes, an increase in the CD8 population (33.4 +/- 6.8 vs 28.6 +/- 6.5%; P = 0.0144) and decreases in class I HLA antigen (96.6 +/- 7.3 vs 99.4 +/- 0.7%; P = 0.0049), beta 2-microglobulin (97.9 +/- 2.1 vs 99.3 +/- 1.0%; P = 0.0055) and especially in vivo DNA synthesis (3.8 +/- 1.2 vs 5.3 +/- 2.1%; P = 0.0102) percent expressions were found in the atherosclerotic patients with respect to the controls. This study shows that circulating monocytes are increased in atherosclerotic disease, possibly due to their participation in the phagocytosis of lipids in the arterial wall, with no further immunologic involvement. Conversely, the replicative activity of T lymphocytes is decreased, which might be a consequence of or a factor predisposing to atherosclerosis.

[Satisfaction and critical aspects of inpatients care among patients with psoriasis]. / Soddisfazione e criticità nella gestione del paziente ricoverato affetto da psoriasi.

OBJECTIVES: To evaluate satisfaction with care for psoriatic inpatients. Identify areas in need of interventions and actions to improve the satisfaction with care. METHODS: We analyzed 133 patients with psoriasis and 335 patients affected by other dermatological diseases in their first access at the hospital. Six determinants of satisfaction with care were investigated with a self administered questionnaire. Moreover the overall satisfaction was documented. Descriptive analysis and a multiple logistic regression analysis correcting for confounding factors were performed. Focus groups were conducted with patients to further investigate about specific aspects of relationships between patients and personnel. RESULTS: Psoriatic inpatients were less satisfied than other dermatological inpatients regarding Coordination of care, Information and education, Emotional support. Emotional support was the determinant with the smallest percentage of satisfied patients. Focus groups confirmed what was identified with the questionnaire and suggested necessary interventions. CONCLUSIONS: It is necessary to improve the communication skills of health personnel. Information for patients need to be enhanced and the management of psoriatic patients has to be improved.