The impact of COVID-19 pandemic on emergency services.

BACKGROUND: The SARS-Cov-2 pandemic has placed enormous strain on the global healthcare system. The strict containment measures have adversely affected population movements and mobility, daily activities, and the patterns of healthcare-seeking behavior. Although the Emergency and Admission Departments (EADS) activity has never been disrupted, the pandemic had a significant impact on the routine healthcare delivery. This study aims to assess the changes in healthcare delivery, with a focus on the elderly as a vulnerable component of the general population. DESIGN OF THE STUDY: Retrospective study. METHODS: All non-COVID visits to the EAD of the Local Health Unit (ASL1) in Abruzzo (Italy) from 9 March to 3 May 2020 were analyzed. These were compared to the hospital admissions recorded in the same period of the previous year. RESULTS: We found a 60.4% reduction in overall visits during the study period and an increase in the hospitalization rate from 30% to 39%. Emergency department visits have declined markedly for less acute medical conditions, while we have observed a statistically significant increase in the hospitalization rates for all age groups. Moreover, in 2020 we recorded a decrease in the ratio non-urgent/non-deferrable medical conditions for each age group; while the percentage of hospitalizations for each registered red code increased for each group, particularly for the 65-74 age group. CONCLUSIONS: The COVID-19 pandemic has significantly affected the care-seeking behavior of patients. During the COVID-19 epidemic, total hospital admissions have decreased, particularly for less severe illnesses, whereas the percentage of hospitalizations has increased. During 2020, hospital admissions for mild cases decreased, and patients presented to the EAD only in cases of acute medical condition, selecting those in need for more intensive care. However, several patients may have deferred necessary medical care even for potentially urgent conditions. Such reluctance to seek medical care may have caused delays in diagnosis. The impact of deferred care on patients' health is difficult to estimate at this time. This information will serve as a starting point for further research to improve healthcare management not only during emergency but also in non-emergency periods.

Biomechanics of the tympanic membrane.

The tympanic membrane is a key component of the human auditory apparatus which is a complex biomechanical system, devoted to sound reception and perception. Over the past 30 years, various bioengineering approaches have been applied to the ear modeling and particularly to the middle part. The tympanic membrane, included in the middle ear, transfers sound waves into mechanical vibration from the ear canal into the middle ear. Changes in structure and mechanical properties of the tympanic membrane due to middle ear diseases or damages can deteriorate sound transmission. An accurate model of the tympanic membrane, which simulates the acoustic-mechanical transmission, could improve clinical surgical intervention. In this paper a detailed survey of the biomechanics and the modeling of the tympanic membrane focusing on the finite element method is conduced. Eight selected models are evaluated and compared deducing the main features and most design parameters from published models, mainly focusing on geometric, constraint and material aspects. Non-specified parameters are replaced with the most commonly employed values. Our simulation results (in terms of modal frequencies and umbo displacement), compared with published numerical and experimental results, show a good agreement even if some scattering appears to indicate the need of further investigation and experimental validation.

Pharmacokinetic changes induced by the volume of chemotherapy solution in patients treated with hyperthermic intraperitoneal mitomycin C.

BACKGROUND: The rationale supporting the use of intraperitoneal chemotherapy in peritoneal surface malignancy relates to a large local-regional effect and low systemic toxicity. While optimizing the use of this treatment strategy, little information regarding the effect of volume of chemotherapy solution is available. OBJECTIVE: The goal of this study was to provide data regarding the effect of volume of chemotherapy solution on the pharmacokinetics of intraperitoneal chemotherapy. Data by which to optimally adjust this parameter during intraperitoneal chemotherapy treatments were sought. METHODS: Forty-eight patients with peritoneal surface malignancy were treated with hyperthermic intraperitoneal mitomycin C chemotherapy after a complete cytoreduction to remove all visible evidence of mucinous tumor. The dose of mitomycin C was always 12.5 mg/m(2) in males and 10 mg/m(2) in females. The first 12 patients were treated with 6 l of 1.5% dextrose peritoneal dialysis solution. The next 14 patients were treated with 4 l of fluid and then ten patients were treated with 2 l. In the last 12 patients the volume of fluid was 1.5 l/m(2) . Blood, peritoneal fluid, and urine samples were obtained every 15 min for 90 min; additional blood and urine samples were obtained at 120 min. Mitomycin C concentrations, urine volumes, and final intraperitoneal fluid volume were obtained. RESULTS: The intraperitoneal and the plasma concentrations were highest in the 2-l group, less in the 4-l group, and least in the 6-l group. All differences were statistically significant. Also, the percent of mitomycin C absorbed decreased significantly from 2, to 4, to 6 l of fluid. The area under the curve (AUC) ratio of intraperitoneal concentration times time to intravenous concentration times time was 27.01+/-4.92 for 2 l, 22.22+/-7.95 for 4 l, and 24.01+/-8.46 for 6 l. These differences were not statistically significant. If both the volume of chemotherapy solution and the total dose of mitomycin C were determined from the body surface area, the pharmacokinetics of intraperitoneal mitomycin C were more consistent. CONCLUSIONS: In order to prescribe a uniform treatment for patients receiving hyperthermic intraperitoneal mitomycin C, the total dose of the drug and the total volume of chemotherapy solution should be determined from the body surface area. If the volume of chemotherapy solution is not based on patient body surface area, predictions regarding toxicity are less precise.

Synchronous extraperitoneal and intraperitoneal dissemination of appendix cancer.

BACKGROUND: The aim of this study was to report the role of combined treatments, including cytoreductive surgery and perioperative regional chemotherapy, in patients with synchronous systemic and intraperitoneal dissemination of appendix cancer. METHODS: Patients with synchronous systemic and intraperitoneal dissemination of appendix cancer were treated with cytoreductive surgery and perioperative regional chemotherapy. Variables statistically analyzed with survival as an end point included demographic characteristics, prior surgical score (PSS), tumour marker levels, peritoneal cancer index (PCI), and completeness of cytoreduction (CC). RESULTS: Mean follow up was 42.6 months, median survival time (MST) for 15 patients was 28 months and 5-year survival rate was 29.4%. Female patients had a longer MST than male patients (p=0.0199). Survival was better in patients with PSS 0 and 1 (p=0.0277). Patients with elevated CEA and CA 19-9 levels had a shorter MST (p=0.0083 and p=0.0193, respectively). PCI and CC comparisons did not show significant differences. Morbidity (n=2) and mortality (n=2) rates were 13.3% respectively. CONCLUSION: Acceptable morbidity and mortality and a 29.4% 5-year survival rate allows cytoreductive surgery and regional chemotherapy to be considered as a treatment option for selected patients with synchronous systemic and intraperitoneal dissemination of appendix cancer.

Utility of CEA and CA 19-9 tumor markers in diagnosis and prognostic assessment of mucinous epithelial cancers of the appendix.

BACKGROUND AND OBJECTIVES: Tumor markers are a clinical tool frequently used in oncology in association with other clinical and radiologic information. For gastrointestinal cancer, carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) tumor markers have found selected clinical application. The use of these tumor markers in mucinous epithelial tumors of the appendix has not been previously determined. METHODS: In patients with peritoneal dissemination of a mucinous epithelial malignancy of the appendix, tumor markers CEA and CA 19-9 were prospectively recorded preoperatively within 1 week prior to definitive treatment. Also, if the appendiceal tumor recurred, the tumor marker was determined. The accuracy of these two tumor markers in the management of this disease was determined for these two specific clinical situations. RESULTS: CEA was elevated in 56% of 532 patients and CA 19-9 was elevated in 67.1% of these patients. Although the absolute level of tumor marker did not correlate with prognosis, a normal value indicated an improved survival. CEA was elevated in 35.2% of 110 patients determined to have recurrent disease; CA 19-9 was elevated in 62.9% and at least one of the tumor markers was elevated in 68.2% of patients. An elevated CEA tumor marker at the time of recurrence indicated a reduced prognosis. CONCLUSIONS: Both CEA and CA 19-9 tumor markers were elevated in a majority of these patients and should be a valuable diagnostic tool previously underutilized in this group of patients. These tumor markers were also of benefit in the assessment of prognosis in that a normal level indicated an improved prognosis. At the time of a reoperative procedure, CEA and CA 19-9 tumor markers gave information regarding the progression of disease. These tumor markers have practical value in the management of epithelial appendiceal malignancy with peritoneal dissemination.

Comprehensive approach to advanced primary and recurrent ovarian cancer: a personal experience.

Despite improvements in chemotherapy agents and schedules and new drug combinations, epithelial ovarian cancer remains a leading cause of gynecologic cancer death in Western countries. It is usually diagnosed at late stages of the disease, which makes complete surgical resection technically more difficult. The targeted comprehensive approach described in this review includes cytoreductive surgery and perioperative intraperitoneal chemotherapy. The goal of this aggressive therapy is to remove all the macroscopic disease with the use of peritonectomy procedures and visceral resections, and also to eradicate microscopic disease using heated intraoperative intraperitoneal chemotherapy and early postoperative intraperitoneal chemotherapy. Patients that received a complete cytoreduction followed by perioperative intraperitoneal chemotherapy had an improved survival, with reasonable morbidity and mortality, as compared with those who received incomplete cytoreduction.

The management of synchronous peritoneal carcinomatosis and hematogenous metastasis from colorectal cancer.

AIMS: Combined local and distant dissemination for colorectal cancer occurs especially in younger patients. New strategies combining maximal cytoreductive surgery with intraperitoneal and systemic chemotherapy have been used in an attempt to prolong survival with an acceptable morbidity and mortality. METHODS: Twenty-seven patients with histologically proven peritoneal carcinomatosis from colorectal cancer had distant metastases in addition to peritoneal carcinomatosis. The goal for treatment in all patients was complete local and distant cytoreduction. Aggressive intraperitoneal and systemic chemotherapy was used. The endpoint for all the analysis was survival from the time of definitive treatment at our Institution. RESULTS: In addition to peritoneal carcinomatosis, 16 patients had liver metastases, six patients had lung metastases, four had liver and lung metastases and one had supraclavicular lymph-node metastases. Median survival time (MST) for the entire group was 15.2 months. Patients that received a complete cytoreductive surgery had a MST of 20.6 months and patients with incomplete cytoreduction had a MST of 9.0 months (p= 0.0471). Post-operative morbidity and mortality was 14.8 and 0%, respectively. CONCLUSION: A group of carefully selected patients with peritoneal carcinomatosis and distant metastases from colorectal cancer may benefit from cytoreductive surgery and intraperitoneal chemotherapy.

Regional lymph node metastasis from port site implants after laparoscopic surgery.

Although overall incidence of laparoscopic port site implants is decreasing, it remains problematic in patients with occult intraabdominal malignancy. Port-site metastases may themselves become the source of new metastases. A 42-year-old man underwent a laparoscopic cholecystectomy for cholelithiasis. One month later, he was diagnosed with a right colon cancer, for which a right colectomy was performed. Eleven months later, a CT scan showed nodules in the umbilicus (one of the original laparoscopic port sites) and behind the right rectus abdominis muscle, adjacent to the deep epigastric vessels. These sites were resected, and histopathology confirmed metastatic adenocarcinoma. The right deep epigastric nodule was reported to be lymph node-positive for metastatic adenocarcinoma. It is probable that dissemination of cancer cells to this lymph node occurred from the port site implants. Presence of metastasis in the lymph nodes draining the abdominal wall should be examined in all patients with port site implants.

Intraperitoneal cancer dissemination: mechanisms of the patterns of spread.

BACKGROUND: Well known patterns govern the distribution of hematogenous and lymphatic metastasis of cancer. In the past the distribution of cancer cells free within abdominal cavity received little attention and was thought to be a random event. However, surgical observation led the authors to generate and test hypotheses regarding patterns of spread that vary with tumor type, with the intraperitoneal environment, and with the physiology of the peritoneal surface tissues. METHODS: The distribution and volume of peritoneal surface malignancy was prospectively recorded in 129 patients with 5 different types of tumors at the time of cytoreductive surgery. The malignancies studied included pseudomyxoma peritonei (PMP) of appendiceal origin, colonic mucinous adenocarcinoma (MA), nonmucinous colonic adenocarcinoma (NMA), ovarian carcinoma (OV) and sarcoma (SA). The abdominal and pelvic cavity was divided into 3 horizontal sectors, 9 regions and 25 sites. The incidences of tumor implants in these designated areas were statistically analyzed for each tumor type and comparisons between tumor types studied. RESULTS: The magnitude of intraperitoneal cancer dissemination was similar for mucinous tumors, including PMP and MA and significantly higher than for non-mucinous tumors. Also the mucinous cancers were more likely to be present in the upper horizontal sector than were non-mucinous. When NMA was compared to PMP and MA the epigastric region was significantly less likely to contain tumor. For all cancer diagnoses the colon, greater omentum and cul-de-sac of Douglas were most often affected. The ileocecal valve region was more likely to have large tumor masses on its surface than small bowel surface or small bowel mesentery. CONCLUSIONS: Peritoneal carcinomatosis had a wider distribution when mucinous fluid was present; this cancer distribution by intraperitoneal fluid hydrodynamics occurred regardless of histologic aggressiveness. The organs that have peritoneal fluid resorption (omentum and omental appendages) have a high incidence of implants. Small bowel and its mesentery free to move by peristalsis had a reduced incidence of implants as compared to the ileocecal area, which is fixed to the retroperitoneum. These observations may facilitate efforts to treat peritoneal surface malignancy.

Ophthalmic vehicles containing polymer-solubilized tropicamide: "in vitro/in vivo" evaluation.

Commercial 1.0% aqueous tropicamide (TR) eyedrops are buffered to pH 4.4-5.0 to produce sufficiently stable solutions of the weakly basic, poorly soluble drug. These acidic solutions, however, are irritants and may induce copious lachrimation, thus reducing the drug bioavailability. The aim of the present study was to evaluate some solubilizing agents for the preparation of 1.0% TR ophthalmic solutions adjusted at physiologically compatible pH, potentially showing increased eye tolerance, activity, and stability when compared with standard commercial eyedrops. The tested solubilizers were two non-ionic surfactants-Tyloxapol (TY) and Cremophor EL (CR) and one polymer, Pluronic P85 (PL). Four stable 1% TR formulations, containing 3% TY, 7.5% CR, 15% PL, or 5% CR + 10% PL were submitted to mydriatic activity tests in rabbits. They improved to a small but statistically significant extent the AUC for mydriatic effect of TR in the test animals when compared with commercial 1.0% TR eyedrops.

Solubilization of tropicamide by hydroxypropyl-beta-cyclodextrin and water-soluble polymers: in vitro/in vivo studies.

1% (w/v) aqueous solutions of tropicamide (TR), a poorly water-soluble mydriatic-cycloplegic drug, are usually obtained by adjusting the pH to approximately 5.0, at the expense, however, of ocular tolerance and bioavailability. The capacity of hydroxypropyl-beta-cyclodextrin (HP-beta-CD) to solubilize TR in pH 7.4 0.02 M phosphate buffer was investigated in the absence and presence of hydrophilic polymers (PVP, CMC and HPMC). Approximately 3.5% (w/v) HP-beta-CD was required to solubilize 1% (w/v) TR in pH 7.4 buffer at room temperature. The required amount was reduced to 0.9% (w/v) by heating at 120 degrees C in the presence of 0.1% (w/v) HPMC. Mydriatic activity tests in rabbits showed an improved bioavailability and maximal mydriatic response for two CD formulations, with and without HPMC, when compared to standard 1% (w/v) TR eyedrops, buffered at pH 5.0. The improved in vivo behaviour of the CD formulations are likely due to their physiological pH, resulting in a reduced irritant effect, although an effect of HP-beta-CD on corneal permeability cannot be dismissed a priori.

Acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.

Acute hyperparathyroidism occurs infrequently and sometimes represents a diagnostic problem in urological patients. We report a case of acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.