Aortic valve and vascular calcium score in pre-TAVI CT: correlation with early post-procedural complications.

PURPOSE: The aim of our study was to evaluate the prevalence of early complications after Transcatheter Aortic Valve Implantation (TAVI) and their correlation with the Calcium Score (CS) of the aortic valve, aorta and ilio-femoral arteries derived from pre-procedural computed tomography (CT). MATERIALS AND METHODS: We retrospectively reviewed 226 patients (100 males, mean age 79.4 ± 6.7 years) undergoing 64-slice CT for pre-TAVI evaluation from January 2018 to April 2021. The population was divided into CS quartiles. RESULTS: Overall, 173 patients underwent TAVI procedure, of whom 61% presented paravalvular leak after the procedure, 28% presented bleeding or vascular complications, 25% presented atrioventricular block, and 8% developed acute kidney injury. The prevalence of paravalvular leak and vascular complications was higher in the upper CS quartiles for aortic valve and ilio-femoral arteries. CONCLUSIONS: Aortic valve and vascular CS could help to predict post-TAVI early complications.

Does fear expectancy prime fear? An autonomic study in spider phobics.

This study investigated whether fear expectancy in phobic individuals induces priming of the defensive system, thus generating a "blind" phobic response even to non-phobic stimuli. We employed a paradigm in which two different visual cues signalled the upcoming picture presentation of either a spider or an innocuous animal (congruent condition). Unknown to the participants, the visual cue was incorrectly followed by a picture from the opposite category on two additional trials (incongruent condition). Cardiac and skin conductance responses were recorded from young adults with (n=15) or without (n=14) spider phobia during both the expectation and exposure of these pictures in the congruent and incongruent conditions. In the congruent condition, the autonomic responses during expectation matched the responses during exposure. In particular, non-phobic controls showed an orienting response (bradycardia and moderate skin conductance increase) to both picture categories, while spider phobics showed an orienting response to the innocuous animals and a defence response (tachycardia and marked skin conductance increase) to spiders. In the incongruent condition, the autonomic responses during exposure were driven by the affective content of the pictures, and their amplitude was greater than in the congruent condition, likely due to the signal-stimulus discrepancy. In particular, the response to the innocuous picture of phobic participants expecting a spider did not shift in the direction of the defence response. Thus, spider phobics did not show priming of the defensive system but maintained discrimination between phobic and innocuous stimuli. Finally, the greatly amplified response to the incorrectly signalled spider in phobics suggests a discrepancy-phobia interaction.

Supporting clinical engineering in Italy: results of a survey conducted by the AIIC.

This article presents the outcomes of a survey developed and conducted by the Italian Association of Clinical Engineers (AIIC) in 2010 [1]. The AIIC, affiliated with the International Federation for Medical and Biological Engineering (IFMBE) since 2003, conducted this in-depth survey to investigate the educational profile of clinical engineers (CEs) as well as the activities and organization of clinical engineering departments (CEDs) in Italy. The survey consisted of a six-section questionnaire designed by the AIIC Board, which was based on other previous international surveys of CEDs. The questionnaire was sent to the AIIC members and to the most important Italian health-care organizations.

Emotion processing without awareness: features detection or significance evaluation?

Studies on the physiological responses to emotional stimuli demonstrated that they can occur even when emotional stimuli are not consciously perceived. In this study, the subliminal stimulation was obtained by means of Backward Masking. Specifically, we analyzed the cardiac and electrodermal responses evoked by the unmasked and masked presentation of spider shapes in arachnophobic individuals. To evaluate whether unaware processing entails discrimination of physical features vs emotional significance, crabs, morphologically similar to the spiders but different for emotional significance, and squirrels, different in both shape and emotional content, were also employed. The response to unmasked spiders consisted of a typical defense response (sympathetic activation), while that to innocuous stimuli of an orienting response (moderate electrodermal and vagal activations). In the subliminal condition, the electrodermal response to masked spiders was greater than that to the other animals suggesting an early detection of emotional content rather than of physical characteristics. In contrast, cardiac responses to the masked stimuli did not show any differences as a function of valence. These findings suggest that individuals can appraise the emotional content of unconsciously perceived stimuli and react with an arousal response. However, subliminal emotional stimuli does not seem able to elicit the complete pattern of autonomic responses typical of the defense response.

Systemic cytokine response after emergency and elective surgery for colorectal carcinoma.

BACKGROUND: Systemic cytokines (SC) are accepted mediators of host immune response. It is debated if long-term survival is influenced by emergency presentation of colorectal cancer, and the role of immunitary response is still unknown. The aim of this prospective study was to compare the SC response after emergency resection with that after elective resections of colorectal carcinoma. MATERIALS AND METHODS: One hundred six consecutive subjects with colorectal cancer were submitted to emergency (complete bowel obstruction; EMS, n = 50) or elective resection (ELS, n = 56) of the tumour. Sera were collected before surgery and at appropriate time points afterward and assayed for interleukin-1beta (IL-1beta), tumour necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6) and C-reactive protein (CRP). Five-year survival was analysed according to Kaplan-Meier test. The Cox proportional hazard model was used for the multivariate analysis. RESULTS: Pre-operative levels of IL-1beta, IL-6 and CRP were statistically higher in the EMS group. Levels of TNF-alpha were not elevated after surgery and there was no difference between the groups. Five-year survival was significantly lower in the EMS group (p < 0.05). CONCLUSIONS: Immunitary response, as reflected by SC, was better after elective resection than after emergency resection of colorectal carcinoma and this difference may have implication in the long-term survival.

Inguinal hernia repair with porcine small intestine submucosa: 3-year follow-up results of a randomized controlled trial of Lichtenstein's repair with polypropylene mesh versus Surgisis Inguinal Hernia Matrix.

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of Lichtenstein's hernioplasty using Surgisis Inguinal Hernia Matrix (SIHM; Cook, Bloomington, Indiana) compared with polypropylene (PP; Angiologica, Pavia, Italy). METHODS: This was a prospective, randomized, double-blind trial comparing Lichtenstein's inguinal hernioplasty using SIHM versus PP. RESULTS: Seventy male patients underwent Lichtenstein's hernioplasty (n = 35 in the SIHM group and n = 35 in the PP group). At 3 years after surgery, there were 2 deaths (5.7%) in the PP group and 1 death (2.9%) in the SIHM group (not significant [NS]). Although the study was underpowered to evaluate the recurrence rate, only 1 recurrence (2.9%) was seen in the PP group (NS). Although a significant decrease in postsurgical pain incidence was never observed among patients in the SIHM group, a significantly lower degree of pain was detected at rest and on coughing at 1, 3, and 6 months and on movement at 1, 3, and 6 months and 1, 2, and 3 years. A significant decrease in postsurgical incidence and degree of discomfort when coughing and moving were observed among patients in the SIHM group at 3 and 6 months and at 1, 2, and 3 years after surgery. COMMENTS: SIHM hernioplasty seems to be a safe and effective procedure.

Prospective controlled randomized trial on prevention of postoperative abdominal adhesions by Icodextrin 4% solution after laparotomic operation for small bowel obstruction caused by adherences [POPA study: Prevention of Postoperative Adhesions on behalf of the World Society of Emergency Surgery].

BACKGROUND: Adhesive small intestine occlusion [ASIO] is an important cause of hospital admission placing a substantial burden on healthcare systems worldwide. Often times, ASIO is associated with significant morbidity and mortality.Icodextrin 4% solution [Adept, Shire Pharmaceuticals, UK] is a high-molecular-weight a-1,4 glucose polymer that is approved in Europe for use as an intra-operative lavage and a post-operative instillate to reduce the occurrence of post-surgery intra-abdominal adhesions.There are no randomized trials on the use of this solution to prevent adhesions after ASIO operation in current medical literature.The current clinical study evaluates the safety and effectiveness of Icodextrin 4% for decreasing the incidence, extent, and severity of adhesions in patients after abdominal surgery for ASIO. DESIGN: The study project is a prospective, randomized controlled investigation performed in the Department of Transplant, General and Emergency Surgery of St. Orsola-Malpighi University Hospital [Bologna, Italy]. The study is designed and conducted in compliance with the principles of Good Clinical Practice regulations.The study compares the results of Icodextrin 4% against a control group who does not receive anti-adhesion treatment. This randomized study uses a double-blind procedure to evaluate efficacy end points. In other words, designated third party individuals who are unaware of the treatment assigned to the patients to assess adhesion formation. TRIAL REGISTRATION NUMBER: ISRCTN22061989 Prospective controlled randomized trial on Prevention of Postoperative Abdominal Adhesions by Icodextrin 4% solution after laparotomic operation for small bowel obstruction caused by adherences[POPA study: Prevention of Postoperative Adhesions].

The ACTIVE (Acute Cholecystitis Trial Invasive Versus Endoscopic) study: multicenter randomized, double-blind, controlled trial of laparoscopic (LC) versus open (LTC) surgery for acute cholecystitis (AC) in adults.

BACKGROUND: In some randomized trials successful laparoscopic cholecystectomy for cholecystitis is associated with an earlier recovery and shorter hospital stay when compared with open cholecystectomy. Other studies did not confirm these results and showed that the potential advantages of laparoscopic cholecystectomy for cholecystitis can be offset by a high conversion rate to open surgery. Moreover in these studies a similar postoperative programme to optimize recovery comparing laparoscopic and open approaches was not standardized. These studies also do not report all eligible patients and are not double blinded. DESIGN: The present study project is a prospective, randomized investigation. The study will be performed in the Department of General, Emergency and Transplant Surgery St Orsola-Malpighi University Hospital (Bologna, Italy), a large teaching institutions, with the participation of all surgeons who accept to be involved in (and together with other selected centers). The patients will be divided in two groups: in the first group the patient will be submitted to laparoscopic cholecystectomy within 72 hours after the diagnosis while in the second group will be submitted to laparotomic cholecystectomy within 72 hours after the diagnosis. TRIAL REGISTRATION: TRIAL REGISTRATION NUMBER ISRCTN27929536 - The ACTIVE (Acute Cholecystitis Trial Invasive Versus Endoscopic) study. A multicentre randomised, double-blind, controlled trial of laparoscopic versus open surgery for acute cholecystitis in adults.

Immune response to small intestinal submucosa (surgisis) implant in humans: preliminary observations.

Surgisis IHM is an acellular biomaterial derived from porcine small intestinal submucosa (SIS) that induces site-specific remodeling in the organ or tissue into which it is placed. Previous animal studies have shown that the graft recipient mounts a helper T type 2-restricted immune response to the SIS xenograft without signs of rejection. The aims of this study were to evaluate the immune response to the SIS implant in a small series of humans and to examine the long-term clinical acceptance of the xenograft in these patients. Five consecutive male patients (mean age 56 years, range 34-68) who underwent inguinal hernioplasty with Surgisis IHM were assessed at 2 weeks, 6 weeks, and 6 months after implant for SIS-specific, alpha-1,3-galactose (alpha-gal) epitope and type I collagen specific antibodies. All five patients were also clinically assessed up to 2 years for signs of clinical rejection, hernia recurrence, and other complications. All 5 patients implanted with Surgisis IHM produced antibodies specific for SIS and alpha -gal with a peak between 2 and 6 weeks after implantation. By 6 months, all patients showed decreasing levels of anti-SIS antibodies. Two patients developed a transient, mild local seroma that resolved spontaneously. None of the patients showed any clinical signs of rejection, wound infection, hernia recurrence, or other complications in the follow-up out to 2 years. Thus, this study showed that in a small series of patients the SIS elicits an antibody response without clinical rejection of the xenograft and minimal postoperative complications.

Hernioplasty with Surgisis Inguinal Hernia Matrix (IHM).

Although at present nonabsorbable meshes are the preferred material for tension-free hernioplasty, some problems with their use are still to be addressed (i.e., chronic pain and infections). To address these disadvantages, a collagen-based material, the porcine small intestinal submucosa mesh, has recently been developed for hernia repair. The technique to use this material in performing an hernioplasty is described. A preshaped Surgisis Inguinal Hernia Matrix (IHM) is fashioned as appropriate, with a slit 2 cm from its inferior edge to accommodate the spermatic cord, placed for at least 10 min into a dish with room-temperature normosaline to be rehydrated and then transferred to the already prepared and dissected inguinal region. After drawing its tails around the cord, the mesh is sutured to the inguinal ligament with a continuous suture of PDS II 2/0, starting from the pubic tubercle laterally up to the deep orifice. The fixation of the mesh to the internal oblique abdominal muscle and the rectus sheath is accomplished with interrupted stitches. An extra stitch is placed between the two tails to close the new deep orifice. We conclude that an hernioplasty using Surgisis IHM is feasible with promising results.

Role of relaxation and specific suggestions in hypnotic emotional numbing.

The cognitive characteristics of highly hypnotizable subjects (Highs) allow them to easily modify their cognitive and autonomic state. Under hypnosis, Highs receiving cognitive, fear-like stimulation exhibit the cardiovascular changes typical of fear/stress, but also show an EEG pattern indicating a balance between fear-induced arousal and hypnotic relaxation. Indeed, hypnosis is effective in the attenuation of both emotional experience and behaviour (emotional numbing). The aim of the present experiment was to investigate the possible different role of relaxation and suggestion in hypnotic emotional numbing. Tonic skin conductance, respirogram, heart rate, systolic and diastolic blood pressure were recorded in 3 groups of hypnotized subjects: Group 1 received a fearful guided imagery associated with threat suggestions (Threat) followed by the same fearful suggestion associated with numbing instructions (relaxation and "No-Threat"); Group 2 received the same instructions in the opposite order of presentation; Group 3 received the fearful suggestion with threat instructions twice. The numbing suggestion reduced fear-related emotional experience and autonomic responses; if No-Threat preceded Threat, the heart rate, heart rate variability and blood pressure were also reduced during Threat, in spite of self reports of high negative emotion. Thus, 1) the subjective experience and the autonomic response to fear can be dissociated; 2) the efficacy of numbing suggestion is extended to a subsequent Threat stimulation; 3) habituation does not contribute to the numbing effect. The results indicate that the specific numbing suggestion is the main factor in hypnotic modulation of the experience of fear.

Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk?

OBJECTIVE: To evaluate the overall incidence of transvaginal evisceration following hysterectomy and to assess the risk associated with indication, route of surgery, age and vaginal cuff closure technique. MATERIALS AND METHODS: A database was used to identify all patients undergoing hysterectomy from 1995 to 2001 at our institution and all the patients admitted for vaginal evisceration during the same period. Each vaginal evisceration was analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. RESULTS: Of the 3593 patients enrolled in the study, 63.5% underwent abdominal hysterectomy, 33.0% vaginal hysterectomy, and 3.5% laparoscopic hysterectomy. Ten patients (0.28%) presented to the emergency room with vaginal evisceration. No statistical differences in evisceration rates were seen according to the route of surgery. No differences were found between the 1440 patients who had closure of the vaginal cuff and the 2153 who had an unclosed cuff closure technique. CONCLUSIONS: Our data suggest that, in young patients, sexual intercourse is to be considered the main trigger event before the complete healing of the vaginal cuff while, in elderly patients, the evisceration is a spontaneous event. Uterine prolapse was not associated with a higher rate and the route of surgery or vaginal cuff closure technique did not influence the dehiscence rate.

Emergency surgery for recurrent intraabdominal cancer.

BACKGROUND: Recurrent abdominal cancer can manifest in many ways but there are certain situations that are a great challenge to clinicians. Emergency presentation is one such situation. Surgeons are faced with a therapeutic dilemma that on the one hand most of these patients have a limited life expectancy, and on the other surgical procedures are unavoidable. We reviewed our experience of recurrent abdominal cancers presenting with acute abdominal symptoms requiring emergency. PATIENTS AND METHODS: Over the last 10 years, 81 patients with recurrent abdominal cancer presented with an abdominal emergency. Case records, operative notes and histology were reviewed. Frequency distributions were prepared for clinical, hematological, biochemical parameters, treatment and complications. Surgical analysis was carried out by the Kaplan Meier method and groups were compared using a log-rank test. RESULTS: The mean age of the patients was 70.1 years with a female to male ratio of 1.25. An overall postoperative mortality of 11.1% and morbidity of 27.1% was observed. Postoperative infections and respiratory complications were the most common causes of morbidity and mortality. Emergency resections carried the same risk of mortality and morbidity as the other surgical procedures (p > 0.05). Patients who underwent radical or palliative resections had a better survival than patients undergoing other procedures (p < 0.05). Preoperative Apache II score was found to be single most important predictor of postoperative mortality and morbidity. CONCLUSIONS: We conclude that surgical resection offers the best chance for improvement in survival after emergency surgery for recurrent abdominal cancer. If resection is not feasible, the possibility of creating a bypass or enterostomies should be considered to improve the patients' quality of life.

Prospective randomized, double-blind, controlled trial comparing Lichtenstein's repair of inguinal hernia with polypropylene mesh versus Surgisis gold soft tissue graft: preliminary results.

INTRODUCTION: Although polypropylene mesh are the preferred prosthesis materials for the tension-free hernioplasties because they handle well and become quickly integrated, having reduced the recurrence rate below 1%, some problems with their use are still to be addressed (postoperative pain, long-term discomfort, infections, intestinal obstruction and fistulization). In order to answer to these disadvantages, a new degradable and reabsorbable material, the porcine small intestinal submucosa (SIS mesh gold, Surgisis), has recently been used in humans for laparoscopic hernia repairs. Aim to our study is to evaluate the safety and efficacy of the Lichtenstein's hernioplasty using the Surgisis gold soft tissue graft, as a mesh, and to compare it with the traditional Lichtenstein procedure performed with polypropylene mesh. METHODS: A prospective, randomised, double-blinded comparison of Lichtenstein's repair of inguinal hernia with polypropylene mesh versus Surgisis ES soft tissue graft was carried out at the Department of Emergency Surgery of St Orsola-Malpighi University Hospital with the participation of 4 surgeons who accept to standardise the Lichtenstein's procedures with the two different types of meshes. RESULTS: From july 2002 up to now 20 patients submitted to Lichtenstein's repair of inguinal hernia using Surgisis gold mesh with a 6 month minimum follow-up were enrolled. 12 subjects were treated with Surgisis ES mesh, while 8 were treated polypropylene mesh. There were not intraoperative or postoperatively complications. No recurrences and wound infections were observed. The post-hernioplasty acute and chronic pain/discomfort (tested with visual analogue scale and simple verbal scale) and parenteral/oral analgesic consumption were lower in Surgisis ES group. CONCLUSIONS: Lichtenstein's hernioplasty using the Surgisis gold soft tissue graft has a promising safety and efficacy.

Ogilvie's syndrome treatment.

INTRODUCTION: Ogilvie's Syndrome (OS) is a rare condition caused by parasympathetic dysfunction of large bowel characterized by acute and massive colon distension without mechanical obstruction. Rarely this disease has to be treated by the surgeon but operations may be indicated in case of medical treatment failure. METHODS: A retrospective analysis was carried out at the Emergency Surgery DPT of St Orsola-Malpighi University Hospital Bologna Italy. From 1995 to 2002 11 patients were treated for severe OS: they were 8 males and 3 females and the mean age was 68 yrs. All these subjects had large bowel distension with caecum diameter more than 8 cm without any evidence of mechanical obstruction. RESULTS: In 4 patients (36%) OS was caused by trauma or surgical procedures whereas in 7 cases (64%) was produced by other conditions. Only in 3 cases (27%) conservative treatment was successful; the remaining 8 patients were submitted to surgical therapy. 6 patients were submitted to decompressive caecostomy and in 2 cases a subtotal colectomy was done. Mortality was 36%. DISCUSSION AND CONCLUSIONS: Surgical treatment of OS is indicated when there is a conservative treatment failure. The high mortality is related to diagnostic and therapeutic delays, advanced age and comorbidities.