Evaluation of vacuum packaging for extending the shelf life of Sardinian fermented sausage.

Salsiccia sarda or Sardinian fermented sausage is a traditional dry-fermented sausage included in the list of traditional food products of Sardinia (Italy). At the request of some producing plants, the possibility of extending the shelf life of the vacuum-packed product up to 120 days was evaluated. Manufacturing of 90 samples, representing 3 different batches of Sardinian fermented sausage was carried out in two producing plants (A and B). In the packaged product and subsequently every 30 days for four months (T0, T30, T60, T120), the following analyses were conducted on all samples: physicochemical characteristics, total aerobic mesophilic count, Enterobacteriaceae count, detection of Listeria monocytogenes, Salmonella spp., mesophilic lactic acid bacteria, and coagulase-positive Staphylococci. Moreover, surfaces in contact and surfaces not in contact with food were sampled in both producing plants. Sensory profile analysis was also performed for every analysis time. At the end of the extended shelf life, pH values were equal to 5.90±0.11 (producing plant A) and 5.61±0.29 (producing plant B). Water activity mean values at T120 were 0.894±0.02 (producing plant A) and 0.875±0.01 (producing plant B). L. monocytogenes was detected in 73.3% (33/45) of the samples from producing plant A, with mean levels of 1.12±0.76 log10 CFU/g. In producing plant B, L. monocytogenes was never detected. Enterobacteriaceae were detected in 91.1% (41/45) of samples in producing plant A with mean values of 3.15±1.21 log10 CFU/g, and in 35.5% (16/45) samples in producing plant B samples with mean values of 0.72±0.86 log10 CFU/g. Salmonella and Staphylococcus aureus were never detected. Regarding environmental samples, the sites that were most contaminated by L. monocytogenes were the bagging table (contact surface) and processing room floor drains (non-contact surface) with a prevalence of 50% each (8/16 positive samples for both sampling sites). Sensory analysis results showed that at T30 the overall sensory quality was at its highest;moreover, the visual-tactile aspect, the olfactory characteristics, the gustatory aspects, and the texture showed significant differences in samples throughout the shelf life, with a decreased intensity at 120 days of storage. Overall, the quality and sensory acceptance of the vacuumpacked Sardinian fermented sausage was not affected until 120 days of shelf-life. However, the possible contamination by L. monocytogenes calls attention to the hygienic management of the entire technological process. The environmental sampling was confirmed as a useful verification tool during control.

Epidemiological survey on the prevalence of Salmonella spp. in the Sardinian pig production chain, using real-time PCR screening method.

The aim of this study was to evaluate the prevalence of Salmonella spp. in the Sardinian pig production chain in order to establish the incidence of monophasic serovariant of Salmonella Typhimurium on isolates with molecular methods (real-time PCR and multiplex PCR). Samples were collected in three EC slaughterhouses, four small slaughterhouses annexed to farmhouses, one meat distribution center, four meat cutting laboratories and four sausage processing plants. A total of 166 samples were collected and analyzed: 46 environmental samples, 48 finishing pigs, 16 piglets, 24 samples of non-processed meat, 28 meat preparations and 4 meat products. All samples were processed with an initial screening using the real-time PCR MicroSEQ® Salmonella spp detection Kit (Applied biosystems, life technologies) and with the TaqMan® Real-time PCR to confirm the kit results. Samples that tested positive for Salmonella spp were confirmed with cultural method using the standard ISO 6579. Positive samples were submitted to phenotypic identification. One colony from each positive sample was serotyped with multiplex PCR method. Salmonella spp was isolated in 7 on 166 samples (4.22 %). Among the positive samples, two came from finishing pigs, two belonged to the category meat preparations, two to meat products, one was an environmental sample. Multiplex PCR confirmed that the collected strains belonged to the species Salmonella Typhimurium (1), Salmonella derby (3) and monophasic serovariant of Salmonella Typhimurium (3).

Surgical management of primary and recurrent carcinoma showing thymous-like elements (CASTLE).

INTRODUCTION: Carcinoma showing thymous-like elements (CASTLE) is a rare tumor with only a few cases described in the scientific literature. The aim of the present review is to analyze the data available on the therapeutic options employed in CASTLE tumors and to outline the best surgical management to adopt. MATERIALS AND METHODS: English-language articles published from 1985 through November 2016, and related to CASTLE cases were retrieved using the Pubmed database and specific key-words. RESULTS: Eighty seven cases included in 23 papers, published in the period under investigation, were analyzed in detail. The mean age of the patients was 50.2 years and the male to female ratio 1:1.2. There were performed 31 (35.6%) lobectomies, 29 (33.3%) total thyroidectomies, 15 (17.2%) subtotal thyroidectomies, 4 (4.6%) excisions, 3 (3.4%) partial thyroidectomies, 1 (1.1%) hemithyroidectomy, and 8 (9.2%) additional procedures including tracheal, pharyngeal, and esophageal resections. Lymph node dissection and radiotherapy were associated in 59 (67.8%) and 44 (50.6%) cases respectively. Among the patients with available data 62 (75.6%) were free of disease, 16 (19.5%) were alive with disease, 3 (3.7%) died for the disease, and 1 (1.2%) died for cerebrovascular complications at the time of follow-up. Globally 20 (24.4%) cases of local or distant recurrence were reported. Surgery and radiotherapy, alone or in combination were the treatments most frequently used for recurrences. CONCLUSIONS: CASTLE is a rare tumor which generally respond well to complete surgical resection and adjuvant radiotherapy. These treatments can be further employed for the recurrences, which occur in 24.4% of the cases, along with specific chemotherapy regimens and palliative procedures. KEY WORDS: Cancer, CASTLE, Excision, Lobectomy, Thymous-like elements, Thyroidectomy.

MicroRNA Expression Analysis of Centenarians and Rheumatoid Arthritis Patients Reveals a Common Expression Pattern.

Micro-RNA (miRNA) are a family of small non-coding ribonucleic acids that inhibits post-transcriptionally the expression of their target messenger RNA (mRNA). We are interested in studying the involvement of miRNA in longevity and autoimmune diseases. In this study we compared the different expression of seven microRNAs between human plasma healthy controls, plasma samples of centenarians and samples from patients with rheumatoid arthritis. We used the Life Technologies' protocol to quantify seven miRNAs from 62 plasma samples: 20 healthy human controls, 14 centenarians, 28 patients with rheumatoid arthritis. TaqMan MicroRNA assays were used to analyze the expression profiles of miR-125b-5p, miR-425-5p, miR-200b5p, miR-200c-3p, miR-579-3p, miR-212-3p, miR-21-5p and miR-126-3p. The relative expression of mature miRNAs was analyzed using software REST. Our results show that miR-425-5p, miR-21 and miR-212 significantly decreased in centenarians and in patients with rheumatoid arthritis compared with controls. Furthermore in this work we highlight a connection between corticosteroid treatment and miRNAs expression.

Proteomic analysis of human plasma and peripheral blood mononuclear cells in Systemic Lupus Erythematosus patients.

Systemic Lupus Erythematosus (SLE) is a systemic autoimmune disease with a broad spectrum of clinical presentations and incompletely understood pathogenesis. This autoimmune disease is characterized by alterations in both the innate and adaptive immune system that lead to the loss of immunologic tolerance. In autoimmune diseases particularly in SLE, early diagnosis, flare or remission phases can be difficult to identify. Proteomics can help to find new therapeutic targets and it also could help to better understand the cellular mechanisms. The aim of this study was to observe the variations in plasma and Peripheral Blood Mononuclear Cells (PBMCs) proteome in order to increase our knowledge about pathogenesis and to find possible diagnostic markers and/or therapeutic targets for improving diagnosis and treatment. The comparative proteomic analyses showed that several proteins were differentially expressed in the PBMCs from SLE patients. Among these, PRDX2 may be used as candidate biomarker or target protein for further investigations. In plasma, we showed that plasma clusterin levels increased in SLE patients compared to healthy controls, but this increase is not statistically significant. These proteomic results provide suggestions for understanding the molecular mechanisms of SLE, as well as the physiological changes correlated with SLE disease.

Shelf Life Evaluation of Ricotta Fresca Sheep Cheese in Modified Atmosphere Packaging.

Ricotta fresca cheese is the product of Sardinian dairy industry most exposed to microbial post-process contamination. Due to its technological characteristics, intrinsic parameters, pH (6.10-6.80) and water activity (0.974-0.991), it represents an excellent substrate for the growth of spoilage and pathogenic microorganisms, which are usually resident in cheese-making plants environments. Generally, ricotta fresca has a shelf life of 5-7 days. For this reason, at industrial level, modified atmosphere packaging (MAP) is used to extend the durability of the product. However, few investigations have been conducted to validate the use of MAP in ricotta fresca. The aim of this work is to evaluate the shelf life of ricotta fresca under MAP. A total of 108 samples were collected from three Sardinian industrial cheese-making plants and analysed within 24 h after packaging and after 7, 14 and 21 days of refrigerated storage. Aerobic mesophilic bacteria, mesophilic and thermophilic cocci and lactobacilli, Enterobacteriaceae and E. coli, L. monocytogenes, Pseudomonas spp, Bacillus cereus, yeasts and moulds, and the chemical-physical parameters and composition of the product were determined. At the end of the shelf life, Pseudomonas spp. and Enterobacteriaceae reached high concentrations, 5 to 7 and 3 to 6 log10 colony forming unit g-1, respectively. The presence of environmental contaminants indicates that the use of MAP without the appropriate implementation of prerequisite programmes is not sufficient to extend the durability of ricotta fresca. Gas mixture and packaging material should be selected only on the basis of scientific evidence of their effectiveness.

Listeria Spp. and Listeria Monocytogenes Contamination in Ready-To-Eat Sandwiches Collected from Vending Machines.

Ready-to-eat (RTE) food is characterised by a long shelf-life at refrigerated temperature and can be consumed as such, without any treatment. The aim of the work was to evaluate the presence of Listeria spp. and Listeria monocytogenes in RTEs collected from refrigerated vending machines placed in hospital environment and accessible to the hospitalised patients. In 4 different sampling, 55 RTEs were collected from vending machines of six hospitals located in different areas of Sardinia region. All the samples were characterised by similar manufacturing process, such as the use of modified atmosphere packaging and belonged to 5 different producers. Listeria spp. was not countable using the enumeration method in all of the analysed samples. Using the detection method, Listeria spp. was recovered from 9 sandwich samples. Interestingly, 3 of these samples (5.5%) made by the manufacturer, were positive for L. monocytogenes contamination. The risk related to the L. monocytogenes presence in RTEs proportionally increases when food is introduced in susceptible environments, such as hospitals and consumed by susceptible people. Although the RTEs analysed showed values that complied with the European microbiological criteria for foodstuffs, the availability of these products in a susceptible environment should be carefully checked. Therefore, in order to limit the possible exposition to L. monocytogenes, more information on the risk related to RTE consumption should be provided to the hospitalised patients.

Evolution of the Microbiological Profile of Vacuum-Packed Ricotta Salata Cheese During Shelf-Life.

Ricotta salata cheese is a salted variety of ricotta traditionally made in Sardinia (Italy) from the whey remaining after the production of Pecorino Romano protected designation of origin or other sheep milk cheeses. Ricotta salata cheese is very critical for the possible growth of pathogenic and spoilage microorganisms. Sporadic cases of listeriosis associated with ricotta salata cheese have been reported over recent years. The objective of the present study was to assess the evolution of spoilage and pathogen microorganism of vacuum-packed ricotta salata cheese during the entire product shelf-life. The durability study was conducted on 18 vacuum-packed ricotta salata cheese samples analysed at the beginning of the shelf-life and after 60 and 90 days of refrigerated storage. Pathogens as Listeria monocytogenes and Bacillus cereus were never detected. During shelf-life total bacterial counts ranged between 7.90±0.64 and 9.19±0.58 CFU g-1 on the rind and between 2.95±0.68 and 4.27±1.10 CFU g-1 in the inner paste, while Enterobacteriaceae ranged between 4.22±0.66 and 5.30±0.73 CFU g-1 on the rind and 3.13±1.80 and 2.80±0.88 CFU g-1 in the inner paste. By considering the technology used, the intrinsic properties and the almost total absence of competing microflora, ricotta salata cheese can support the growth of spoilage and pathogen microorganisms originating from the processing environment. The high level of total bacterial counts and Enterobacteriaceae observed both on the rind and in the inner paste suggests contamination of the product from the processing environment. Therefore, a strict implementation of hygiene during processing is essential in order to reduce the load of environmental contaminants that may grow during refrigerated storage.

Breast Nodular Fasciitis: A Comprehensive Review.

BACKGROUND: This article describes the demographic, clinical, pathological and prognostic features of breast nodular fasciitis through a comprehensive review of the cases reported in modern literature. MATERIAL AND METHODS: English-language articles published from January 1970 to October 2015 and related to breast nodular fasciitis were non-systematically retrieved using the PubMed database. Titles, abstracts and references were evaluated in order to include the most relevant studies. The demographic characteristics of the patients and the signs and symptoms of the disease were reviewed, as well as the results of the radiological and diagnostic procedures employed and of the treatments adopted. RESULTS: 26 papers reporting on 28 cases were enrolled; however, manuscripts published before 1990 were excluded because of old methodologies, technologies and clinical approaches. Thus, 22 cases included in 20 papers were analyzed in detail. CONCLUSION: The rarity and the unspecific clinical and radiological characteristics of breast nodular fasciitis make the differential diagnosis and management challenging. Knowledge of the clinical, pathological and prognostic aspects of this condition is crucial for breast care specialists in order to improve their diagnostic and therapeutic interventions.

Occurrence and behavior of Bacillus cereus in naturally contaminated ricotta salata cheese during refrigerated storage.

The present study shows the fate of Bacillus cereus in refrigerated ricotta salata cheese during shelf-life. 144 ricotta salata cheese belonging to nine naturally contaminated batches were stored refrigerated and analyzed at 24 h, 30, 60 and 90 days of storage. Total bacterial count, B. cereus spores and vegetative forms, intrinsic properties and composition were determined. The presence of spores was sporadic while the prevalence and the level of B. cereus vegetative cells decreased respectively from 83.3 % to 4.65 ± 0.74 cfu g(-1) at the beginning of the observation period to 33.3 % and 1.99 ± 0.55 cfu g(-1) after 90 days. No information is currently available on the fate of B. cereus in ricotta salata. The production process of ricotta salata includes steps such as whey heating followed by slow cooling of clots, which expose to the risk of spore germination and successive growth to levels compatible with toxins production. The prolonged refrigerated storage was not favorable to sporulation, explaining the successive death of vegetative cells. The present study demonstrate the potential risk of food poisoning as consequence of pre-formed emetic toxins in ricotta salata. Food safety of ricotta salata relies on the rapid refrigeration of the product during critical phases for cereulide production.

Inactivation of Listeria monocytogenes using Water Bath Heat Treatment in Vacuum Packed Ricotta Salata Cheese Wedges.

UNLABELLED: Ricotta salata cheese is frequently contaminated on the surface with Listeria monocytogenes. Water bath heat treatment in vacuum packed whole ricotta salata cheese wheels demonstrated to be effective in inactivating L. monocytogenes. However, the risk of cross-contamination in ricotta salata wedges is increased during cheese cutting. Therefore, the effectiveness of heat treatment in ricotta salata wedges has to be demonstrated conducting a new validation study. In this study, 9 different time temperature combinations, 75, 85, and 90 °C applied for 10, 20, and 30 min each, were tested on artificially contaminated ricotta salata cheese wedges. The extent of the lethal effect on L. monocytogenes was assessed 1 and 30 d after the application of the hot water bath treatment. Five of 9 combinations, 75 °C for 30 min, 85 °C for 20, and 30 min, and 90°C for 20 and 30 min, demonstrated to meet the process criteria of at least 5 log reduction. Sensory analyses were also conducted in order to account for the potential impact on sensory features of ricotta salata wedges, which showed no significant differences between treatments. PRACTICAL APPLICATION: This study allowed to select water bath heat treatments of vacuum packed ricotta salata wedges effective to reduce L. monocytogenes contamination. Such treatments can be successfully applied by food business operator to meet compliance with microbiological criteria through the designated shelf-life.

Microbiological Challenge Testing for Listeria Monocytogenes in Ready-to-Eat Food: A Practical Approach.

Food business operators (FBOs) are the primary responsible for the safety of food they place on the market. The definition and validation of the product's shelf-life is an essential part for ensuring microbiological safety of food and health of consumers. In the frame of the Regulation (EC) No 2073/2005 on microbiological criteria for foodstuffs, FBOs shall conduct shelf-life studies in order to assure that their food does not exceed the food safety criteria throughout the defined shelf-life. In particular this is required for ready-to-eat (RTE) food that supports the growth of Listeria monocytogenes. Among other studies, FBOs can rely on the conclusion drawn by microbiological challenge tests. A microbiological challenge test consists in the artificial contamination of a food with a pathogen microorganism and aims at simulating its behaviour during processing and distribution under the foreseen storage and handling conditions. A number of documents published by international health authorities and research institutions describes how to conduct challenge studies. The authors reviewed the existing literature and described the methodology for implementing such laboratory studies. All the main aspects for the conduction of L. monocytogenes microbiological challenge tests were considered, from the selection of the strains, preparation and choice of the inoculum level and method of contamination, to the experimental design and data interpretation. The objective of the present document is to provide an exhaustive and practical guideline for laboratories that want to implement L. monocytogenes challenge testing on RTE food.

Antibiotic resistance traits and molecular subtyping of Staphylococcus aureus isolated from raw sheep milk cheese.

UNLABELLED: The main objective of the present research was to evaluate the antibiotic resistance profiles of Staphylococcus aureus isolated from raw sheep milk cheese. A total of 150 strains were isolated from curd cheese samples and identified as S. aureus. The survey on antibiotic resistance was carried out on 47 strains, selected among isolates showing differences in the banding pattern after Pulsed Field Gel Electrophoresis (PFGE) screening or, belonging at the same pulsotype but isolated from different cheese samples. On selected strains antimicrobial resistance against ampicillin, penicillin, cloxacillin, tetracycline, erythromycin, and vancomycin was assessed by broth microdilution method. The presence of the genes coding for antibiotic resistance and virulence factors (agr alleles, sea-see, and tst) was also investigated by PCR. Thirty-one isolates belonging to agrI and agrIII groups carried at least one gene coding for enterotoxins or toxic shock syndrome toxin. Approximately 60% of the selected strains were susceptible to the tested antibiotics. Twelve of 47 isolates showed multiple resistance against ampicillin and penicillin. Only 1 strain, represented by a unique PFGE profile showed simultaneous resistance to ampicillin, penicillin and cloxacillin. Single resistance against tetracycline was found in 5 isolates belonging to 2 different pulsotypes. The results of this study suggest that the recovery of S. aureus resistant strains in raw milk cheese samples is quite common but it is limited to few antibiotic classes, mainly ß-lactams and tetracyclines. None of the strains showed resistance to erythromycin and vancomycin. PRACTICAL APPLICATION: The present research contributes to increase the knowledge on the diffusion of antibiotic resistant S. aureus strains isolated from raw sheep milk cheeses. These can be regarded as a vehicle for the introduction of strains of animal origin to humans through food.

Prophylactic central neck lymphadenectomy in high risk patients with T1 or T2 papillary thyroid carcinoma: is it useful?

INTRODUCTION: The aim of this study was to evaluate the role of prophylactic central neck lymph node dissection in high risk patients with T1 or T2 papillary thyroid cancer. MATERIALS AND METHODS: Seventy-three patients who had undergone total thyroidectomy for papillary thyroid cancer smaller than 4cm, without cervical lymphadenopathy and prophylactic central neck lymph node dissection were included. Patients were divided in two groups: low risk patients (group A) and high risk patients (group B). High risk patients were considered those with at least one of the followings: male sex, age ≥ 45 years, and extracapsular or extrathyroid disease. Statistical significant differences in persistent disease, recurrence and complications rates between the two groups were studied. RESULTS: Persistence of the disease was observed in one case in group A (5.9%) and in three cases in group B (5.4%), while thyroid cancer recurrence was registered in zero and two (3.6%) cases respectively. One single case (5.9%) of transitory recurrent laryngeal nerve damage was reported in group A and none in group B, while transitory hypoparathyroidism was observed in 2 (3.6%) patients in group A, and 1 (1.8%) patient in group B. Permanent recurrent laryngeal nerve damage was observed in one patient in group A, while permanent hypoparathyroidism was registered in one case in group B. Logistic regression evidenced that multifocality was the only risk factor significantly related to persistence of disease and recurrence. CONCLUSIONS: Our results suggests that prophylactic central neck lymph node dissection can be safely avoided in patients with T1 or T2 papillary thyroid cancer, except in those with multifocal disease. KEY WORDS: Cancer, Central neck, Cervical, Lymphadenectomy, Lymph nodes, Papillary carcinoma, Thyroid.

Impact of transthoracic endoscopic sympathectomy on plantar hyperhidrosis.

INTRODUCTION: The aim of this study is to evaluate the impact of transthoracic endoscopic sympathectomy on plantar hyperhidrosis in patients operated on for upper limb hyperhidrosis. MATERIALS AND METHODS: From 2003 to 2011, 41 consecutive patients underwent videothoracoscopic T3-T4 sympathicotomy or T3-T4 ganglion block at our Unit for upper limb hyperhidrosis. Twenty-one (51%) were affected by palmar hyperhidrosis and 20 (49%) by palmar and axillary hyperhidrosis combined. The patients affected by the plantar form were 26 (63%). Clinical follow-up was performed at 3, 6 and 12 months after surgery. Phone interviews and/or clinical assessment were made after a variable period of time (range 6 months to 8 years) to asses long term results. RESULTS: Plantar hyperhidrosis improved in 14 patients, which represents the 54% of the sufferers and the 34% of all patients. It was partially regressed in 11 patients (79%) and resolved in 3 cases (21%). There were not significant differences between patients treated with sympathicotomy and those treated with ganglion block. CONCLUSIONS: Transthoracic endoscopic sympathectomy performed through T3-T4 sympathicotomy or ganglion block improves plantar hyperhidrosis in approximately 54% of the affected patients, with a partial and complete resolution rate of 79% and 21% respectively.

Radiofrequency ablation in the management of advanced stage thymomas: a case report on a novel multidisciplinary therapeutic approach.

We describe in this report a case of successful radiofrequency ablation of an unresectable stage III-type B3 thymoma, and we discuss the role of this novel approach in the management of patients with advanced stage thymoma. The patient, a 59-year-old Caucasian male underwent neoadjuvant chemotherapy with only a slight reduction of the mass. Subsequently, an explorative sternotomy and debulking were performed; before closing the thorax, radiofrequency ablation of the residual tumor was carried out and a partial necrosis of the mass was achieved. A further percutaneous radiofrequency ablation was performed subsequently, obtaining complete necrosis of the lesion. Successively, the patient underwent adjuvant radiotherapy. As a result of this multidisciplinary treatment, complete and stable response was obtained. It is hard to say which of the single treatments had the major impact on cure; nevertheless, the results obtained suggest that radiofrequency ablation must be taken into account for the treatment of advanced stage thymomas, and its effectiveness must be further assessed in future studies.

Axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells: is it necessary?

AIMS AND BACKGROUND: Sentinel lymph node biopsy is the standard method for axillary lymph node staging in patients with early stage breast cancer. The aim of the study was to evaluate the necessity of axillary lymph node dissection in patients with breast cancer and sentinel lymph node micrometastasis or isolated tumor cells. METHODS: Sentinel lymph node biopsy was performed in 136 patients for breast cancer staging: 16 of them (11.7%) were found to have micrometastasis or isolated tumor cells and underwent axillary lymph node dissection. Micrometastases were considered when tumor invasion was ≤ 2 mm and >0.2 mm in diameter and isolated tumor cells when detected alone or in clusters of <0.2 mm in diameter. The dissection of the three axillary lymph node levels of Berg was performed in all cases. RESULTS: Two patients (12.5%) presented isolated tumor cells and 14 (87.5%) micrometastasis in the sentinel lymph node. Among them, 25% presented nonsentinel axillary lymph node tumor invasion, whereas 75% had no further nodal involvement. CONCLUSIONS: Results suggest that micrometastasis or isolated tumor cells of the sentinel lymph node represent the only site of cancer involvement of the axilla, especially in patients with early breast tumors, and that axillary lymph node dissection may be unnecessary in these cases and represent an overtreatment.

T2-T4 sympathectomy versus T3-T4 sympathicotomy for palmar and axillary hyperhidrosis.

OBJECTIVE: To evaluate and compare the immediate and long-term outcomes of videothoracoscopic T2-T4 sympathectomy and T3-T4 sympathicotomy for the treatment of palmar and axillary hyperhidrosis. METHODS: Between October 1993 and September 2007, we treated a total of 88 patients affected by palmar and axillary hyperhidrosis. Twenty-four patients underwent T2-T4 sympathectomy with 5-10 mm trocars (Group A), 43 T2-T4 sympathectomy with 2-5 mm trocars (Group B), 15 T3-T4 sympathicotomy with 5-10 mm trocars and 6 T3-T4 ganglion block with 2-5 mm trocars (Group C). The mean operative time, for each side, was 15 min for sympathicotomy and 28 min for sympathectomy. In September 2008, we recontacted 98% of patients (total 86), by telephone, to establish long-term results (follow-up range 1-15 years). RESULTS: In this series, we did not find any significant difference between T2-T4 sympathectomy and T3-T4 sympathicotomy in terms of postsurgical palmar anhidrosis or onset of compensatory hyperhidrosis, while both methods show high efficacy for remission of palmar hyperhidrosis. The slightly higher recurrence rate in our early experience (Group A) can be attributed to the learning curve. Using smaller trocars (2-5 mm), we reduced postsurgical intercostal pain and obtained better aesthetic results and a higher grade of patient's satisfaction. INTERPRETATION: Thoracoscopic approach to hyperhidrosis has evolved in the last few decades with a consequent decrease in side effects. In this series, all patients experienced an improvement in quality of life even in case of recurrence or onset of compensatory hyperhidrosis. Due to these results, the shorter operative time and easier performance of sympathicotomy, we prefer this method.

Multimodality approach to malignant pleural mesothelioma. A case report.

INTRODUCTION: We report a case of diffuse malignant pleural mesothelioma (DMPM) in a 68-years-old male patient who was admitted for right sited pleural effusion. The patient was treated by multimodality approach consisting in surgical treatment with Extrapleural Pleuropneumonectomy followed by chemotherapy with Cisplatin and Pemetrexed. He had a disease free period of one year and survived for 31 months. CASE REPORT: The patient was admitted to our Institute for a right sited pleural effusion diagnosed on chest X ray. Anamnesis revealed professional asbestos exposure and the patient presented dyspnea, dry cough, right sited chest pain, low fever and loss of weight. As thoracentesis and CT scan did not reveal pathological findings except of the effusion, we performed videothoracoscopy. Several grey nodular lesions involving the costal, diaphragmatic and mediastinic parietal pleural sheets were found. Histological examination of the specimens extracted revealed the presence of epithelial malignant pleural mesothelioma with sarcomatoid areas. Further examinations staged the lesion as Butchart I. Extrapleural pleuropneumonectomy was performed followed by a chemiotherapic treatment with Cisplatin and Pemetrexed. The patient underwent a follow up program with CT scan every four months. The disease free period was of about one year and the patient died after 31 months from diagnosis for septic complications related to chronic effusion. DISCUSSION: Single treatments do not demonstrate an acceptable efficacy on the treatment of DMPM. Multimodality therapy provides good survival improvement and acceptable quality of life for the patients.