The management of endoscopic retrograde cholangio- pancreatography-related infections risk: results of an italian survey at regional level.

Background and aim: Among the Endoscopic retrograde cholangiopancreatography (ERCP) adverse events, an increasingly arising problem is the transmission of Multi Drug Resistant (MDR) Bacteria through duodenoscopes. The aim of this survey was to evaluate the current clinical practice of management of ERCP associated infections in Emilia-Romagna, Italy. Methods: An online survey was developed including 12 questions on management of ERCP associated infections risk. The survey was proposed to all 12 endoscopy centers in Emilia Romagna that perform at least > 200 ERCPs per year. Results: 11 centers completed the survey (92%). Among all risk factors of ERCP infections, hospitalization in intensive care units, immunosuppressant therapies, and previous MDR infections have achieved a 80 % minimum of concurrence by our respondents. The majority of them did not have a formalized document in their hospital describing categories and risk factors helpful in the detection of patients undergoing ERCP with an high-level infective risk (9/11, 82%). Most centers (8/11, 72%) do not perform screening in patients at risk of ERCP infections. Post procedural monitoring is performed by 6 of 11 centers (55%). Conclusion: Our survey showed that, at least at regional level, there is a lack of procedures and protocols related to the management of patients at risk of ERCP infections.

A study on the antimicrobial activity of thymol intended as a natural preservative.

A quantitative investigation on the inhibitory activity of thymol against some microorganisms that could represent a potential spoilage risk both in acid and mild thermally treated foods is presented in this work. In order to assess potential biostatic or biocidal activity of thymol, both the growth kinetics and dose-response profiles were obtained and analyzed. A suitable macrodilution methodology based on a turbidimetric technique was adopted to produce inhibitory data used for characterizing microbial susceptibility against thymol at sub-MIC levels. Microbial growth was monitored through absorbance measurements at 420 nm as a function of contact time with the active compound. Moreover, for each tested microorganism, the noninhibitory concentration (NIC) and the MIC were quantified. Results prove that thymol can exert a significant antimicrobial effect on each phase of the growth cycle. The microbial susceptibility and resistance were found to be nonlinearly dose related. It is worth noting that significant biostatic effects were observed at sub-MIC levels.

Perifoveal laser treatment for subfoveal choroidal neovascularization in age-related macular degeneration.

The management of subfoveal choroidal neovascularization (CNV) secondary to age-related macular degeneration presents a major therapeutic dilemma. No treatment may lead to severe visual loss, and direct laser treatment to the entire subfoveal lesion results in acute loss of visual acuity. Encouraging results have been described with a foveal-sparing laser technique for subfoveal CNV. The authors performed perifoveal confluent laser treatment on a relatively well-defined occult CNV, sparing the foveal avascular zone. One month after treatment, the visual acuity had improved from 20/400 to 20/30. At 24 months, the visual acuity was 20/40 with no recurrence. Confluent perifoveal laser treatment for subfoveal CNV may be useful in preserving central visual acuity in selected patients.

Traumatic retinal detachment from a water balloon slingshot.

The authors describe a case of traumatic retinal dialysis with retinal detachment from a water balloon slingshot during a "water balloon war." A 31-year-old woman presented with decreased visual acuity in her right eye 2 days after being hit by a water balloon. The visual acuity in the right eye was counting fingers and fundus examination showed subtotal retinal detachment secondary to a superonasal dialysis. The patient underwent a scleral buckling procedure with external drainage, and at 18 months visual acuity was stable at 20/50 with attached retina. Water balloon eye injuries can result in permanent visual loss. More public awareness needs to be created regarding the potential harmful effects of this commonly used "toy."

Vitreomacular traction syndrome confused with pseudophakic cystoid macular edema.

Vitreomacular traction syndrome causes visual loss as a consequence of persistent traction on the fovea from an attached posterior hyaloid. The diagnosis can be challenging because the attachment may be subtle. Cystoid macular edema secondary to cataract extraction is well known and can occur in the absence of any surgical complication. Herein, a patient is described who had vitreomacular traction syndrome diagnosed after uneventful cataract surgery. Pars plana vitrectomy with detachment of the posterior hyaloid restored vision to an acceptable level. Careful examination and clinical suspicion are important because recognition and surgical intervention will benefit the majority of these patients.

Roth spots seen on ophthalmoscopy: diseases with which they may be associated.

Roth spots seen on fundoscopic examination (white-centered hemorrhages) were classically described as septic emboli in patients with subacute bacterial endocarditis (SBE). Many physicians have considered them pathognomonic for this entity. More recent evidence suggests, however, that they are nonspecific and may be found in other disease states. A review of the pathogenesis of these white-centered hemorrhages will be provided, along with some diseases other than SBE in which they may occur.

Delayed onset of bilateral acute retinal necrosis syndrome: a 34-year interval.

The case is described of a male patient who had a history of acute retinal necrosis (ARN) OS at age 13 years. The eye subsequently had an inoperable retinal detachment with residual light perception visual acuity. After a 34-year disease-free interval, ARN developed OD that responded to medical treatment. This case represents the longest reported interval of ARN quiescence with eventual bilateral involvement and illustrates the importance of long-term patient follow-up.

Hydroxychloroquine toxicity despite normal dose therapy.

The risk of retinopathy associated with the use of hydroxychloroquine is said to be nullified if the dosage recommendations are followed strictly. In this case report, we describe an elderly patient with rheumatoid arthritis who had bilateral maculopathy, presumably secondary to hydroxychloroquine therapy, despite a dosing regimen within therapeutic guidelines. We believe special attention should be given to elderly patients who are being treated with hydroxychloroquine because their retinal pigment epithelium may be more susceptible to the toxic effects of this drug.

Toxoplasmic papillitis as the initial manifestation of acquired immunodeficiency syndrome.

Toxoplasmic retinochoroiditis has been reported as the initial manifestation of acquired immunodeficiency syndrome (AIDS). Two authors have described two patients with AIDS and toxoplasmic papillitis. We report the case of a patient with a papillitis of unknown origin in whom the workup found systemic toxoplasmosis and subsequent positive human immunodeficiency virus status. To our knowledge, this is the first reported case of toxoplasmic papillitis as the initial manifestation of AIDS.

Eighty-four consecutive breast reconstructions using a textured silicone tissue expander.

Breast reconstruction utilizing smooth-surface silicone tissue expanders is associated with certain problems. Significant capsular contracture may develop around the expander with subsequent expander displacement necessitating repositioning or capsulectomy at the time of expander removal. Infection, pain on expansion, chest-wall compression, and complications related to the remote fill valve also have been reported. A textured-surface silicone expander with an integrated fill valve was developed to address these issues. Eighty-four consecutive breast reconstructions were performed by a single surgeon using textured expanders in 55 patients. Intraexpander pressures were measured during expansion for a group of these patients, and both initial and postinflation pressure readings were quite low (average initial pressure 2.88 mmHg; average postinflation pressure 12.87 mmHg). Eighty-one of the reconstructions have been completed without any expander losses and with minimal complications. Tissue expander volume averaged 580 cc, and the expansion duration averaged 5.6 months. Various types and configurations of permanent implants were used to complete the reconstructions. Eighty-four percent of our patients' completed reconstructions (including nippleareola reconstruction and opposite breast alteration, when necessary) were accomplished with just two procedures. Seventeen long-term adjustable textured-surface expander/implants with anatomic breast shape are still in place, all after only one operation. The inframmary fold has generally been established passively by the expansion process alone. Textured-surface silicone expanders have stayed where positioned, have expanded easily with minimal patient pain, and have created a noncontractile soft-tissue cover for the final implant. The textured expander with an integrated fill valve has simplified breast reconstruction by helping to limit the problems encountered with smooth silicone expanders. The resulting reconstructions have remained soft with a very acceptable aesthetic appearance. The patient office and hospital charts and photographs of this consecutive series were notarized and submitted to the Editor of this Journal, whose biostatistician randomly selected the cases illustrated.

Maxillofacial fractures in the elderly: a comparative study.

Previous maxillofacial trauma research has dealt primarily with facial bone fractures in the general population. Very few studies have specifically addressed maxillofacial fractures in the elderly. We compared 45 elderly (65 years of age or older) and 201 younger adult (16 to 64 years of age) patients admitted to our hospital with maxillofacial fractures. The percentage of patients admitted with nasal bone fractures was much greater in the elderly population, while mandibular fractures were more common in the adult group. Motor vehicle accidents accounted for over half the injuries in both groups, while falls were more prevalent in the elderly. Management of the elderly patient may be complicated by their associated injuries or underlying medical problems, perhaps partially accounting for their longer median length of hospital stay. The elderly are a unique subpopulation of maxillofacial fracture patients and deserve further study regarding their injuries and optimal methods for treatment.

Wound metabolism.

The science of wound healing is vital to all aspects of plastic surgery. Knowledge of wound metabolism is essential to a complete understanding of wound healing. Through various laboratory models, we have isolated and studied many of the parameters involved in tissue repair and metabolism. Our findings suggest that biochemical aspects of wound healing are directed by the metabolism of the cellular infiltrate in the wound. These findings help to explain the independent nature of the wound during its healing process ("biological priority").

Decision making in the acute thermal hand burn: an algorithm for treatment.

Acute thermal hand burns require a systematic approach to obtain optimal results. Much has been written about the care of hand burns and the significant studies have been summarized here. Discussion still remains concerning the most appropriate treatment of the second-degree burn injury. Despite the residual controversies, a planned algorithm for treatment should help the hand surgeon decide the best approach when faced with a significant hand burn. Our algorithm for the acute thermal hand burn covers the spectrum of care with the ultimate goal of returning normal hand function.

Nonoperative management of full-thickness intravenous extravasation injuries in premature neonates using enzymatic debridement.

Peripheral intravenous fluid extravasation is a common occurrence among neonatal intensive care unit patients. Fifteen high-risk neonates, averaging less than 35 weeks' gestation and less than 1,500 g birth weight, with full-thickness extravasation injuries were successfully treated nonoperatively by a topical fibrinolysin/deoxyribonuclease ointment. All wounds healed without delaying hospital discharge, and no significant scar contractures were observed in patients followed up to 16 months after injury.

Necrotizing fasciitis as a complication of chickenpox.

Necrotizing fasciitis is a rapid, potentially fatal soft tissue infection. Chickenpox is a common childhood illness not usually associated with severe complications. We present the case of an 8-year-old girl with necrotizing fasciitis of the upper back arising from superinfection of varicella skin lesions. Necrotizing fasciitis may have devastating sequelae, including septic shock, which mandate vigorous fluid resuscitation, appropriate antimicrobial therapy, and early aggressive surgical debridement.

The effect of exogenous fibronectin on wound breaking strength.

Experimental wounds in rats were tested for breaking strength at 4, 7, 11, 14, and 21 days to determine whether incisions treated with homogenous fibronectin differed from control incisions. At 7, 11, 14, and 21 days after wounding, the fibronectin-treated incisions were significantly stronger than the control incisions.