Long-Term Functional Outcome after Internal Delorme's Procedure for Obstructed Defecation Syndrome, and the Role of Postoperative Rehabilitation.

PURPOSE: To evaluate long-term functional outcomes of Internal Delorme's Procedure (IDP) in patients refractory to conservative treatment for Obstructed Defecation Syndrome (ODS), and to compare those who received postoperative rehabilitation with those who did not. MATERIALS AND METHODS: All patients with ODS refractory to nonoperative therapy were identified across three regional pelvic floor referral hospitals, and IDP was performed. Postoperatively selected patients received biofeedback therapy. Functional outcomes were established using the Cleveland Clinic Constipation (CCC) score and obstructed defecation score (OD score) preoperatively at 12 months and at the last available follow-up. Patient satisfaction was assessed with a visual analogue score. RESULTS: From October 2006 to September 2013, IDP was performed in 170 patients: 77 received postoperative biofeedback and 93 did not. Mean follow-up was 6.3 years (range 1-8 years). CCC and OD scores improved significantly in both groups after 12 months and at the last follow-up (p > 0.05). When comparing two groups while there was no significant difference between CCC and OD scores at 12 months, score was significantly better in the group that received rehabilitation at the last follow-up (p = 0.001). Patient satisfaction was higher in the rehabilitation group (67%) compared with those without rehabilitation (55%). Clinical recurrence was recorded in nine patients who did not have postoperative rehabilitation. CONCLUSIONS: It has been demonstrated that IDP is associated with good long-term functional outcomes. Patients receiving rehabilitation had a better long-term follow-up, a higher overall satisfaction, and lower recurrence rate when compared with the patients who did not receive postoperative rehabilitation.

[Breathing sleep disturbances and occupational medicine: study of 20 clinical cases]. / Disturbi respiratori del sonno e medicina del lavoro: considerazioni su 20 casi clinici.

During 2004, in the Center for Sleep Disorders, a questionnaire including Epworth sleepiness scale (ES) was administered to 120 subjects; 20 male subjects of this group with elevated score (ES >14) were selected and submitted to polysomnography. Subjects, all in working age, were represented by 3 (15%) shift-workers, 9 (45%) drivers, 17 (85%) industrial workers (among those 5 building workers) and 3 (15%) employers. By polysomnography, moderatelsevere OSAHS was diagnosed in all subjects (40% moderate, 60% severe). CPAP (Continuous Positive Airway Pressure) therapy led to an improvement of clinical symptoms since the first month. Counselling of Occupational Medicine Physician with the Center for Sleep Disorders, was useful to direct the action of Competent Doctor, especially for jobs requiring high vigilance (drivers or shift-worker). The pass certificate for jobs with an high risk (alone, in high places, heavy means drivers) cannot avoid to evaluate this pathology, that is often associated to other related risk factors (obesity, hypertension, diabetes), because it compromises both the specific suitability and the protection of common health and safety.

Provocative hypothalamopituitary axis tests in severe head injury: correlations with severity and prognosis.

OBJECTIVE: To evaluate the effect of severe head injury on both the secretion of basal pituitary hormones and the response to exogenous synthetic hypothalamic releasing factors administration. DESIGN: Prospective, clinical study. SETTING: General intensive care unit in a university teaching hospital, Italy. PATIENTS: Comatose, head-injured patients (n = 22), all intubated and mechanically ventilated, invasively monitored without previous endocrinologic problems and substitutive therapies. INTERVENTIONS: Routine neuroemergency procedures; administration of exogenous, synthetic hypothalamic releasing hormones. MEASUREMENTS AND MAIN RESULTS: Determinations of basal concentrations of growth hormone (GH), prolactin (PRL), thyroid-stimulating hormone (TSH), triiodothyronine, and thyroxine were performed daily in the first week and on days 15 and 16 after the trauma. Plasma insulin-like growth factor-I and cortisol were also determined on days 2, 7, and 15. We carried out a thyrotropin-releasing hormone (TRH) test for the evaluation of the PRL, TSH, and GH responses on days 1 and 16 after the trauma and a growth hormone-releasing hormone (GHRH) test for the evaluation of GH and PRL responses on days 2, 7, and 15 after the trauma. Outcome was evaluated at 6 mos with the GOS. Triiodothyronine showed low values, even if in the normal range; thyroxine remained in the normal range. Significant increases in insulin-like growth factor-I concentrations were observed on both days 7 and 15 compared with day 2 (p = .024 and p = .034, respectively). The GH response to GHRH was significantly greater on days 7 and 15 than in the very acute phase (p< .01 comparing days 7 and 15 vs. day 2). We found a higher GH response to GHRH on day 7 in group 1 vs. group 2 (as both peak and area under the curve, p = .018 and p = .015, respectively). No difference in GH response was detected on days 2 and 15. A "paradoxical" response of GH to TRH was observed on the day after the head trauma (basal vs. peak, p = .002) but not on day 16. The GH peak response to TRH was greater on day 1 in those patients with an unfavorable course (group 1 vs. group 2, p < .05). The TSH response to TRH was not significantly correlated to the severity of trauma, but it was significantly (p < .04) higher in group 1 than in group 2. Finally, a "paradoxical" PRL response to GHRH administration was present on day 2 (basal vs. peak, p=.0003), day 7 (basal vs. peak, p = .01), and on day 15 after the trauma (basal vs. peak, p = .04). CONCLUSIONS: Some of the responses to provocative tests have been identified as "paradoxical" and seem to have a great importance in the definition of prognosis in severe head-injured patients, specifically the GH response to TRH and the PRL response to GHRH that are significantly correlated with outcome.

[Cerebral vasospasm and intracranial hypertension: transcranial Doppler ultrasonographic findings]. / Vasospasmo cerebrale ed ipertensione endocranica: aspetti Doppler transcranici.

Four consecutive patients with subarachnoid hemorrhage were studied by serial cranial CT and transcranial Doppler ultrasonographic recordings. Patients were in the age range 52 to 67 years. According to Hunt and Hess scale the clinical status varied between grade I and IV. Increase in intracranial pressure "masked" the hemodynamic signs of cerebral vasospasm, reappeared after normalization of intracranial pressure following therapeutic management. Based on the reported findings transcranial Doppler ultrasonography should be considered an indispensabile diagnostic procedure however inadequate for monitoring the natural history of vasospasm complicated by intracranial hypertension.

[Long-term results of a hearing screening in critically ill patients dismissed from an intensive care unit]. / Risultati di uno screening audiologico a distanza su pazienti critici ricoverati in Rianimazione.

AIM: To evaluate the auditive function of a group of critical patients after discharge from an ICU. DESIGN: An audiological screening was carried out 90-120 days after discharge. PATIENTS: Eighteen patients, that had been admitted to a polyvalent ICU for head injury, stroke or complicated neurosurgical procedures. They had all been in a coma. INTERVENTIONS: all the patients had undergone orotracheal intubation and mechanical ventilation lasting more than a week as well as ototoxic drugs (aminoglycosides and furosemide) administration. Antibiotic plasma levels had been monitored. MEASUREMENTS AND RESULTS: At examination, only 7 subjects were aware of being hypoacusic; no other symptom was reported. However audiometry and impedentiometry revealed the presence of mono or bilateral middle ear effusion in 11 subjects (61%) and high frequency neurosensorial hypoacusia in 2 cases (11%). Human voice frequencies were poorly affected by both transmissive and neurosensorial damages so that subjects did not report any hearing loss. CONCLUSIONS: Neurosensorial hypoacusia was probably caused by amynoglycoside toxicity in spite of blood level monitoring; ABR could be effective in preventing toxic damage by detecting early hearing impairment. Middle ear effusion occurrence is difficult to be prevented but appropriate medical therapy is usually effective after the recovery from coma.

Postoperative toxic shock syndrome following adrenalectomy: a case report.

This report describes a fatal case of toxic shock syndrome following surgical procedure of adrenalectomy. Toxic shock syndrome is a severe multisystemic illness associated with Staphylococcus Aureus infection. The disease is usually associated with menstruation and tampon usage. However, it has recently been reported in the postoperative period following simple surgical procedures. The surgical wound does not usually appear infected. The syndrome is associated with specific strains of Staphylococci producing the toxic shock syndrome toxin 1 (TSST-1), that mainly contributes to the illness. The major clinical signs are: fever, diarrhea, cutaneous rash and hypotension. Toxic shock syndrome requires early recognition and prompt aggressive symptomatic treatment based essentially on fluids administration, appropriate intravenous antibiotics and corticosteroids.

[Products of lipid peroxidation in the blood and respiratory secretions in 3 patients with acute respiratory diseases]. / Prodotti della perossidazione lipidica nel plasma e nelle secrezioni respiratorie di tre pazienti affetti da ARDS.

Oxygen free radicals have been suggested to be involved in ARDS pathogenesis. Their production may be caused by leukocyte activation and by administration of high oxygen concentrations. Radicals can oxidize lipids with production of dienes. In order to gather an indirect proof of radical production, dienes were repeatedly assessed in plasma and bronchoalveolar lavage (BAL) samples from three patients affected by ARDS. Plasma levels resulted higher than normal ones in all the patients initially; concentrations in BAL samples were lower than in plasma. Successively dienes decreased progressively in the patient who survived, whereas an increase was observed in BAL samples from the other patients, who died. The last trend was accompanied by a smaller increase in plasma levels.

Beta-2-microglobulin is a reliable tumor marker in chronic lymphocytic leukemia.

Serum beta 2-microglobulin (beta 2M) was measured in 22 patients with B chronic lymphocytic leukemia (CLL) and in 15 healthy age-matched control subjects. The patients were allocated in stages in accordance with the Rai and Binet systems. The beta 2M mean value in the CLL group was significantly higher than in the control group. There was a positive correlation between beta 2M and the clinical stage in both staging systems. The mean serum levels of beta 2M in stages A, B and C of Binet's system showed statistical differences while in stage A they did not differ from those found in the control group. No correlation was demonstrated between beta 2M and the peripheral lymphocyte concentration. A slight correlation was found between beta 2M and the degree of bone marrow lymphocyte infiltration, whereas a stronger relationship was observed when the type of infiltration (non-diffuse versus diffuse) was considered. Patients with bulky disease had mean beta 2M values much higher than the others.

Serum beta 2-microglobulin in patients with monoclonal gammopathies.

Beta-2-microglobulin concentrations were determined in serum samples from 45 patients with benign and malignant monoclonal gammopathies. In the group of patients suffering from multiple myeloma or Waldenström macroglobulinemia the mean beta 2-microglobulin level was significantly higher than in the group with monoclonal gammopathy of undetermined significance. Values above 3 mg/L were highly indicative of a neoplastic process and were observed in all the Waldenström patients and in greater than 90% of myeloma patients. No significant correlation was noticed between beta 2-microglobulin and monoclonal protein levels in any of the groups examined.

The combined use of hyperbaric oxygen, antibiotics and surgery in the treatment of gas gangrene.

The clinical course and treatment of 21 critically ill patients suffering from gas gangrene are reported. Analysis of the results has underlined the importance of intensive care and hyperbaric management to prevent the evolution of disease and to improve patients' clinical conditions for surgical procedures.