CytoSorb® in burn patients with septic shock and Acute Kidney Injury on Continuous Kidney Replacement Therapy is associated with improved clinical outcome and survival.

BACKGROUND: In burn patients, septic shock and acute kidney injury (AKI) with use of continuous renal replacement therapy (CRRT) severely increase morbidity and mortality. Sorbent therapies could be an adjunctive therapy to address the underlying metabolic changes in inflammatory and anti-inflammatory cytokines dysregulated production. METHODS: A retrospectively observational study of 35 severe burn patients admitted to the Burn Center (Turin, Italy, from January 2017 to December 2022), who underwent CRRT for AKI-associated septic shock. Out of 35 patients, 11 were treated with CytoSorb® as adjunctive therapy to CRRT (Sorbent group) and 24 patients only with CRRT (Control group). RESULTS: The application of CytoSorb® took place in a very dispersed way. Out of 11 patients, 7 started the CRRT together with the sorbent application. The patients of the sorbent group exhibited a significant reduction in norepinephrine use compared to that of the control group. A clinical improvement over the first 4 days of Cytosorb® was observed in both survivors and no survivors of the sorbent group, with significant norepinephrine decreased use on day 4 compared to day 1. In-hospital mortality was 45.4% and 70.8% in the sorbent and control group, respectively, and significantly better at Kaplan-Meier survival analysis at 270 days (p = 0.0445). In both groups, all survivor patients recovered renal function at discharge, whereas no survivors did not. CONCLUSIONS: Adjunctive treatment with CytoSorb® for burn patients with AKI-CRRT and septic shock poorly responsive to standard therapy led to a significant clinical improvement, and was associated with a lower mortality rate compared to CRRT alone.

Mediastinal Nodular Lesions Synchronous to Lung Carcinoma on Frozen Section: Trap and Lesson.

Thymoma is the most frequent neoplasm arising in the anterior mediastum. It usually presents as an enlarged central mass. In the literature, multiple thymoma is described as an unusual finding; rare variants have also been described, like the signet ring-like cell variant. Evidence of co-existence of signet ring-like cells and lymphocytes in small biopsies from nodular mediastinal lesions can lead to a diagnosis of metastatic carcinoma, mostly at frozen sections. Thymoma and pulmonary carcinoma are very rarely associated neoplasms. We present a case of two mediastinal lesions discovered during pulmonary carcinoma staging. At frozen section, a diagnosis of 'epithelioid proliferation associated to lymphoid tissue' was advanced on a sample of nodular lesions and of 'carcinoma' on pulmonary biopsy. Double AB Type Thymoma with a signet ring cell-like component, synchronous to pulmonary adenocarcinoma, was the diagnosis made on formalin fixed-paraffin embedded samples. Reporting the coexistence of these two entities can help pathologists and surgeons to establish the best management of similar patients.

[An assessment of the knowledge of school teachers on type 1 diabetes mellitus.] / Una valutazione delle conoscenze degli insegnanti della scuola sul diabete mellito tipo 1.

INTRODUCTION: Type 1 Diabetes Mellitus is one of the most common chronic diseases in children. School children with diabetes may have special needs during their school attendance. Teachers are responsible for the safety of children at school, therefore, to safely manage a student with diabetes, especially in cases of emergency, they should be in possession of adequate informations and a good level of knowledge of the disease. METHODS: 292 teachers from primary and secondary school in the province of Trapani completed a questionnaire designed to assess their knowledge of diabetes mellitus. RESULTS: The level of knowledge about different aspects of diabetes among school teachers was extremely superficial. Teachers who had previous experiences with children with diabetes showed a much higher level of knowledge than those who did not. Only a small percentage of teachers stated that they had previously received specific training (10%) and only 3% of teachers considered their school as equipped to safely manage children with diabetes. DISCUSSION AND CONCLUSIONS: Children with diabetes spend a considerable amount of their time at school and it is not unreasonable to expect their teachers to have a basic working knowledge of diabetes for a safe management of their schooling. This study shows a poor sensitivity of the school institution about diabetes and a very superficial level of knowledge of the different aspects of diabetes among school teachers. Specific training sessions for school personnel can represent a key factors in bringing children with diabetes to a full integration, so improving control of their glycaemic status as well as their quality of life.

Pulmonary Metastases from NSCLC and MPLC (Multiple Primary Lung Cancers): Management and Outcome in a Single Centre Experience.

BACKGROUND: This is an institutional review of surgical management of second pulmonary tumours in patients with history of Non-small Cell Lung Cancer (NSCLC) resection according to The American College of Chest Physicians' (ACCP) revision to the Martini and Melamed's criteria for the classification of multiple primary lung cancers (MPLC). METHODS: All patients who underwent iterative pulmonary resections for pulmonary metastasis (Group A) or MPLC (Group B) between 2006 and 2012 were reviewed and their survivals compared accordingly. The main criteria of insertion in Group B were different histology and the same histology with disease-free interval ≤ 4 years; we excluded loco-regional recurrence in nodes and/or on bronchial stump. RESULTS: Group A: Twenty patients; Disease free time (DFT) after first operation was 15.2 months (range 2-44). One, two and three years overall survival after second resection was 74%, 29%, 14% respectively. Group B: Thirty-six patients. One, two and three years overall survival was 94%, 81%, and 69% respectively. No statistical differences on outcome were found between the two groups in spite of the apparent worse survival rate for Group A (p=.197). CONCLUSIONS: A further resection for additional nodules, whether designated as intrapulmonary metastases or second primary NSCLC, can be an appropriate curative strategy in selected patients with unimpaired respiratory function and no evidence of distant metastatic disease. The site, the extent of the second resection, the histology and even the stage are unlikely to be related to survival.

Selective immunoglobulin a deficiency in type 1 diabetes mellitus: a prevalence study in Western sicily (Italy).

BACKGROUND: The association between type 1 diabetes and immunoglobulin A deficiency (IgA-D) has long been recognized in many populations. The aim of this study was to assess the prevalence of IgA-D in patients with type 1 diabetes mellitus all coming from a defined geographical area and to investigate the clinical features of these subjects. METHODS: The records of 150 consecutive patients with type 1 diabetes mellitus referred in a period of one year were analyzed. A detailed history was obtained for each patient. Information was collected concerning age, gender, time of onset of diabetes, and presence of other autoimmune diseases. RESULTS: Out of 150 patients with type 1 diabetes, eight (5.3%) had a diagnosis of IgA-D. There were one female and seven male; all these patients were diagnosed by screening: none of them had history of recurrent infections. Autoimmune thyroiditis was coexisting in five patients (62%). Although other associated autoimmune disorders were found in a number of patients, there was no different prevalence rate in IgA deficient patients. CONCLUSION: This study shows the prevalence of IgA-D in Sicilian patients with type 1 diabetes as 5.3% which is much higher than reported in other Italian studies. Moreover, our data show a high prevalence of IgA-D in male gender and describe thyroiditis as the most frequent autoimmune disease present in these patients. Finally, in our case report, IgA-D diagnosis always followed routine IgA measurement when case finding for celiac disease with no history of recurrent infections in each patient.

Synchronous thymoma and lung adenocarcinoma treated with a single mini-invasive approach.

A 75 year-old man with a lesion in the middle lobe of the lung was discovered to also have, during the follow-up period, a mass in the mediastinum, diagnosed as a multi-thymic cyst. Both pathologies were successfully treated with a single surgical approach by video-assisted thoracoscopy. We performed a middle VATS lobectomy with complete lymphadenectomy followed by radical thymectomy without additional incision. The postoperative course was uneventful.

Severe weight gain and generalized insulin edema after the starting of an insulin pump.

The possibility of the occurrence of a generalized edema after initiation or intensification of insulin treatment in patients with diabetes, although considered a rare event, has long been described in the literature. In this case, a state of clinically significant edema, with a concurrent severe weight gain, occurred in a patient with type 1 diabetes in whom the implantation of an insulin pump resulted in a dramatic and abrupt improvement in glycemic control.

Video-assisted thoracoscopic lobectomy for non-small cell lung cancer: a morbidity limiting approach in a patient on chronic hemodialysis and double agent antiplatelet therapy.

Patients with end-stage renal disease on hemodialysis undergoing surgery for lung cancer represent a high-risk group because of electrolyte imbalance, anemia, hemodynamic instability, bleeding tendency, and immunocompromised state. We describe a patient on hemodialysis with three lung adenocarcinoma of the right lower lobe as an incidental finding during the clinical course of a myocardial infarction treated with drug-eluting stent implantation and double-agent antiplatelet therapy. Considering patient comorbidities, we decided to perform a right lower lobectomy and complete lymph node dissection by a minimally invasive technique. In our experience, the thoracoscopic approach allowed us to perform lobectomy with complete lymph nodes dissection without morbidity. The use of ultrasound scalpel permits a complete lymph node dissection minimizing bleeding even in a double antiplatelet therapy patient.

Celiac disease in subjects with type 1 diabetes mellitus: a prevalence study in western Sicily (Italy).

The association between celiac disease and type 1 diabetes mellitus is well known. Up to now, celiac disease prevalence in children and adults with type 1 diabetes in Sicily has not been reported. The aim of this study was to assess the prevalence of celiac disease in patients with type 1 diabetes mellitus who come from a defined geographical area in western Sicily and to investigate the clinical features of these subjects. The records of 492 consecutive patients with type 1 diabetes mellitus referred in a period of 5 years were analyzed. During the period of the survey, out of 492 patients with type 1 diabetes, 22 (4.5 %) had a previous diagnosis of celiac disease. There were 14 females and 8 males; these patients showed a mean age of 13 years at diabetes onset. Diagnosis of celiac disease was often simultaneous or subsequent to that of diabetes. Autoimmune thyroiditis was coexisting in 8 patients (36 %). Our data confirm, in a Sicilian population, the not unusual association between celiac disease and type 1 diabetes, although prevalence rate is lower than in others Italian studies. Autoimmune thyroiditis is present with high prevalence in these patients. Celiac disease diagnosis often followed onset of type 1 diabetes, particularly in female subjects with a young age at diabetes onset; therefore, in these subjects, an active search for the presence of celiac disease is warranted for many years after appearance of diabetes.

Sternal resection and reconstruction for local recurrence of breast cancer using the sternal allograft transplantation technique.

Sternal involvement in patients with breast cancer is relatively rare and its treatment is still controversial. Surgery is usually indicated in cases of single metastases in a multimodality protocol. Partial or complete sternectomy associated or not with the resection of surrounding tissues is the technique of choice to obtain safety margins and radical treatment of the disease. The most challenging part of the operation is the reconstruction of the anterior chest wall in order to avoid secondary complications and respiratory failure. In the last few years, different techniques and materials have been used to reconstruct the sternum. We report our experience in two patients with recurrent breast cancer using the sternal allograft technique to replace the sternum after partial sternectomy. The use of a sternal-allograft provides excellent functional and cosmetic results without complications during the follow-up period. The implantation technique is simple and reproducible.

Desmoid tumour of the thoracic outlet in a 70 year-old man successfully removed through cervico-thoracic Dartevelle approach.

Desmoid tumours have a strong tendency for local invasion and recurrence. A 70 year-old male presented with cervical and left shoulder pain associated with a supraclavicular mass. The computed-tomography showed an expansive lesion measuring 10 cm × 6 cm × 5.5 cm in the left supraclavicular space. At magnetic resonance imaging the subclavian vessels and the brachial plexus were dislocated anteriorly but not infiltrated. An incisional biopsy suggested a desmoid tumour. An anterior cervicothoracic approach was used to remove the tumour. The chest wall was reconstructed with titanium bars and a polytetrafluoroethylene-patch. The clavicle was fixed using a titanium clip. The post-operative course was uneventful. The patient was treated with adjuvant radiation therapy. After six months the patient is in good clinical condition free from disease recurrence. In conclusion, desmoid tumour of the thoracic outlet is a challenging situation. Wide radical resection should be attempted whenever possible. The Dartevelle approach gives an optimal surgical field with direct control of vessels and nerve roots facilitating tumour dissection and radical resection en-bloc with the chest wall. The chest wall reconstruction with titanium bars and clips is a simple and effective method to guarantee good respiratory function and to stabilise the shoulder girdle.

Can topical application of tranexamic acid reduce blood loss in thoracic surgery? A prospective randomised double blind investigation.

OBJECTIVE: The systemic or topical use of antifibrinolytic agents is effective in reducing postoperative bleeding and blood product transfusion in cardiac surgery. We sought to study the effect of the topical application of tranexamic acid into the pleural space to reduce postoperative bleeding after lung surgery. METHODS: This was a prospective randomised double blind placebo controlled investigation. From May-2010 to February-2012, 89-patients, scheduled for pulmonary resection, were randomly allocated to one of the two study groups. Group-A received 5 g of tranexamic-acid in 100 ml of saline solution. Group-B received 100 ml of saline solution as placebo. RESULTS: The blood loss in the first 12-h was significantly less in group-A. The same trend was observed in the first 24-h but without reaching a true statistical significance. The mean volume of blood transfusion was statistically lower in group-A. The analysis between post-operative haemoglobin concentration, haematocrit, platelet-count, international-normalised-ratio, fibrinogen and partial-thromboplastin-time of both groups was not statistically significant. CONCLUSION: In our experience, the topical use of tranexamic-acid after lung surgery reduces postoperative bleeding and blood transfusion volume. The topical administration of tranexamic-acid is safe without increasing the risk of post-operative complications related to pharmacological side-effects.

["Double diabetes". A case report]. / Un caso di "diabete doppio"

Obesity and type 2 diabetes mellitus in children and adolescents are two emerging public health problems. The clinical presentation of type 2 diabetes in youth is heterogeneous, from minimal symptomatology to diabetic ketoacidosis. The clinical distinction between a type 2 diabetic young patient and a type 1 diabetic obese patient is often difficult because of the overlapping clinical picture with evidence of islet autoimmunity in a significant proportion of clinically diagnosed youth with type 2 diabetes.

Graves' disease in subjects with type 1 diabetes mellitus: a prevalence study in western Sicily (Italy).

OBJECTIVE: To assess the prevalence of Graves' disease in patients with type 1 diabetes mellitus all coming from a defined geographical area (western Sicily-Italy) and to investigate the clinical features of these subjects. METHODS: The records of 470 consecutive patients with type 1 diabetes mellitus referred in a 5-year period were analyzed. RESULTS: During the period of the survey, out of 470 patients with type 1 diabetes, 14 (3%) had a previous diagnosis of Graves' disease. There were 9 female and 5 male; these patients showed a high age at diabetes onset (mean 38 years). Diagnosis of Graves' disease was often pre-existing or simultaneous to that of diabetes. Vitiligo was coexisting in 4 subjects; none of them presented other autoimmune diseases. Graves' orbitopathy was present in two cases. CONCLUSIONS: Our data confirm the frequent association between Graves' disease and type 1 diabetes. Graves' disease often preceded diagnosis of type 1 diabetes, particularly in female subjects with a high age at diabetes onset; therefore, in these subjects, an active search for the presence of pancreatic autoimmunity is warranted for many years after thyroid dysfunction appearance.

[Restless legs syndrome and diabetes mellitus: an accidental association?]. / Sindrome delle gambe senza riposo e diabete mellito: un'associazione casuale?

Although limited in number, several studies have documented an increased prevalence of Restless Legs Syndrome (RLS) in type 2 diabetes. Polyneuropathy only partially explains the relation between the two disorders. This association could be due to the effects of a prolonged sleep loss: in increasing the probability of developing insulin-resistance and metabolic disturbances.

Ophthalmoplegia in diabetes mellitus: a retrospective study.

Ophthalmoplegia, despite being a rare entity in diabetes mellitus, is associated with great anxiety for the patients and often appears to be a serious problem from a diagnostic and therapeutic point of view. There have been few studies primarily concerned with the relative frequencies and clinical characteristics of oculomotor neuropathies in diabetic subjects. Those published have emanated largely from neurological and/or ophthalmological referral centres rather than metabolic departments. Objective of this study was to determine the incidence, the clinical characteristics and risk factors for developing ophthalmoplegia among persons with diabetes mellitus. We have performed a retrospective study of all diabetic patients with ophthalmoplegia who were seen in the Metabolic Division at "S. Biagio" Hospital, Marsala, over the 10 year period from 1998 to 2007. A detailed history and blood laboratory profile were obtained for each patient. During the period of the survey a total of 6,765 diabetic subjects were hospitalised and ophthalmoplegia was identified in 27 patients (0.40%). Isolated III nerve palsies accounted for the majority of patients (59.3%), with VI nerve palsies (29.6%) occurring more frequently than multiple palsies (11.1%). These patients had a marked comorbidity and were found to have a poorly controlled diabetes. The patients with VI nerve palsies showed a tendency toward a higher coexistence of diabetic retinopathy and cardiovascular risk factors than those with III cranial nerve palsies. Ophthalmoplegia is a serious and not common problem among patients with diabetes mellitus; the oculomotor nerve was most frequently affected in our case-report. The fact that the coexistence of diabetic complications and cardiovascular risk factors was slightly higher in patients with VI nerve palsy is compatible with the hypothesis that this ischemic event might be more closely related to diabetes and metabolic syndrome in its pathogenesis.