Application and internal validation of lung ultrasound score in COVID-19 setting: The ECOVITA observational study.

BACKGROUND: The severe acute respiratory syndrome Coronarovirus-2 associated still causes a significant number of deaths and hospitalizations mainly by the development of respiratory failure. We aim to validate lung ultrasound score in order to predict mortality and the severity of the clinical course related to the need of respiratory support. METHODS: In this prospective multicenter hospital-based cohort study, all adult patients with diagnosis of SARS-CoV-2 infection, performed by real-time reverse transcription polymerase chain reaction were included. Upon admission, all patients underwent blood gas analysis and lung ultrasound by expert operators. The acquisition of ultrasound scan was performed on 12 peculiar anatomic landmarks of the chest. Lung ultrasound findings were classified according to a scoring method, ranging 0 to 3: Score 0: normal A-lines. Score 1: multiple separated B-lines. Score 2: coalescent B-lines, alteration of pleural line. Score 3: consolidation area. RESULTS: One thousand and seven patients were included in statistical analysis (male 62.4 %, mean age 66.3). Oxygen support was needed in 811 (80.5 %) patients. The median ultrasound score was 24 and the risk of having more invasive respiratory support increased in relation to higher values score computed. Lung ultrasound score showed negative strong correlation (rho: -0.71) with the P/F ratio and a significant association with in-hospital mortality (OR 1.11, 95 %CI 1.07-1.14; p < 0.001), even after adjustment with the following variables (age, sex, P/F ratio, SpO2, lactate, hypertension, chronic renal failure, diabetes, and obesity). CONCLUSIONS: The novelty of this research corroborates and validates the 12-field lung ultrasound score as tool for predicting mortality and severity clinical course in COVID-19 patients. Baseline lung ultrasound score was associated with in-hospital mortality and requirement of intensive respiratory support and predict the risk of IOT among COVID-19 patients.

An apparatus for the continuous measurement of thickness during the electropolishing of superconducting cavities.

An apparatus allowing continuous acquisition of thickness measurements during electropolishing of superconducting cavities is described. The instrument is based on the ultrasound thickness measurement technique and allows the connection of up to six probes. The apparatus has been employed to monitor the surface treatment of PIP-II low beta single cell prototypes developed and manufactured by LASA-INFN and specifically to measure surface removal at different points of interest on the cavity surface. The apparatus facilitated the development and optimization of electropolishing parameters for incorporation into the cavity manufacturing process.

Pronounced dys-autonomic symptoms announcing a primary Sjögren's syndrome.

Sjögren's syndrome (SS) is an autoimmune disease that involves the nervous system in about 20% of cases. In 25-92% of patients affected by Sjögren's syndrome, neurological symptoms may precede the sicca syndrome. A 65-year-old male presented with a seven-month history of episodes of near-syncope, constipation, anhidrosis, disabling fatigue and asthenia. Physical examination was unremarkable, whilst the ECG revealed sinus bradycardia. Laboratory tests showed lymphopenia and normal inflammatory markers. In order to assess a potential autonomic neuropathy, "Deep Breathing Test" (E/I 1.02), "Lying to Standing Test" (R/R' 0.95), and "Orthostatic Hypotension Tests" (T 120s Systolic reduction >20 mmHg and Diastolic reduction >10 mmHg) were performed, all of which were abnormal. ECG Holter monitoring revealed sinus bradycardia, and right bundle branch block with 24-h blood pressure monitoring revealing a diurnal hypotensive profile. The patient reported a three-month history of worsening dry mouth. On physical examination, the patient had anisocoria in response to light stimulation. Auto-antibody testing was performed to evaluate the presence of any autoimmune disease. The results of these studies included an abnormal elevation of ANA (1:320 speckled pattern), Ro/SS-a (>240U/l), and La/SS-b (162 U/ml) antibodies. The patient was discharged with a diagnosis of "Autonomic Neuropathy Most Likely Due to Primary Sjögren's Syndrome (SS)" and started the immunotherapy. After one month, he reported a significant improvement in his symptoms with a concomitant normalization of his "Orthostatic Hypotension Tests." This case underlines the potential for dys-autonomic symptoms to precede the onset of sicca syndrome in patients with Sjogren's Syndrome.

Mesenteric cyst and recurrent abdominal pain in a patient with Gorlin-Goltz syndrome: a case report.

Gorlin-Goltz syndrome (GGS) is an infrequent autosomal do-minant multisystemic disease with complete penetrance and variable expressivity. It is estimated to have an incidence of 1:50,000 - 1:150,000 cases with a M/F = 1:1. This report describes a case of recurrent abdominal pain due to a large mesenteric cyst in a 38-year-old female patient affected by a rare disease: Gorlin-Goltz syndrome.

Predictive factors of difficult procedure in octogenarians undergoing elective laparoscopic cholecystectomy: a single center experience.

AIM: To assess the feasibility and safety of laparoscopic cholecystectomy (LC) in very elderly patients with particular attention to the predicitive factors of difficulty. PATIENTS AND METHODS: All patients aged ≥ 80 undergoing elective LC for lithiasis at our institution since 1st January 2015 to 31st December 2015 were included in the study. Exclusion criteria were: a) acute cholecystitis; b) biliary pancreatitis; c) biliary tract neoplasms; d) urgent procedure. Pre-, intra- and postoperative data were recorded. RESULTS: During the study period, we performed 72 LC and we enrolled 17 patients aged ≥ 80 with a M:F = 5:12. Of these, 10 patients had a "difficult" cholecystectomy. In seven cases an intraoperative cholangiography (IOC) was performed. Postoperative course was regular but in two patients we had an Oddian spasm in 1st postoperative day. Female sex (p=0.03) and preoperative high level of serum amylase (p= 0.02) were significantly associated to difficult cholecystectomy in elderly patients. CONCLUSION: LC in octogenarians is feasible and safe. However, sex and serum amylase can help the surgeon to predict a more difficult procedure in elective LC. In this group of patients an approach based on the individual risk is desirable and the patient could be referred to a multidisciplinary approach.

Search for compensation postures with videofluoromanometric investigation in dysphagic patients affected by amyotrophic lateral sclerosis.

PURPOSE: This study was undertaken to verify the effectiveness of compensatory postures, suggested on the basis of the type of dysphagia identified at videofluoromanometric (VFM) investigation to ensure safe oropharyngeal transit. MATERIALS AND METHODS: Eighty-one patients with amyotrophic lateral sclerosis (ALS) underwent speech therapy assessment and VFM investigation of the swallowing process. In the event of altered transit, penetration or aspiration of contrast material into the airways, compensation postures for correction of the swallowing disorder were suggested and verified during VFM examination. RESULTS: In 37 patients, contrast agent transport was preserved and safe; in 19, we observed penetration of the contrast agent into the laryngeal inlet without aspiration; in 24, there was aspiration (four preswallowing, eight intraswallowing, nine postswallowing, three mixed), whereas in one patient no transit was seen. Penetration without aspiration was resolved by coughing or throat clearing; aspiration was resolved in 13 patients by assuming the chin-tuck posture and in six by rotating the head; in five patients, it was not resolved. A hyperextended head posture proved to be effective to resolve lack of transit. CONCLUSIONS: By correlating morphological with functional data, VFM enables one not only to precisely characterise the dysphagic disorder but also to identify the most appropriate compensation posture for each patient and verify its effectiveness.

A new radioguided procedure for localization and surgical treatment of neck node metastasis of papillary thyroid cancer.

AIM OF THE STUDY: We intended to use a radioguided technique for pre-operative localization of neck node recurrences in patients with papillary thyroid cancer (PTC) already submitted to thyroidectomy and radioiodine treatment. PATIENTS AND METHODS: We selected 20 patients affected by PTC with evidence of neck nodes recurrences at ultrasound examination. Our method has been derived from the Radioguided Occult Lesion Localization technique used for pre-operative localization of occult breast lesions. The technique involves the inoculation of human albumin macroaggregates labeled with radioactive technetium (0.4 mCi in a volume of 0.05 ml) directly in the suspicious lesion, under ultrasound guidance. The persistence of the radioactive tracer in the nodes is confirmed by a scintigraphy performed 2 h after injection. During surgery, a gamma detecting probe is used to locate the suspicious lesions as "hot spots". RESULTS: Fifty lymph-nodes were injected with the tracer. All radiolabeled lymph-nodes were located and removed during surgery. At histology, metastasis of PTC was confirmed in 38/50 (76%) lymph-nodes. At least one metastatic lymph-node per patient was removed. In 8/20 (40%) patients, reactive lymphoid hyperplasia was found in 12/50 (24%) lymph-nodes. CONCLUSIONS: This radioguided technique has been highly effective for localization and surgical treatment of suspicious lymph-node detected at neck ultrasound and may play a valuable role in case of node metastases of thyroid cancer that show no radioiodine uptake.

Combined videofluoroscopy and manometry in the diagnosis of oropharyngeal dysphagia: examination technique and preliminary experience.

PURPOSE: Dysphagia is a symptom of different pathological conditions characterised by alteration of the swallowing mechanism, which may manifest at different levels. We report our experience in the evaluation of the swallowing mechanism with combined videofluoroscopy and manometric recordings. MATERIALS AND METHODS: For the combined study, we used a Dyno Compact computerised system (Menfis Biomedical s.r.l., Bologna, Italy) equipped with: (1) graphics card for the management of ultrasonographic or radiological images; (2) A.VI.U.S. dedicated software package, which enables digital-quality recording (PAL/NTSC, composite video or S-Video) of the videofluoroscopy study in AVI format with 320 x 240 resolution and 25 Hz acquisition frequency. The delay introduced by the process of image digitalisation is in the order of 200 ms, so for analysis purposes, the images can be considered synchronised with the manometric recordings. The videomanometry study was performed with the administration of contrast material either in bolus form or diluted. Data were collected on a specifically designed grid for the evaluation of 46 videofluoroscopic items, of which 34 are derived from the laterolateral view (seven in the oral preparatory phase, 15 in the oral transport phase and 12 in the pharyngeal phase) and 12 in the anteroposterior view (six in the oral preparatory phase and six in the oropharyngeal phase). A positive finding for the individual parameters is expressed in a binary fashion. Manometric evaluation was based on 11 items divided into four major and seven minor criteria. RESULTS: Dynamic videofluoroscopy swallow study combined with concurrent manometry enabled the simultaneous recording of anatomical alterations and the functional data of oropharyngeal pressure, thus providing a picture of the anatomical, biomechanical and physiological conditions of swallowing and the manner of bolus propulsion and transit. CONCLUSIONS: An early and effective diagnosis of oropharyngeal dysphagia means being able to effectively implement appropriate rehabilitation techniques, improve the patient's quality of life, and minimise the complications associated with swallowing disorders (choking, aspiration pneumonia, malnourishment). Distinction of the anatomical level of dysphagia is not a matter of simple classification; rather, it is essential in that different clinical presentations require different diagnostic strategies, and a precise definition of the anatomical-functional substrate is required to implement the correct therapeutic approach. This study presents the authors' experience with the use of combined videofluoroscopy and manometry with particular emphasis on the examination technique.

[Cryptococcosis in AIDS patients: case study from 1996 to 2006 in Paroissien Hospital]. / Criptococosis en pacientes con SIDA: estudio de casos en el Hospital Paroissien en el período 1996-2007.

Clinic, epidemiological and microbiological characteristics of 128 episodes of cryptococcosis were retrospectively evaluated in 106 positive HIV patients hospitalized at the Paroissien Hospital on period 1996-2007. There were 75 male and 31 female patients, with a median age of 34 years, ranging from 20 to 68 years. Addiction to intravenous drugs was the main cause of HIV infection in 55 patients (51.9%). Cryptococcosis was detected as single episode in 85 patients (80.2%) and as relapse in 19 (17.9%). It appeared as the first marking disease in 36 patients (34.0%). Diagnosis was established in 116 episodes by CSF study (Indian ink, culture, antigen detection), in 9 cases by Cryptococcus sp. recovery from blood cultures, and in 3 cases by antigen detection in patient's serum with a latex reactive. Neurological symptomatology, with headache and fever as the most common signs, was presented by 89.6% of patients. Induction treatment was done in all cases with amphotericin B, and maintenance treatment was carried out with fluconazole. Mortality rate was 35.8%, being higher in those patients who had suffered relapses (41.3%) compared to those who presented a first episode of the mycosis (33.3%).

Saporin as a novel suicide gene in anticancer gene therapy.

We used a non-viral gene delivery approach to explore the potential of the plant saporin (SAP) gene as an alternative to the currently employed suicide genes in cancer therapy. Plasmids expressing cytosolic SAP were generated by placing the region encoding the mature plant ribosome-inactivating protein under the control of cytomegalovirus (CMV) or simian virus 40 (SV40) promoters. Their ability to inhibit protein synthesis was first tested in cultured tumor cells co-transfected with a luciferase reporter gene. In particular, SAP expression driven by CMV promoter (pCI-SAP) demonstrated that only 10 ng of plasmid per 1.6 x 10(4) B16 cells drastically reduced luciferase activity to 18% of that in control cells. Direct intratumoral injection of pCI-SAP complexed with either lipofectamine or N-(2,3-dioleoyloxy-1-propyl) trimethylammonium methyl sulfate (DOTAP) in B16 melanoma-bearing mice resulted in a noteworthy attenuation of tumor growth. This antitumor effect was increased in mice that received repeated intratumoral injections. A SAP catalytic inactive mutant (SAP-KQ) failed to exert any antitumor effect demonstrating that this was specifically owing to the SAP N-glycosidase activity. Our overall data strongly suggest that the gene encoding SAP, owing to its rapid and effective action and its independence from the proliferative state of target cells might become a suitable candidate suicide gene for oncologic applications.

[Ultrasound-guided vacuum-assisted biopsy: review of 382 cases]. / Macrobiopsies assistées par le vide sous guidage échographique: à propos de 382 cas.

PURPOSE: To evaluate the use of US-guided vacuum biopsy for diagnosis and treatment of probably benign breast masses. MATERIALS AND METHOD: Retrospective review of 382 US guided vacuum biopsies over a 44 months period (september 2001 to may 2005) with the 11-g handheld mammotome. A total of 308 benign tumors, 59 borderline lesions and 15 carcinomas were diagnosed. The average number of specimens is 13.1 (3-37). Surgical resection has been systematic for carcinomas and selective for papillomas. Surgical correlation (n:35) or mammographic follow-up (n:347) are presented. RESULTS: Complete removal occurred in 371/382 (97.1%) immediately after biopsy and 337/382 (88.2%) after one month: 138/142 (93.7%) for fibroadenomas and 52/53 (98.1%) papillomas less than 15 mm. Open surgical biopsy was carried out for 35 patients on the basis of incomplete removal (3 cases) or histologic findings (8 invasive carcinomas, 7 ductal carcinoma in situ, 3 atypical ductal hyperplasia, 1 fibrocystic changes with atypia and 11 papillomas). No lesion was under-diagnosed and the rate of avoided surgery was 94.5%. Of the 347 lesions that were not surgically biopsied (42 borderline lesions and 305 benign lesions), 337 were monitored at 1-43 months (average: 20 months, > or =24 months: 57 patients). Ten underwent additional biopsy but no missed cancer was detected. Patients tolerance was good or very good in 83%, and the complication rate was 1.3%. CONCLUSION: US-guided vacuum biopsy is an accurate and well tolerated technique. It is an alternative to surgery for masses less than 15 mm including fibroadenomas and papillomas or in patients with imaging-histologic discordance at core biopsy.

The effect of esophageal myotomy and myectomy on the lower esophageal sphincter pressure profile: intraoperative computerized manometry study.

SUMMARY: The surgical treatment of achalasia, based on Heller's myotomy is the procedure of choice to reduce the sphincterial high pressure zone, either by laparotomy or, most recently, by laparoscopy. What is the right length of the myotomy? Many authors have reported 10-15% postoperative residual dysphagia, due to the incomplete gastric myotomy and not to esophageal pouring. The aim of this study is to experimentally determine the modifications induced by Heller's myotomy and myectomy of the esophago-gastric junction on lower esophageal sphincter (LES) pressure profile, using a computerized manometric system. Myotomy of the esophageal portion of the LES (i.e. without dissection of the gastric fibers) has not modified the parameters considered, while the dissection of gastric fibers for at least 2-3 cm on the anterior gastric wall has created a significant modification of the LES pressure profile. Our observations seem to confirm and more clearly demonstrate the important role played by gastric fibers in sustaining the sphincteric HPZ. Moreover, analysis of our data, showed the need to always perform a complete myotomy. This was objectively shown during the intervention by means of intraoperative manometry, in order to significantly reduce the possibility of a dysphagic relapse, caused by inadequate treatment.

Abdominal radiography findings in small bowel anastomoses with V-BAR.

PURPOSE: The aim of the present paper is to describe the normal radiological findings and the fragmentation time of the VALTRAC BAR (V-BAR). MATERIALS AND METHODS: Ten cases of Roux-en-Y jejuno-jejunostomy with anastomosis with a n.25 Valtrac ring for gastric cancer were followed up during the postoperative period by plain abdominal X-ray examination. RESULTS: Abdominal X-ray examination showed V-BAR fragmentation between day 14 and 21 after surgery. In one case only did fragmentation fail and the V-BAR migrated resulting in mechanical ileus. CONCLUSIONS: The possible non-fragmentation and migration of the V-BAR confirms the need to follow up patients with plain abdominal radiography performed at short intervals during the postoperative period.

[Total gastrectomy for gastric cancer: can the type of lymphadenectomy condition the long-term results?]. / Gastrectomia totale per cancro gastrico: può il tipo di linfadenectomia condizionare i risultati a distanza?

INTRODUCTION: Gastric cancer is the second tumor for frequency in the world. Surgery is still the only curative treatment. Good results in terms of long distance survival, postoperative morbidity and mortality have been achieved in the last years. The extension of lymphadenectomy is an important and discussed matter and it is not clear if lymphadenectomy may contribute to improve the surgical results. The Japanese surgeons were the first ones, in the 60's, to introduce a D2-D3 extended lymphadenectomy, but the real benefits of this technique are still being discussed. Indeed lymphonodal metastasis seem to be one of the most important prognostic factors in the gastric cancer and the level and the number of metastatic nodes are useful to predict the patients' survival. The aim of this study is to value the D2 lymphadenectomy in the patients who were treated with total gastrectomy for gastric adenocarcinoma, comparing the results both with the D1 lymphadenectomy and the D3-D4, paying attention to the survival rates related with the lymphonodal dissection. PATIENTS AND METHOD: From 1998 to 2004, we studied 87 patients with gastric cancer. Out of 78 patients treated surgically, 9 were judged unresectable. Out of 69 patients treated surgically, one died before surgery and so he was put away by this study. All the patients were treated with total gastrectomy and a GI tract reconstruction by Roux's Y termino-lateral esophageal-jejunal anastomosis. In 20 patients we also made a splenectomy. We followed the Japanese Research Society for Gastric Cancer guidelines, according to which nodes are gathered into 16 levels and divided in 4 groups (N1-N4) depending on the cancer localization. The extension of the lymphadenectomy has been classified according to the level of the removed nods. The patients were divided into 3 groups. First group: patients undergone a total gastrectomy with D1 lymphadenectomy. Second group: patients undergone D2 lymphadenectomy. Third group: patients undergone D3 and D4 lymphadenectomy. The data we obtained let us value the survival rate. RESULTS: Out of the 78 patients treated, 69 were resected with a 88.5% resection rate (69/78). Perioperatory mortality was 1.4% (1/69). Global survival was 53.8% (44/68). The 5 years survival for the Ia stage was 82.6%, 89.3% for the Ib stage, 67.8% for the II stage, 56.6% for the IIIa, 16.8% for the IIIb and 0% for the IV stage. In addition the 5 years survival in the patients without lymphnodal metastasis was 79%, much higher than the 30.6% obtained in the patients with lymphonodal metastasis (p <0.0001). In the patients who underwent D1 lymphadenectomy, survival was 73.4%, while we obtained a result of 70.4% and 13.8% respectively in the D2 and D3-D4 (p <0.05). In the advanced stages (IIIa, IIIb, IV), the survival rate in the patients with lymphadenectomy D2 vs D1 vs D3-D4 was 38.9% vs 0% vs 36.3% (p <0.0001). The survival rate based on the extension of the lymphadenectomy in the patients with lymphonodal metastasis resulted to be much higher in those patients who underwent a D2 lymphadenectomy (43.5% in 5 years) compared both to D1 (0% in 6 months) and (29.5% in 5 years) D3-D4 lymphadenectomy. CONCLUSIONS: The relation between long distance survival and extension of the lymphadenectomy in the patients with gastric adenocarcinoma is still being discussed. Different studies show the importance of a careful lymphadenectomy as the main mean for a better long distance survival in the patients with gastric cancer. Other studies showed a link between gastric cancer prognosis and number of positive nodes. If more than 7-8 nodes are affected with metastasis, prognosis is usually poor. Therefore the presence of nod metastasis has a negative influence in the prognosis of this tumor; for this reason D2 lymphadenectomy is the technique to be used for the treatment of the gastric adenocarcinoma, both for a good staging and a better long distance survival, but particularly in the advanced cancers which are, at the moment, the highest number of cases that reach the surgeon's attention.

Gastric cancer in the elderly patient.

The incidence of gastric cancer is increasing in elderly patients, unlike what it's being observed in the younger patients. The aim of this study is to evaluate the impact of the age on the resecability, resection type (R0-R1-2), morbidity, mortality and survival rate. The higher mortality observed in the elderly patients, the discussed role of an extended lymphadenectomy and the poor survival rate, would lead to a surgical approach which mostly tends to the palliation of the symptoms than the obtainment of a curative resection. But, on the other hand, the impossibility of making chemotherapy in most of the over 75 year old patients, lead us to a R0 surgery treatment.

[Antithrombotic prophylaxis in day surgery: proposal of a clinical protocol]. / La profilassi antitrombotica in day surgery. Proposta di un protocollo clinico.

The considerable diffusion of the day surgery has new problems such as the use of antithrombotic prophylaxis, now carried out systematically in major surgery. An the basis of the poor data present in the literature, a protocol of study is proposed to evaluate the real effectiveness of this type of prophylaxis in DS, dividing the patients into 3 groups, according to the patient's risk factors to the intervention and to the disease.