201 cases of foreign body ingestion in a Surgical Emergency Unit A 16-year retrospective study.

AIM: The aim of this study is to analyse clinical characteristics of FB ingestion and predictive factors for complications, in order to reduce mortality and morbidity. MATERIALS AND METHODS: A retrospective study of emergency surgical consultation records has been carried out from June 2005 through June 2015 yielded 201 episodes with the diagnosis of ingestion of foreign objects at the Surgical Unit of the University of Bari. RESULTS: Natural Removal in 44,8% of cases; Endoscopic retrieval in 42,4%, Surgical Procedures 4,4%. Statistical analysis was based on multivariate analysis and the model R2 of the Naegelkerke value. DISCUSSION: First of all, the approach to ingestion should be endoscopic. The second approach is surgical in selected cases. The most frequent site of impaction were oesophagus, stomach and right colon. An EGD proved to be the most used procedure with a no morbidity and no mortality. CONCLUSION: The ingestion of foreign bodies is a frequent, complex and expensive condition to treat. Observation and endoscopy are the most appropriate procedures to be considered to manage the ingestion of FB in Emergency Surgery Unit. KEY WORDS: Emergency surgery, Foreign bodies, Ingestion.

Chest radiography or computed tomography for COVID-19 pneumonia? Comparative study in a simulated triage setting.

INTRODUCTION: For the management of patients referred to respiratory triage during the early stages of the severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) pandemic, either chest radiography or computed tomography (CT) were used as first-line diagnostic tools. The aim of this study was to compare the impact on the triage, diagnosis and prognosis of patients with suspected COVID-19 when clinical decisions are derived from reconstructed chest radiography or from CT. METHODS: We reconstructed chest radiographs from high-resolution CT (HRCT) scans. Five clinical observers independently reviewed clinical charts of 300 subjects with suspected COVID-19 pneumonia, integrated with either a reconstructed chest radiography or HRCT report in two consecutive blinded and randomised sessions: clinical decisions were recorded for each session. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and prognostic value were compared between reconstructed chest radiography and HRCT. The best radiological integration was also examined to develop an optimised respiratory triage algorithm. RESULTS: Interobserver agreement was fair (Kendall's W=0.365, p<0.001) by the reconstructed chest radiography-based protocol and good (Kendall's W=0.654, p<0.001) by the CT-based protocol. NPV assisted by reconstructed chest radiography (31.4%) was lower than that of HRCT (77.9%). In case of indeterminate or typical radiological appearance for COVID-19 pneumonia, extent of disease on reconstructed chest radiography or HRCT were the only two imaging variables that were similarly linked to mortality by adjusted multivariable models CONCLUSIONS: The present findings suggest that clinical triage is safely assisted by chest radiography. An integrated algorithm using first-line chest radiography and contingent use of HRCT can help optimise management and prognostication of COVID-19.

Point-of-Care Chest Ultrasonography as a Diagnostic Resource for COVID-19 Outbreak in Nursing Homes.

OBJECTIVE: Bedside chest ultrasonography, when integrated with clinical data, is an accurate tool for improving the diagnostic process of many respiratory diseases. This study aims to evaluate the feasibility of a chest ultrasonographic screening program in nursing homes for detecting coronavirus disease-19 (COVID-19)-related pneumonia and improving the appropriateness of hospital referral of residents. DESIGN: Pragmatic, descriptive, feasibility study from April 2 to April 9, 2020. SETTING AND PARTICIPANTS: A total of 83 older residents (age 85 ± 8) presenting mild to moderate respiratory symptoms and not previously tested for COVID-19, residing in 5 nursing homes in Northern Italy. METHODS: Chest ultrasonography was performed at the bedside by a team of hospital specialists with certified expertise in thoracic ultrasonography, following a systematic approach exploring 4 different areas for each hemithorax, from the anterior and posterior side. Presence of ultrasonographic signs of interstitial pneumonia, including comet-tail artifacts (B-lines) with focal or diffuse distribution, subpleural consolidations, and pleural line indentation, was detected. The specialist team integrated ultrasonography data with clinical and anamnestic information, and gave personalized therapeutic advice for each patient, including hospital referral when needed. RESULTS: The most frequent reasons for ultrasonographic evaluation were fever (63% of participants) and mild dyspnea (40%). Fifty-six patients (67%) had abnormal ultrasonographic findings. The most common patterns were presence of multiple subpleural consolidations (32 patients) and diffuse B-lines (24 patients), with bilateral involvement. A diagnosis of suspect COVID-19 pneumonia was made in 44 patients, and 6 of them required hospitalization. Twelve patients had ultrasonographic patterns suggesting other respiratory diseases, and 2 patients with normal ultrasonographic findings were diagnosed with COPD exacerbation. CONCLUSIONS AND IMPLICATIONS: In nursing home residents, screening of COVID-19 pneumonia with bedside chest ultrasonography is feasible and may represent a valid diagnostic aid for an early detection of COVID-19 outbreaks and adequate patient management.

The Role of Chest Imaging in Patient Management During the COVID-19 Pandemic: A Multinational Consensus Statement From the Fleischner Society.

With more than 900,000 confirmed cases worldwide and nearly 50,000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.

The Role of Chest Imaging in Patient Management during the COVID-19 Pandemic: A Multinational Consensus Statement from the Fleischner Society.

With more than 900 000 confirmed cases worldwide and nearly 50 000 deaths during the first 3 months of 2020, the coronavirus disease 2019 (COVID-19) pandemic has emerged as an unprecedented health care crisis. The spread of COVID-19 has been heterogeneous, resulting in some regions having sporadic transmission and relatively few hospitalized patients with COVID-19 and others having community transmission that has led to overwhelming numbers of severe cases. For these regions, health care delivery has been disrupted and compromised by critical resource constraints in diagnostic testing, hospital beds, ventilators, and health care workers who have fallen ill to the virus exacerbated by shortages of personal protective equipment. Although mild cases mimic common upper respiratory viral infections, respiratory dysfunction becomes the principal source of morbidity and mortality as the disease advances. Thoracic imaging with chest radiography and CT are key tools for pulmonary disease diagnosis and management, but their role in the management of COVID-19 has not been considered within the multivariable context of the severity of respiratory disease, pretest probability, risk factors for disease progression, and critical resource constraints. To address this deficit, a multidisciplinary panel comprised principally of radiologists and pulmonologists from 10 countries with experience managing patients with COVID-19 across a spectrum of health care environments evaluated the utility of imaging within three scenarios representing varying risk factors, community conditions, and resource constraints. Fourteen key questions, corresponding to 11 decision points within the three scenarios and three additional clinical situations, were rated by the panel based on the anticipated value of the information that thoracic imaging would be expected to provide. The results were aggregated, resulting in five main and three additional recommendations intended to guide medical practitioners in the use of chest radiography and CT in the management of COVID-19.

Blunt traumatic injury to the thoracic aorta treated with thoracic endovascular aortic repair: a single-centre 20-year experience.

OBJECTIVES: Blunt thoracic aortic injury can be treated with thoracic endovascular aortic repair (TEVAR) with excellent short and mid-term outcomes. However, few data are available about the long-term results. Our goal was to report our single-centre, 20-year experience using TEVAR to treat blunt thoracic aortic injury. METHODS: We retrospectively reviewed our institutional database to identify all patients treated with TEVAR for traumatic lesions of the aortic isthmus. We identified 35 patients since 1998. Patients' charts were analysed for preoperative characteristics, intraoperative variables and short-term outcomes. Information about the long-term follow-up was collected by analysing cross-sectional images and via phone calls. Follow-up was 100% complete. Rates of survival and of freedom from aortic redo were estimated using Kaplan-Meier methods. RESULTS: Twenty-nine patients were men (82%). The median age was 42 years (range 22-79 years) and the mean injury severity score was 38 (±13). The endovascular procedure was successfully carried out in all patients. The left subclavian artery was intentionally overstented in 11 patients (31%). Two patients died perioperatively (5.7%). The estimated survival was 92% and 87% at 5 and 10 years, respectively, with no aorta-related deaths. The estimated freedom from aortic redo was 96% and 91% at 5 and 10 years, respectively. CONCLUSIONS: Our data corroborate the excellent results of the endovascular treatment of blunt thoracic aortic injury when follow-up is extended to 20 years. New-generation devices, which are more comfortable and have smaller diameters, may further improve the results of TEVAR in treating traumatic aortic injury. Surveillance with cross-sectional imaging remains mandatory.

Predictive factors for incidental gallbladder cancer (IGBC) in patients undergoing cholecystectomy for presumed benign disease. A single-center experience.

AIM: The incidence of incidental gallbladder cancer (IGBC) is estimated at 0.3-2.1%. The purpose of our study is to evaluate IGBC incidence in our department and to establish its predictive factors, considering patients' clinical characteristics and pre-operative ultrasound gallbladder features. MATERIAL OF STUDY: From January 2012 to December 2015, 434 patients (225 females and 209 males) were enrolled in this retrospective observational study in our General Surgery Department. To analyze potential predictive factors, we divided all the patients into two groups: patients with and without histological diagnosis of IGBC. We focused our attention on the patients' clinical characteristics and preoperative ultrasound gallbladder measurements RESULTS: Seven cases were post-operatively identified as incidental gallbladder cancer (IGBC) and after histological examination an IGBC incidence of 1.6% was encountered. DISCUSSION: Considering the increasing numbers of video laparoscopic cholecystectomies (VLC) performed worldwide, cases of IGBC are appearing more frequently. In most cases of IGBC, a second surgical look will be necessary because of feasibility and safety procedures. CONCLUSIONS: There is no possibility to establish which risk factors might be predictive for IGBC because of a discordance in the literature and a statistical analysis with low sample size. An accurate surgical procedure needs to be performed to reduce the spread of neoplastic cells and, as a result, improve long-term outcomes. KEY WORDS: Incidental Gallbladder cancer, Laparoscopy, Ultrasound.

How health service delivery guides the allocation of major trauma patients in the intensive care units of the inclusive (hub and spoke) trauma system of the Emilia Romagna Region (Italy). A cross-sectional study.

OBJECTIVE: To evaluate cross-sectional patient distribution and standardised 30-day mortality in the intensive care units (ICU) of an inclusive hub and spoke trauma system. SETTING: ICUs of the Integrated System for Trauma Patient Care (SIAT) of Emilia-Romagna, an Italian region with a population of approximately 4.5 million. PARTICIPANTS: 5300 patients with an Injury Severity Score (ISS) >15 were admitted to the regional ICUs and recorded in the Regional Severe Trauma Registry between 2007 and 2012. Patients were classified by the Abbreviated Injury Score as follows: (1) traumatic brain injury (2) multiple injuriesand (3) extracranial lesions. The SIATs were divided into those with at least one neurosurgical level II trauma centre (TC) and those with a neurosurgical unit in the level I TC only. RESULTS: A higher proportion of patients (out of all SIAT patients) were admitted to the level I TC at the head of the SIAT with no additional neurosurgical facilities (1083/1472, 73.6%) compared with the level I TCs heading SIATs with neurosurgical level II TCs (1905/3815; 49.9%). A similar percentage of patients were admitted to level I TCs (1905/3815; 49.9%) and neurosurgical level II TCs (1702/3815, 44.6%) in the SIATs with neurosurgical level II TCs. Observed versus expected mortality (OE) was not statistically different among the three types of centre with a neurosurgical unit; however, the best mean OE values were observed in the level I TC in the SIAT with no neurosurgical unit. CONCLUSION: The Hub and Spoke concept was fully applied in the SIAT in which neurosurgical facilities were available in the level I TC only. The performance of this system suggests that competition among level I and level II TCs in the same Trauma System reduces performance in both. The density of neurosurgical centres must be considered by public health system governors before implementing trauma systems.

Surgical approach for ulcerated locally advanced breast cancer. A single Center experience: a retrospective study.

AIM: The aim of our retrospective study is to analyze surgical possibilities for the extended LABC in those cases not suitable for a neoadjuvant chemotherapy step and to consider various reconstruction techniques. MATERIAL OF STUDY: Between 2009 and 2015 we enrolled 11 patients, admitted to the Emergency Department, presenting ulcerated LABC that needed palliative surgical demolitive procedures because of bleeding and anemia and in which was necessary to use natural tissues transposition or synthetic substitutes for the reconstruction of the skin flaps. RESULTS: The mean follow up was 12 months. Mortality rate was 82% (9 patients); in 2 cases there was local relapse after 6 months; 9 months was the longest disease free survival. DISCUSSION: Thanks to multidisciplinary strategies LABC's surgical treatment improved results with a five-year survival rate between 30-40% and better quality of survival. Despite extended demolitive approach, there is still a 50% of death because of metastases. CONCLUSIONS: Our results confirm that musculocutaneous flap, skin anterior thigh grafts, bilayer matrix wound dressing are excellent reconstructive strategies in locally advanced ulcerated breast cancer after aggressive extended surgery even if palliative to improve patients' further survival. Our data also showed that those patients presenting medium level of malignancy as "luminal b" subtype (7 patients) if treated earlier with a radical surgical procedure would have better prognosis. KEY WORDS: Oncoplastic techniques, Ulcerated breast cancer.

Blood Component Therapy and Coagulopathy in Trauma: A Systematic Review of the Literature from the Trauma Update Group.

BACKGROUND: Traumatic coagulopathy is thought to increase mortality and its treatment to reduce preventable deaths. However, there is still uncertainty in this field, and available literature results may have been overestimated. METHODS: We searched the MEDLINE database using the PubMed platform. We formulated four queries investigating the prognostic weight of traumatic coagulopathy defined according to conventional laboratory testing, and the effectiveness in reducing mortality of three different treatments aimed at contrasting coagulopathy (high fresh frozen plasma/packed red blood cells ratios, fibrinogen, and tranexamic acid administration). Randomized controlled trials were selected along with observational studies that used a multivariable approach to adjust for confounding. Strict criteria were adopted for quality assessment based on a two-step approach. First, we rated quality of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Then, this rating was downgraded if other three criteria were not met: high reporting quality according to shared standards, absence of internal methodological and statistical issues not detailed by the GRADE system, and absence of external validity issues. RESULTS: With few exceptions, the GRADE rating, reporting and methodological quality of observational studies was "very low", with frequent external validity issues. The only two randomized trials retrieved were, instead, of high quality. Only weak evidence was found for a relation between coagulopathy and mortality. Very weak evidence was found supporting the use of fibrinogen administration to reduce mortality in trauma. On the other hand, we found high evidence that the use of 1:1 vs. 1:2 high fresh frozen plasma/packed red blood cells ratios failed to obtain a 12% mortality reduction. This does not exclude lower mortality rates, which have not been investigated. The use of tranexamic acid in trauma was supported by "high" quality evidence according to the GRADE classification but was downgraded to "moderate" for external validity issues. CONCLUSIONS: Tranexamic acid is effective in reducing mortality in trauma. The other transfusion practices we investigated have been inadequately studied in the literature, as well as the independent association between mortality and coagulopathy measured with traditional laboratory testing. Overall, in this field of research literature quality is poor.

Cellular and humoral inflammatory response after laparoscopic and conventional colorectal surgery. Preliminary report.

Our aim is to compare the immune response after colorectal surgery performed laparoscopically and via traditional technique. This response seems to be proportional to the level of the surgical trauma and presumably is directed to improve host defence. This is a prospective reported study based on patients' randomisation. Fourteen patients with colorectal diseases undergoing laparoscopic or open surgery were enrolled. After both laparoscopic and open colorectal surgery, we observed a significant increase of circulating C-Reactive Protein (CRP) levels. The count of lymphocytes subpopulations did not show significant differences after both procedures. IL-6 serum levels increased immediately after laparoscopic approach. IL-6 production was preserved only in the laparoscopic group, while its plasma levels were significantly higher in conventional group. Postoperative cell-mediated immunity was better preserved after laparoscopic than after conventional colorectal resection. Laparoscopy became a popular approach to treat surgically benign and malignant colorectal diseases and several authors reported a better immune response in patients performing laparoscopic surgery after comparing to conventional colorectal surgery. These findings may have important implications in performing a laparoscopic colorectal resection. KEY WORDS: C-Reactive Protein IL-6, Laparoscopic Surgery.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.

Choledochal cysts in pregnancy A case report and literature review.

AIM: Aim is to demonstrate that surgery can be the best way to reduce the risk of malignancy in choledochal cysts (CC) and how hard can be the diagnosis and the treatment during pregnancy. CASE REPORT: We report a case of a pregnant young woman (36 week) with a Todani's score II CC. After caesarean, due to increasing jaundice, she underwent magnetic resonance cholangiopancreatography (MRCP) and Endoscopic retrograde cholangiopancreatography (ERCP) that confirmed the diagnosis. Surgical operation consisted in "cholecystectomy, resection of the choledocal cyst and poli-jejunum anastomosis. drainage of the abscess in the iv hepatic segment". DISCUSSION: This case report highlights the difficult diagnosis and consequently treatment of a CC, especially during pregnancy. A significant association of biliary duct cyst and hepato-bilio-pancreatic malignancy has been reported with an age-related incidence. CONCLUSION: Surgery is considered as the best treatment with a close follow-up because of the risk of recurrent cholangitis and malignant degeneration. This case represents also a challenge because of physiological changes in pregnancy and also because of the risk of fetal mortality and maternal morbidity. KEY WORDS: Choledochal cyst, Colangiocarcinoma, Pregnancy, Todani's score.

Laparoscopic management of pancreatic cancer. Our experience.

AIM: Minimally invasive techniques have a definite role in the surgical treatment of several gastrointestinal tract cancers but there is still no widespread use of the laparoscopic approach for cancers of the head of the pancreas. The aim of this retrospective study is to review our experience from 2003 to 2013 in the management of pancreatic cancer with particular emphasis on the clinical application of minimally invasive techniques. METHODS: One hundred fifty-eight pancreatic cancer patients (median age 69,7±12,6 years) with obstructive jaundice were enrolled in our study. One hundred eighteen (74,7%) had an endoscopic biliary stent, 68 patients (43,03%) were eligible for surgery. Only 22 of the patients eligible for surgical intervention underwent pancreaticoduodenectomy (PD): 14 had open PD and 8 had laparoscopic PD (LPD). Thirteen of the PD patients had a pylorus-preserving procedure (8 open and 5 laparoscopic procedures) whereas in 9 the pylorus was not preserved (6 open and 3 laparoscopic procedures). The other 46 patients had un-resectable tumors and 34 of them underwent palliative surgery consisting of gastrojejunal and hepatojejunal anastomosis (18 open and 6 laparoscopic procedures), and gastrojejunal anastomosis in 10 patients (4 open and 6 laparoscopic procedures). Ten patients had only explorative laparoscopy and 2 only explorative laparotomy. RESULTS: The resectability rate was 13,9%. The median age in patients treated with an endoscopic biliary stent was significantly higher than in those who underwent surgery (73,2±13,3 years vs 64,4±9,6 years; p < 0,05). Operative time in LPD patients was significantly longer than in PD patients (521±68 minutes vs 381±88 minutes; p<0.05). The hospital stay of patients who underwent PD was significantly longer than that of those who underwent palliative surgery (27±4 days vs 10±5 days; p < 0.05). in PD patients the morbidity rate was 22,72 % and the mortality rate 4.5%. CONCLUSIONS: In recent years laparoscopic surgery has become very important in oncologic surgery because it is minimally invasive and reduces postoperative complications and because there is sufficient evidence based data showing that results in terms of complications and survival are as good as the results of conventional surgery. However the learning curve for laparoscopic cancer surgery of the head of the pancreas is steep and our results indicate that in LPD operative time is significantly longer than in PD, and moreover the laparoscopic approach is not associated with a shorter hospital stay. Therefore LPD should be performed only in well-established laparoscopic and oncological centers with a multidisciplinary team. KEY WORDS: Laparoscopy, Pancreatic cancer, Pancreaticoduodenectomy.

Systematic review of the literature and evidence-based recommendations for antibiotic prophylaxis in trauma: results from an Italian consensus of experts.

BACKGROUND: Antibiotic prophylaxis is frequently administered in severe trauma. However, the risk of selecting resistant bacteria, a major issue especially in critical care environments, has not been sufficiently investigated. The aim of the present study was to provide guidelines for antibiotic prophylaxis for four different trauma-related clinical conditions, taking into account the risks of antibiotic-resistant bacteria selection, thus innovating previous guidelines in the field. METHODS: The MEDLINE database was searched for studies comparing antibiotic prophylaxis to controls (placebo or no antibiotic administration) in four clinical traumatic conditions that were selected on the basis of the traumatic event frequency and/or infection severity. The selected studies focused on the prevention of early ventilator associated pneumonia (VAP) in comatose patients with traumatic brain injury, of meningitis in severe basilar skull fractures, of wound infections in long-bone open fractures. Since no placebo-controlled study was available for deep surgical site-infections prevention in abdominal trauma with enteric contamination, we compared 24-hour and 5-day antibiotic prophylaxis policies. A separate specific research focused on the question of antibiotic-resistant bacteria selection caused by antibiotic prophylaxis, an issue not adequately investigated by the selected studies. Randomised trials, reviews, meta-analyses, observational studies were included. Data extraction was carried out by one author according to a predefined protocol, using an electronic form. The strength of evidence was stratified and recommendations were given according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: Uncertain evidence deserving further studies was found for two-dose antibiotic prophylaxis for early VAP prevention in comatose patients. In the other cases the risk of resistant-bacteria selection caused by antibiotic administration for 48 hours or more, outweighed potential benefits. CONCLUSIONS: When accounting for antibiotic-resistant bacteria selection we found no evidence in favour of antibiotic prophylaxis lasting two or more days in the studied clinical conditions.

Is the TMPM-ICD9 revolution in trauma risk-adjustment compatible with imperfect administrative coding?

BACKGROUND: TMPM-ICD9 is the latest injury-severity measure based on empirical estimation from ICD-9-CM codes. It is candidate to replace expert-based AIS measures worldwide because of easier accessibility and better predictive performances. In Italy and other countries administrative ICD coding is generally less complete than dedicated AIS coding. We attempted to ascertain how this affects TMPM performances. METHODS: Discrimination (c statistics) and calibration (calibration curves, Akaike's criterion) of hierarchical logistic regression models for hospital mortality comprising TMPM or ISS were compared using trauma-registry data on 3570 patients of years 2007-2009. The completeness of AIS vs. ICD-9-CM coding was also investigated through the ratio of the respective numbers of codes per patient. Model discrimination was further analyzed after stratification according to the above ratio (>1 and ≤ 1). RESULTS: The models with TMPM showed worse performances. The differences, concerned calibration (graphical evidence) in univariate models and discrimination (-1.2% of area under the ROC curve, p<0.05) in models completed with age, gender, mechanism of injury, motor GCS and systolic pressure. In parallel, ICD coding was less complete than AIS, as expected: 68% of patients had a ratio >1. The discrimination of TMPM vs. ISS models improved when the ratio changed from >1 to ≤ 1. CONCLUSIONS: The predictive performances of TMPM-ICD9 vs. ISS were lower than in the previous studies; the sub-optimal quality of ICD coding was a main cause. Imperfect administrative coding may hence hamper the TMPM-ICD9 revolution, although in our setting the negligible differences and the ready availability of administrative data may still give reason for adopting TMPM-ICD9.

Gender differences in case mix and outcome of critically ill patients.

INTRODUCTION: The potential for gender-related bias in the provision of medical treatments has gained increased interest in recent years. The aim of this retrospective, observational study was to evaluate the association between gender and clinical outcome in an Italian mixed medical-surgical ICU population. METHODS: Data on 1978 patients admitted to the ICU during a 3-year period were analyzed. Demographics, diagnosis, and hospital stay details were recorded. RESULTS: Male ICU admissions were predominant over female ones (64% vs 36%). Neither ICU survival rate (80% in group male, 79% in group female; P = 0.602) nor hospital survival rate (72% in group male, 72% in group female; P = 0.820) showed gender-related differences. A statistically significant difference was found in terms of mean (SD) age (57 [19] years in group male, 62 [18] years in group female; P < 0.001), ICU length of stay (7.0 [9.1] days in group male, 5.7 [7.7] days in group female; P < 0.001) and length of mechanical ventilation (6.3 [8.4] days in group male, 5.3 [7.5] days in group female; P = 0.001). Severity of illness, measured through the simplified acute physiology score II, was not statistically different between gender groups; nor was the incidence of infective complications. After stratifying for diagnostic subgroups a few gender differences were pointed out, but none of them affecting ICU and hospital survival rates. A Kaplan-Meier 30-day ICU survival analysis revealed no differences between the male and female groups of the study population. CONCLUSIONS: According to our results, mortality among critically ill patients was not influenced by gender. Despite a higher frequency of men admitted, women were older than men. Moreover, men were treated for a longer period of time than women. Limitations of the study were the inability to establish causal relations and to account for variables with important effects on the reported associations. Moreover, the sample size was small if compared to similar multicenter studies.

[The role of laparoscopy in surgical treatment of pancreatic cancer]. / Il ruolo della laparoscopia nel trattamento chirurgico del carcinoma pancreatico.

AIM: The authors reviewed their experience in surgical treatment of pancreatic cancer between 2003-2008. METHODS: Eighty two pancreatic cancer patients (median age 66.7 +/- 12.5) with obstructive jaundice were enrolled in our study: 36 (44%) had an endoscopic biliary stent; 46 patients (56%) were eligible for surgery: 14 received a curative surgery (pancreatoduodenal resection; 4 had a laparoscopic procedure) and 32 patients with non resectable tumor a palliative surgery: 18 had a gastro-jejunal with a biliary anastomosis (in 4 patients the hepatic-jejunal anastomosis was performed in laparoscopy), 6 had a gastro-jejunal anastomosis (2 laparoscopic procedure and 8 patients had only an explorative laparoscopy. RESULTS: The resectability rates was 17.1%. Median age in patients treated with endoscopic biliary stent was significantly higher than those underwent surgery (72.3 +/- 12.2 vs. 63.5 +/- 9.6; p < 0.05). Hospital length of stay in patients underwent radical surgery was significantly higher than those who received palliative surgery (18 +/- 6 vs. 10 +/- 5; p < 0.05). Morbility rate, including operative mortality of .3%, was 15.2%. CONCLUSIONS: Laparoscopy is largerly used in major oncologic surgery for several reasons: it minimized surgical manipulations and so post-operative complications. There is enough scientific evidence of low incidence of post-operative complications and long-term results compared to those achieved with traditional surgery.

Phase III randomized multicenter study on the effects of adjuvant CMF in patients with node-negative, rapidly proliferating breast cancer: twelve-year results and retrospective subgroup analysis.

The randomized multicenter study on rapidly proliferating breast cancer, assessed according to thymidine labelling index (TLI), was activated at the end of the 1980s. The present work investigated whether and to what degree the short-term advantages observed from adjuvant CMF (cyclophosphamide, methotrexate, 5-fluorouracil) were maintained at a longer follow-up. Two hundred and eighty-one patients with node-negative and high TLI tumors were randomized to receive six cycles of CMF or no further treatment. At a median follow-up of 12 years, CMF produced a 25% and 20% relative reduction in relapse and death cumulative incidence, respectively. A breakdown analysis identified a subgroup of patients with intermediate proliferating tumors for whom a 70% and 73% reduction in relapse and death was observed in the intention-to-treat population. An even higher reduction of 80% and 84% in relapse and death was seen for the patients who had received the full CMF dose. We identified a subgroup of patients with intermediate proliferating tumors in whom the high benefit obtained from adjuvant CMF was maintained at a long-term follow up.