Fast track in colo-rectal surgery. Preliminary experience in a rural hospital.

BACKGROUND: "Fast Track surgery" is a therapeutic program of large application, despite some doubts about its applicability and real validity. Literature review shows that this approach to colo-rectal surgery, particularly video-assisted, can allow a rapid recovery, better performance and a faster postoperative functional autonomy of the work, which can be discharged without cause additional welfare costs; in addition it can be reproducible in different health reality. PURPOSE: To analyze the possibility to apply the Fast Truck protocol in patients undergoing colorectal surgery in a rural hospital and non specialistic Unit of Surgery. PATIENTS AND METHODS: We have conducted a prospective, randomized study on 80 patients subjected to colorectal surgery in the last year. RESULTS: The protocol was observed in 95% of cases, compliance with the Fast Track was high and general morbidity was limited (7.8%). CONCLUSION: This "aggressive" approach, which has fundamentally altered the usual surgical behavior, seems to allow a mean length of stay significantly lower than in controls (p < 0.05) with positive implications for patients and containment of health care costs, even after discharge (no need for home care in 92% of cases, no early re-admittance to the hospital). Homogeneous protocols are desirable, as well as an increased enrollment, to consolidate these rehabilitation programs in order to provide a reference for all hospitals.

[Epidemiologic surveillance in occupational bladder cancer: a Tuscan experience]. / Intervento di ricerca attiva delle neoplasie vescicali di origine professionale: una esperienza toscana.

The percentage of bladder cancer as occupational disease in West-Europe is of 5/10%, but only a few amount of them are recognized as occupational disease from INAIL. The above mentioned research project is realized in order to decrease the gap between expected and claimed cases of occupational disease and it is conducted with the collaboration of ASL of Pisa, ASL of Empoli, Azienda Ospedaliera Universitaria Pisana and INAIL. 677 patients with bladder cancer were interviewed by phone, among them 64 subjects had a working experience compatible with neoplastic risks because had a previous occupational exposure to aromatic amines and metal working fluids. These cases were discussed into a Medical Staff and 40 cases were considered "probable" for occupational disease, 18 "possible", 3 cases are suspended for more research, 3 cases are considered "no professional disease". The research allows finding out a great number of bladder cancer, increasing the total amount of workers with occupational disease. The integrated approach with the collaboration among different institutions is surely the best way to allow and guarantee a suitable and right protection of workers with occupational disease.

Volumetric measure of the frontal and temporal lobe regions in schizophrenia: relationship to negative symptoms.

BACKGROUND: Previous research has provided evidence for brain abnormalities in schizophrenia, but their relationship to specific clinical symptoms and syndromes remains unclear. METHODS: With an all-male demographically similar sample of 53 schizophrenic patients and 29 normal control subjects, cerebral gray and white matter volumes (adjusted for intracranial volume and age were determined for regions in the prefrontal lobe and in the superficial and mesial temporal lobe using T1-weighted magnetic resonance imaging with 2.8-mm coronal slices. RESULTS: As a group, schizophrenic patients had wide-spread bilateral decrements in gray matter in the pre-frontal (7.4%) and temporal lobe regions (8.9%), but not in white matter in these regions. In the temporal lobe, gray matter reductions were found bilaterally in the superior temporal gyrus (6.0%), but not in the hippocampus and parahippocampus. While there were no overall group differences in white matter volumes, widespread decrements in prefrontal white matter in schizophrenic patients (n = 53) were related to higher levels of negative symptoms (partial r[49] = -0.42, P = .002), as measured by the Scale for the Assessment of Negative Symptoms. A post hoc analysis revealed that schizophrenic patients with high negative symptoms had generalized prefrontal white matter reductions (11.4%) that were most severe in the orbitofrontal subregion (15.1%). CONCLUSIONS: These results suggest that gray matter deficits may be a fairly common structural abnormality of schizophrenia, whereas reductions in prefrontal white matter may be associated with schizophrenic negative symptoms.

Structural magnetic resonance image averaging in schizophrenia.

OBJECTIVE: Intersubject averaging of structural magnetic resonance (MR) images has been infrequently used as a means to study group differences in cerebral structure throughout the brain. In the present study, the authors used linear intersubject averaging of structural MR images to evaluate the validity and utility of this technique and to extend previous research, conducted using a different approach to image averaging, in which reduction in thalamic size and abnormalities in perithalamic white matter tracts in the brains of schizophrenic patients were reported by Andreasen et al. METHOD: A 1.5-T MR scanner was used to obtain high-resolution, whole brain T1-weighted structural MR images for an age-matched sample of 25 schizophrenic patients and 25 normal control subjects. A "bounding box" procedure was used to create a single "averaged" brain for the schizophrenic group and for the control group. Differences in signal intensity between the two average brains were examined on a pixel-wise basis through use of one-tailed effect size maps. RESULTS: Effect size maps revealed widespread patchy signal intensity differences between the two groups in both cortical and periventricular areas, including major white matter tracts. The signal intensity differences were consistent with cortical thinning/sulcal widening and ventricular enlargement. No differences were found within thalamus or in immediately surrounding white matter. Effect size maps for differences (schizophrenic minus normal subjects) had only small values. CONCLUSIONS: These results are consistent with diffuse structural brain abnormalities of both gray and white matter in schizophrenic populations such as the one in this study.

Pancreatic carcinoma in childhood: case report of long survival and review of the literature.

A case of exocrine pancreatic carcinoma in a 14-year-old boy is reported. The primary site of the tumor was in the head of the pancreas, and pathologic features were consistent with an anaplastic lesion. Ten years after curative resection the patient is still living. Extensive review of the literature has revealed 27 other cases of pancreatic carcinoma in children under 15 years of age. Aggressive surgical treatment is emphasized by the long survival observed in four patients who underwent radical operations and by this case report.

Fine volumetric analysis of the cerebral ventricular system in schizophrenia: further evidence for multifocal mild to moderate enlargement.

We used traditional volumetric regional analysis and a finer anterior-posterior (AP) profile volumetric analysis to examine the cerebral ventricular system in an all-male, demographically matched sample of schizophrenia patients (n = 73) and normal controls (n = 29) using 2.8-mm-thin coronal T1-weighted magnetic resonance images from a 1.5 tesla scanner. Traditional regional analysis was performed on various regions using absolute volumes after adjusting for intracranial volume (ICV) and age. The fine AP profile analysis was done by intrasubject "stacking" of contiguous coronal cross-sectional volumes (adjusted for ICV and age) across the AP plane, intersubject AP alignment of all slices relative to the mammillary bodies, and plotting of slice volumes along the AP plane with 95 percent t-test-based confidence intervals. Schizophrenia subjects had mild to moderate multifocal ventricular enlargement (overall effect size d = 0.48), which was especially prominent in the right posterior temporal horn and, more generally, in the central to posterior portions of the lateral and third ventricles. Schizophrenia subjects also had milder enlargement in the left frontal horn, but no significant differences were found in the anterior temporal horns and the right frontal horn. Post hoc analyses of demographic, clinical, and neuropsychological variables did not account for much variance in the ventriculomegaly observed in the schizophrenia group. The lack of a single locus in the observed ventricular enlargement, the nonsignificant results from schizophrenia subtypes based on regional distributions, and the strong positive correlations among the ventricular regions for the schizophrenia group suggest that the ventriculomegaly seen in this chronic population reflects a single brainwide disease process leading to a multifocal or patchy loss of integrity in brain structure.

Tumor extension along percutaneous transhepatic biliary drainage tracts.

Percutaneous Transhepatic Biliary Catheterization is commonly employed in the diagnosis and management of obstructive jaundice associated with malignant lesions. Tumor manipulation as an effort to obtain a histological diagnosis or to establish short or long-term internal-external biliary drainage is liable to disseminate the malignancy along the catheter tract. Two cases of malignant seeding of the catheter tract after biliary drainage have been observed.

Muscular blood flow in patients with heart failure.

We studied reactive hyperemia in a group of patients with heart failure before and after therapy, since changes in the characteristics of muscular blood flow may influence the functional class of these patients. At the same time we evaluated some echocardiographic parameters too. When the patients improved clinically, they showed an increase in muscular blood flow at rest and in percent of fractional shortening and a decrease in peripheral vascular resistance. The reactive hyperemia did not change significantly. This fact probably depends on a maximal response to the postischemic hyperemia and represents the integrity of autoregulatory mechanisms.

Influence of dietary carbohydrate on the metabolism of juvenile Litopenaeus stylirostris.

The effect of dietary carbohydrates (CBH) on glucose and glycogen, digestive enzymes, ammonia excretion and osmotic pressure and osmotic capacity of Litopenaeus stylirostris juveniles was studied. The increase of CBH, ranging between 1 and 33%, stimulates activities of alpha-amylase and alpha-glucosidase in the hepatopancreas. High levels of glucose in hemolymph and of glycogen in the hepatopancreas were reached at the highest level of dietary CBH; however, the kinetics of accumulation is different. Shrimps fed with low level of CBH needed 3 h to reached glucose peak, whereas only 1 h is necessary for high CBH levels. A saturation curve was observed in glycogen level and alpha-amylase activity with maximum values in shrimp-fed diets containing 21% CBH. This level could be used to be included as a maximum shrimp dietary CBH level. Pre-prandial glycogen levels were observed in shrimp fed a diet containing 1% CBH, indicating an important gluconeogenesis, which affected the protein metabolism. The present results show that a diet containing 10% CBH may not be enough to cover the CBH requirement, which could be satisfied by dietary protein content. The low osmotic capacity observed in shrimp fed on a diet containing 10% CBH coincided with a relatively low post-prandial nitrogen excretion which reflects a low concentration of amino acids circulating in hemolymph, which affected the osmotic pressure and the osmotic capacity. These results reflect the high plasticity of shrimp species to use protein to obtain metabolic energy from food and its limited capacity for processing dietary CBH.

MRI visualization of bilateral quadriceps tendon rupture in a patient with secondary hyperparathyroidism: implications for diagnosis and therapy.

Many musculoskeletal conditions have in the past been best defined on a clinical basis. However, because of pain, limitation of motion and hematomas, tendon ruptures can often be misdiagnosed clinically and it would be quite helpful to the clinician to have a noninvasive imaging technique. This communication defines the role of MRI in the early diagnosis of a nontraumatic rupture of the quadriceps tendons bilaterally in a patient with renal failure and known secondary hyperparathyroidism. The imaging techniques accurately defined the presence of hemorrhage extending into muscle from the ruptured tendons as well as the actual site and extent of tendon rupture. Since tendons have low mobile proton content and have low signal on MRI--disruptions are easily seen--MRI is the ideal noninvasive imaging technique for tendon injury, acute.

Flow-augmentation device for peripheral vascular Doppler US.

To augment venous blood flow at Doppler ultrasonography (US) of the extremities, a device comprising a blood pressure cuff connected to an external reservoir was tested. Constant and easily controlled pressure was delivered with each compression by the same operator performing US. In 10 patients (four men and six women, aged 54-86 years), discomfort was reduced compared with discomfort during manual compression, which requires two operators.

Use of a metal detector to identify ingested metallic foreign bodies.

A metal detector reveals the presence of metallic objects by measuring the change in the inductance of a coil placed near a metallic mass. The device used in this study is similar in principle to those used for passenger surveillance in airports except for its smaller size and simpler design. In this study, we compared the accuracy of a metal detector with that of plain radiographs for the localization of ingested metallic objects. Twenty-eight consecutive patients with the presumptive diagnosis of metallic foreign-body ingestion were examined with a metal detector. The results were compared with those of plain radiographs which were considered the gold standard. Fifteen positive cases and 13 negative cases were correctly diagnosed by metal detector examination. No false-positive or false-negative results occurred. Our experience suggests that metal detection is a simple and accurate technique for the localization of ingested metallic objects and provides information equivalent to that from plain radiographs for the treatment of patients with suspected foreign-body ingestion.

MR imaging artifacts that simulate disease: how to recognize and eliminate them.

Occasionally, artifacts may simulate pathologic conditions on magnetic resonance (MR) images. Motion artifacts especially affect images of the chest and abdomen. There are a number of techniques for reducing motion artifacts, including respiratory and cardiac gating, k-space phase reordering, gradient moment nulling, even echo rephasing, and physical restraints. Aliasing occurs when the field of view does not include all of the anatomic structures present in the imaged section. Aliasing artifacts can be eliminated by increasing the field of view, oversampling, and use of saturation pulses or surface coils. Truncation artifacts represent the difference between the original and the reconstructed image and can be reduced with data extrapolation algorithms or image filtering. Chemical shift artifacts and magnetic susceptibility artifacts are due to a local deformity of the magnetic field, resulting in spatial misregistration. Chemical shift artifacts are more severe in images acquired with a narrow-bandwidth technique; magnetic susceptibility artifacts are more severe in images acquired with a long echo time. Pitfalls in the interpretation of MR images can be avoided by becoming familiar with the appearances and causes of common MR imaging artifacts.

Bone mineral content in black pre-schoolers: normative data using single photon absorptiometry.

Fifty-nine children aged 18 to 47 months with normal and elevated blood lead levels had bone mineral density (BMD in gm/cm2) and bone mineral content (BMC in gm/cm) measured using the technique of single photon absorptiometry of the radius shaft. No normative data are available for black children of this age group. Moderate elevations of blood lead were not found to influence bone mineralization. The BMC of the study children was significantly higher than the published values for white children of the same age. We found no statistical difference between the bone mineral density of males and females in this age group.

[Respiratory mechanics and gas exchange in anesthesia for laparoscopic cholecystectomy]. / Meccanica respiratoria e scambio dei gas nella anestesia per colecistectomia per via laparoscopica.

OBJECTIVE: To evaluate the influence of endoabdominal CO2 insufflation during anaesthesia for laparoscopic cholecystectomy on airway pressure, gas exchange and their relationships. DESIGN: Perspective; clinical investigation. SETTING: Operating room at a central general hospital. PATIENTS: 14 patients (3 males and 11 females) ASA 1-2, non smokers, without lung disease, scheduled for elective laparoscopic cholecystectomy. INTERVENTIONS: During balanced anaesthesia (N2O/O2, Fentanyl, Isoflurane), with fixed minute ventilation, endoperitoneal insufflation of CO2 held at constant pressure (21 cm H2O). MEASUREMENTS: Serial measurements of: Airway pressure, near-static compliance, ETCO2, CO2 minute production, blood gas analysis and derived data: P(a-A)O2, P(a-ET)CO2, Vd/Vt. MAIN RESULTS: During insufflation peak and pause pressures increased by 6 cm H2O and mean pressure; by 3 cm H2O; Compliance was reduced by 48%; PaO2 decreased evenly with time (p > 0.05) irrespective of the airway pressure. PaCO2, PECO2, VCO2 and Vd/Vt after a sharp increase stabilized at 30% (mean value) over the baseline. P(a-ET)CO2 and Vd/Vt fluctuate in the physiological range except for two short but significant changes (p > 0.05) at insufflation and desufflation time. CONCLUSIONS: Laparoscopic technique for cholecystectomy, at least in healthy patients, produces relevant changes in airway pressures but only minor modifications of gas exchange, similar to those seen during general anaesthesia. This technique can be safely used for routine operation with standard monitoring equipment.

[Alfentanyl and midazolam in combined anesthesia. Clinical evaluation]. / Alfentanile e midazolam nell'anestesia combinata. Valutazione clinica.

We have evaluated the effectiveness of a technique of blended anaesthesia (epidural-general) in 31 patients undergoing major surgery. Thoracic epidural blockade with lidocaina CO2, adrenalin 1/200000, ensures analgesia while induction and hypnosis maintenance were obtained with midazolam, alfentanil, atracurium and N2O/O2. This technique seems able to protect the patients from endotracheal intubation and surgical stress and also to enable a rapid, quiet awakening. The dose of midazolam necessary to maintain hypnosis was inversely proportional to the patient's age. The reversal of hypnosis was necessary in 4 patients only.

[Combined anesthesia (epidural-general) in thoracic surgery: the cardiocirculatory response to induction. Propofol vs midazolam plus alfentanil]. / Anestesia combinata (epidurale-generale) in chirurgia toracica: risposta cardiocircolatoria all'induzione. Propofol vs midazolam più alfentanile.

Thoracic epidural block may unpredictably blunt the physiological sympathetic response to anaesthetic agents and profound hypotension could result at induction time. The authors evaluate two different induction regimens in 16 patients scheduled for major thoracic surgery in order to assess which of them would produce less hemodynamic changes. After the institution of high thoracic epidural block (6 ml lidocaine-CO2 2% + epinephrine 1/200,000 level: th.2-3), patients were randomly allocated in two induction groups: P and M. Group P received 2 mg/kg of propofol over 30 seconds; group M received midazolam 0.2 mg/kg plus alfentanil 30 mcg/kg. In Both groups induction was followed by a significant drop in blood pressure (-18% in group M and -37% i group P. In P group the fall in blood pressure is more pronounced than M group (p < 0.05). Noteworthy in both groups cardiac frequency do not increase and in M group significantly lowers. In the authors view the midazolam plus alfentanil induction technique compare well with propofol alone and would recommend its use in poor risk patients.

New electronics for the Beckman LB-1 carbon dioxide analyzer.

This paper describes an amplifier and linearizer for the Beckman LB-1 carbon dioxide analyzer head. All electronics are solid state and DC regulated in contrast to the original LB-1 amplifier which was of vacuum tube design and AC regulated largely by means of a voltage stabilizer transformer. A new detection principle is adopted which reduces drift due to mechanical imperfections of the chopper motor (e.g., bearing drag), but also offers the advantage that the phasing of the chopper blades is no longer necessary. Furthermore, the amplifier with a digital readout and an end-tidal hold circuit can be built for less than $500 and is plug compatible with the LB-1 head.

Detailed evaluation of angiographic findings in the surgical assessment of resectability for pancreatic cancer.

The role of angiography as a diagnostic approach and surgical assessment of resectability in pancreatic cancer patients is considered. Pre-operative arteriography of the celiac axis and superior mesenteric artery was performed in 27 patients with surgically proved pancreatic cancer. The operatibility of each patient was assessed according to arteriographic findings. The arteriographic features considered to establish tumor unresectability included: neoplastic arterial encasement or displacement, multiple involvement of pancreatic arteries, involvement of portal, splenic or superior mesenteric veins, liver metastasis. Nineteen angiographically predicted unresectable lesions proved to be unresectable at surgery. Of the eight additional patients who showed no remarkable unresectable angiographic features, 6 were confirmed resectable, while 2 were unresectable. Angiography was shown to be very accurate in differentiating resectable from unresectable cancer of the pancreas.