From keyhole to sandwich: change in laparoscopic repair of parastomal hernias at a single centre.

BACKGROUND: Nearly 50% of patients with an ostomy will develop a parastomal hernia (PSH). Its repair remains a surgical challenge. Both laparoscopic "modified Sugarbaker" (SB) and Keyhole (KH) repair are currently in use, frequently with unsatisfactory results.''Sandwich Repair'' (SR) may be an alternative to reduce recurrence rates. We present the change of our technique from KH to SR. METHODS: We collected data from all consecutive laparoscopic PSH repairs at our institution from 2004 until now (from 2004 to 2013 treated with KH, from 2014 with SR) and compared the results of the two groups. Primary endpoint was recurrence rate at 1 year. Secondary outcomes were operative time, PO length of hospital stay (LOS), and short and long-term complications. RESULTS: 13 patients underwent SR. Main changes in surgical technique concerned primary defect closure, no stay sutures, use of glue for first mesh fixation, and partial lateral covering of the underlying mesh with a peritoneal flap. Early postoperative course after SR was uneventful and no recurrence at 1 year was recorded. In the KH group (19 patients), short-term complications occurred in two cases (10%), with one parietal hematoma and one case of intensive pain; we had four recurrences at 1 year (21%). LOS was shorter in the SR group (mean 4 days vs 6, p = 0.004). The KH group had 2 (10%) occurrences of chronic seroma and one bowel perforation (5%), while the SR group had one (8%) occurrence of chronic pain. Median follow-up was 26 months (range 13-78) for the SR group and 47 months (12-105) for the KH group. CONCLUSION: SR is safe and effective in expert hands and provides promising preliminary results.

[Alcohol and work. Consensus Document of the La.R.A. (Workers representing a risk for others) group]. / Alcol e Lavoro. Documento di consenso del gruppo La.R.A.

AIM: Current Italian legislation obliges employers to prevent workers who are occupationally at risk or who perform jobs that may be hazardous for the safety or health of third parties from consuming alcohol. The LaRA Group undertook to assess whether the law fully safeguards the health and safety of both workers and third parties, without impinging upon the civil rights of workers. METHOD: A written document expressing agreement was produced following discussions between doctors, lawyers, bioethicists and social partners. RESULTS: There are gaps and inconsistencies in current laws; the differences in local and regional provisions prevent authorities from applying a single strategy at national level. There should be a change in existing rules under which the employer's obligation to enforce the ban on consumption alcohol in the workplace is enacted solely by the "competent" physician whose institutional role is to safeguard and promote health. Some occupational categories that are subject to a ban on alcohol consumption do not currently under-go health surveillance. For example, if road transport drivers are not exposed to a specific occupational risk foreseen under another law, they can be placed under health surveillance only in those regions where the local laws contemplate this type of control. In other cases, the practice of assessing the risk to third parties and providing for compulsory health surveillance in the Risk Assessment Document, is considered by some jurists to be a "consuetudo praeter legem" and therefore acceptable in a field not yet covered by a specific law, but to be "contra legem" or unlawful by other jurists. Moreover, the competent physician who uses a breathanalyser or tests for alcohol addiction faces an ethical dilemma, since by communicating the results to an employer or authorities responsible for the issuing of licenses, he may be violating his professional oath of secrecy. Furthermore, the emphasis placed on testing has induced companies and inspectors to overlook educational and rehabilitation aspects. It is essential to involve general practitioners, educators and specialist services in addressing the problems of alcohol abuse so as to inform/train, recover and rehabilitate. The few studies available indicate that the rules are poorly enforced and that non-compliance may go unobserved. CONCLUSIONS: The Group urges all employers to assess the risk for third parties caused by alcohol abuse and to devise a policy on alcohol. Controlling alcohol-related risks in the workplace calls for a better definition of the roles of Vigilance Bod-ies and Company Physicians together with a shift from a reactive to a proactive attitude of all the parties involved.

New strategies to classify canine pleural effusions and the diagnostic value of acute phase proteins, amylase, and adenosine deaminase in pleural exudates.

BACKGROUND: In dogs, simplified Light's criteria can discriminate transudates from exudates. Other tests used in human medicine are pleural effusion cholesterol (CHOLPE) and butyrylcholinesterase [BChEPE], the pleural effusion/serum ratio of these analytes (CHOLratio and BChEratio), and the serum albumin minus pleural effusion albumin gradient (SEAG). OBJECTIVES: We aimed to assess the diagnostic accuracies of different biomarkers in dogs with pleural effusion in differentiating exudates from transudates. Secondarily, we evaluated the potential diagnostic utility of pleural effusion acute phase proteins, amylase, and adenosine deaminase in discriminating causes of exudative effusions. METHODS: Cross-sectional study including 68 client-owned dogs with pleural effusion. RESULTS: There were 48 exudates (10 septic, 16 neoplastic, 9 hemorrhagic, and 13 classified as other exudates) and 20 transudates. All the variables analyzed, except SEAG, were significantly different between exudates and transudates. Using the cut-off values adopted in human literature, accuracies for CHOLPE, CHOLratio, BChEPE, and BChEratio were between 82.35% and 85.29%; all values were significantly lower compared with the previously published simplified Light's criteria accuracy (i.e., 98%, p < .001 for all comparisons). We found the accuracy of the simplified Light's criteria to be similar to what has been previously reported (95.59%, p = .238). Paraoxonase-1 (PON-1PE) activity and the pleural effusion/serum paraoxonase-1 ratio (PON-1ratio) were significantly lower in exudative neoplastic effusions than in exudative hemorrhagic (p = .004 and p = .001) and septic (p = .004 and p < .001) effusions. CONCLUSION: Simplified Light's criteria were the best method for discriminating transudates from exudates, and a low PON-1PE activity and PON-1ratio in exudative effusions may suggest an underlying neoplasia.

Two-meshes approach in posterior component separation with transversus abdominis release: the IMPACT study (Italian Multicentric Posterior-separation Abdominal Complex hernia Transversus-release).

BACKGROUND: Surgical management of large ventral hernias (VH) has remained a challenge. Various techniques like anterior component separation and posterior component separation (PCS) with transversus abdominis release (TAR) have been employed. Despite the initial success, the long-term efficacy of TAR is not yet comprehensively studied. Authors aimed to investigate the early-, medium-, and long-term outcomes and health-related quality of life (QoL) in patients treated with PCS and TAR. METHODS: This multicenter retrospective study analyzed data of 308 patients who underwent open PCS with TAR for primary or recurrent complex abdominal hernias between 2015 and 2020. The primary endpoint was the rate of hernia recurrence (HR) and mesh bulging (MB) at 3, 6, 12, 24, and 36 months. Secondary outcomes included surgical site events and QoL, assessed using EuraHS-QoL score. RESULTS: The average follow-up was 38.3 ± 12.7 months. The overall HR rate was 3.5% and the MB rate was 4.7%. Most of the recurrences were detected by clinical and ultrasound examination. QoL metrics showed improvement post-surgery. CONCLUSIONS: This study supports the long-term efficacy of PCS with TAR in the treatment of large and complex VH, with a low recurrence rate and an improvement in QoL. Further research is needed for a more in-depth understanding of these outcomes and the factors affecting them.

Hair determination of per- and polyfluoroalkyl substances (PFAS) in the Italian population.

Per- and polyfluoroalkyl substances (PFAS) are anthropogenic chemicals present in the environment and defined as persistent organic pollutants (POPs). The interest in these forms of contaminants is related to the toxic consequences for health derived from exposures and bioaccumulation processes. The present research aims at assessing differences in the exposure of PFAS in the Italian population by hair analyses. To this aim, 20 compounds of the PFAS family were investigated in hair of 86 Italian subjects distributed across the regions of Veneto, Emilia-Romagna, Lombardy and Marche. The applied method was ad hoc developed in a previous research and included SPE extraction and LC-QTOF analysis. In the analyzed population, 66.4 % had quantifiable amounts of one or more PFAS molecules (up to 4 compounds); mean PFAS content, expressed as sum of PFAS, was 0.1457 ng/g, ranging from "not detected" to 0.85 ng/g (SD 0.1867). PFOA and PFOS were the chemicals most frequently detected, with mean concentrations of 0.1402 ng/g and 0.1155 ng/g, respectively. PFBA was detected in 9.3 % of subjects with a mean concentration of 0.3760 ng/g; PFNA in 3.5 % of subjects with mean concentration 0.12 ng/g; PFDA was found in one subject at the concentration of 0.541 ng/g. PFUnA and PFHxS were detected below the limit of quantification. The overall results displayed differences in the presence and prevalence of PFAS in hair of the Italian population on a geographical base. On the contrary, no significatively differences in the amount of PFAS were observed when considering gender or age classes. On this base, hair can be considered a good diagnostic tool to assess PFAS exposure on a regional-scaled base. Of course, more studies are required to infer PFAS internal dose from hair results due to its peculiar detection window and to interpretative issues derived from external contamination.

Frailty in major oncologic surgery of upper gastrointestinal tract: How to improve postoperative outcomes.

INTRODUCTION: Certain surgical interventions, especially those involving upper GI tract remain challenging, due to high morbidity and mortality rates. The study of frailty in the surgical population has allowed the identification of those patients with a higher risk of poor postoperative outcomes. There remains a lack of evidence regarding the possibility of improving these results through a preoperative holistic management of the patients. The aim of this study is to evaluate whether preoperative treatment, in carefully selected patients, can improve the outcome following surgery. PATIENTS AND METHODS: Between March 2015 and February 2016 patients affected by malignant tumors of the upper GI tract were enrolled at our Institution for major oncologic surgery. Amongst them, frail patients (Group 1) were identified using a validated scoring system and underwent a multidisciplinary preoperative management plan, composed of nutritional intervention, physical/respiratory enhancement and optimization of ongoing therapy. Short-term postoperative outcomes were then compared with a control group (Group 2) of patients with comparable frailty features and surgical indications, who had undergone surgery in the period from March 2013 to February 2014. RESULTS: 30-days and 3-months mortality, overall and severe complication rates were found to be significantly lower (p < 0.05) in Group 1 (41 patients) when compared with Group 2 (35 patents). No significant differences were recorded for the following outcomes: length of stay, referral to post-discharge institutionalisation and hospital re-admission. DISCUSSION: This study confirms advantages provided by preoperative treatment in frail patients, suggesting a new pathway for the improvement of postoperative outcomes.

Distribution of embutramide and mebezonium iodide in a suicide after tanax injection.

Tanax is a veterinary formulation for euthanasia comprising embutramide, mebezonium iodide and tetracaine. A 37-year-old female was found dead on her bed, with three empty used syringes and a bottle of Tanax beside her body. Three needle puncture marks were observed on the body. The aim of this study was to evaluate the distribution of embutramide and mebezonium iodide in different biological matrices (femoral and cardiac blood, liver, muscle and vitreous humor) using a chromatographic method for the simultaneous determination of the two drugs. A direct and sensitive liquid chromatography-tandem mass spectrometry method was developed in multiple reaction monitoring mode with positive ionization. Lidocaine was used as an internal standard. Limits of detection and quantitation of 0.01 and 0.05 mg/L, respectively, were reached for both compounds. Embutramide levels ranged from 2.74 mg/L in vitreous humor to 5.06 mg/L in femoral blood, while mebezonium iodide was found at widely differing concentrations (ranging from 2.80 mg/kg in muscle to 24.80 mg/kg in liver). The chromatographic method developed for this study provides a very simple and sensitive means for the simultaneous determination of embutramide and mebezonium iodide, the emetic concentrations of which were consistent with suicides reported in the literature.

Ethyl glucuronide and ethyl sulfate in meconium and hair-potential biomarkers of intrauterine exposure to ethanol.

This study investigated ethyl glucuronide (EtG) and ethyl sulfate (EtS) concentration in meconium and in maternal and neonatal hair (HEtG and HFAEEs, respectively) as potential markers of intrauterine exposure to ethanol together with meconium fatty acid ethyl esters (FAEEs) in a cohort of 99 mother-infant dyads, 49 coming from the Arcispedale of Reggio Emilia (Italy) and 50 from the Hospital del Mar of Barcelona (Spain). FAEEs, EtG and EtS were measured in meconium samples using liquid chromatography-tandem mass spectrometry. A head space-solid phase microextraction-gas chromatography-mass spectrometry was used to test HEtG and HFAEEs in hair samples from mothers and their newborns. Eighty-two meconium samples (82.8%) tested positive for EtG, 19 (19.2%) for EtS while 22 (22.2%) showed FAEEs levels higher than 2 nmol/g, the cut-off used to differentiate daily maternal ethanol consumption during pregnancy from occasional or no use. Although EtG and EtS in meconium did not correlate with total FAEEs concentration, a good correlation between EtG, EtS and ethyl stearate was observed. Moreover, EtG correlated well with ethyl palmitoleate, while EtS with ethyl laurate, myristate and linolenate. Neither maternal nor neonatal hair appears as good predictors of gestational ethanol consumption and subsequent fetal exposure in these mother-infant dyads. In conclusion, these data show that meconium is so far the best matrix in evaluating intrauterine exposure to ethanol, with EtG and EtS being potentially good alternative biomarkers to FAEEs.