Metaverse and Telementoring: From Surgery to Workshop.

BACKGROUND: The Coronavirus 2019 (COVID-19) pandemic has favored the growth of telemedicine systems and in this context the idea of Metaverse was born and developed. A 3D reality in which people can interact with each other through digital reproductions of themselves. Metaverse has already been tested in numerous medical fields due to its ability to combine visual and auditory information with tactile sensations. The purpose of this study is to highlight its potential also in its ability to be used as a telementoring place where the skills and knowledge of surgeons from all over the world can be combined. MATERIAL AND METHODS: The first HPB Surgery Workshop was held at the "Metaverse Surgical Hospital, USA". During the workshop, surgeons located in various parts of the world reported on hepatic, pancreatic and biliary tract surgery and remotely supported the execution of a robotic liver resection. RESULTS: The Metaverse gave the opportunity for surgeons to meet and discuss HPB pathologies and its surgical strategies and for surgeons in training to interface with experts by participating in a moment of advanced training. CONCLUSION: In the Metaverse, telementoring can be used at very low cost to improve clinical and surgical practice.

Impact of COVID-19 on the mental health in a cohort of Italian rehabilitation healthcare workers.

The COVID-19 pandemic has had a strong impact on healthcare workers (HCWs), affecting their physical and mental health. In Italy, HCWs have been among the first exposed to unprecedented pressure, dealing with large numbers of infections during the first pandemic wave. However, the severe psychological consequences on HCWs find little evidence in the literature, especially in terms of comparison to the status quo ante pandemic. The aim of this study was to provide an assessment of the mental health burden in a cohort of Italian HCWs during the COVID-19 pandemic, comparing their condition with that before the emergency, to direct the promotion of mental well-being among HCWs worldwide. In this retrospective study, we included physicians, physical therapists, and nurses working in the Respiratory Intensive Care Unit, Neurology Unit, and Rehabilitation Unit from a Southern Italy University Hospital. All study participants underwent a battery of psychological tests, aimed at verifying their state of mental health during the COVID-19 emergency and before it. Depressive, anxiety, and burnout symptoms were assessed using the following questionnaires: Maslach Burnout Inventory, Patient Health Questionnaire-9 (PHQ-9), and General Anxiety Disorder-7. Depressive, anxiety, and burnout clinical relevance symptoms were present in HCWs during the COVID-19 pandemic more than those before the emergency. Fifty percent of the HCWs obtained a score clinically significant during the emergency. Moreover, a depersonalization factor showed a statistically significant increase in average scores (p < 0.0001). The PHQ-9 scale showed that 47.1% of the operators reported depressive state presence. The number of operators scoring above the cut-off for the anxiety scale tripled during the emergency (p < 0.0001). The female gender conferred greater risks for depression. Taken together, the findings of this study showed that our sample of Italian HCWs showed a greater risk for depression, anxiety, and stress during the COVID-19 pandemic. These data might be a starting point to plan mental health monitoring and prevention programs for HCWs, thus ensuring patients receive the best possible care performances even during healthcare crises such as the current pandemic.

Maternal serum PAPP-A as an early marker of obstetric complications?

OBJECTIVE: The aim of this study was to investigate whether low first-trimester PAPP-A levels are associated with an adverse pregnancy outcome. MATERIALS AND METHODS: A retrospective case-control study was carried out using a Down's syndrome assays database over a 6-year period, between the 8th and 11th week of pregnancy. There were 164 women with PAPP-A multiples of median (MoM) levels <0.3 and 1,640 women with PAPP-A MoM levels ≥0.3 who served as a control group. Outcome measures were the prevalence of miscarriages, gestational hypertension, preeclampsia, pre-term delivery, gestational diabetes and intrauterine growth retardation in both groups. RESULTS: The two groups significantly differed only for miscarriages: 29 (17.7%) vs. 159 (9.7%), p = 0.04, OR 1.7; gestational hypertension: 15 (9.1%) vs. 74 (4.5%), p = 0.02, OR 2.1, and preeclampsia: 9 (5.5%) vs. 29 (1.8%), p = 0.02, OR 2.5. DISCUSSION: Even if in this study the PAPP-A cutoff considered was lower and was assayed in an earlier period compared with other studies, the detection rate for adverse pregnancy outcomes did not improve.

Intrathecal Baclofen Infusion-Botulinum Toxin Combined Treatment Efficacy in the Management of Spasticity due to Cerebral Palsy.

BACKGROUND: Cerebral Palsy (CP) is a group of permanent, but not unchanging, disorders of movement and/or posture and motor function, which are due to a non-progressive interference, lesion, or abnormality of the developing/immature brain. One clinical presentation is muscle spasticity, which leads to a significant impact on the individual's functionality and quality of life. Spasticity treatment is multidisciplinary and includes pharmacological and physical intervention; intrathecal baclofen shows a positive effect in severe spasticity and suboptimal response to oral drugs, while local injection of Botulinum toxin type A (BTXA) improves muscle tone, motion and pain. OBJECTIVE: The aim of this study was to evaluate the efficacy of the combined intrathecal baclofen infusion (ITB) - botulinum toxin treatment in the management of spasticity in CP. METHODS: 8 patients with spastic tetraparesis were enrolled. All patients were treated with intrathecal Baclofen; in lower limbs, no spastic symptoms appeared, while marked spasticity was noted in upper limbs. We injected the right and left Biceps Brachial (BB) and Flexor Digitorum Superficialis (FDS) muscles with botulinum toxin type A. All patients underwent Myometric measurement, Ashworth Scale, Numerical Rating Scale, and Visual Analogic Scale evaluation before infiltration (T0), 30 days after injection (T1), 60 days after injection (T2), and 90 days after treatment (T3). RESULTS: All data demonstrated an improvement in spasticity, pain, quality of life, and self-care during the study, with p < 0.05. No side effects appeared. CONCLUSION: This study demonstrated the efficacy and safety of intrathecal baclofen infusion and botulinum toxin combined treatment in the management of spasticity, pain, quality of life, and selfcare in CP patients.

Diffusion-weighted magnetic resonance imaging: new perspectives in the diagnostic pathway of non-complicated acute pyelonephritis.

OBJECTIVES: The diagnosis of acute pyelonephritis (APN) requires demonstration of parenchymal involvement. When no predisposing conditions are found, non-complicated APN is suspected and CT or MRI should be performed. Diffusion-weighted (DW) MRI might be useful, quicker and cheaper than the standard gadolinium-enhanced (GE) MRI. The aim of this study is to compare DW-MRI with GE-MRI to test its diagnostic accuracy in APN. METHODS: Of 318 consecutive patients hospitalised for APN, 279 underwent MRI. Four hundred and fourteen MR studies (first test and follow-up examinations) were gathered and data were processed using Diffusion Analysis software. DW-MRI has been compared with GE-MRI for evaluating diagnostic agreement. RESULTS: Two hundred and forty-four patients were diagnosed as having APN; 35 were negative. One hundred and sixty-three APN cases were considered non-complicated and selected for the study. Among the 414 MR examinations, comparing DW-MRI with GE-MRI, positive correlation was found in 258 cases, negative in 133. There were 14 false-negatives and 9 false-positives. DW-MRI achieved sensitivity 95.2 %, specificity 94.9 %, positive predictive value 96.9 %, negative predictive value 92.3 % and accuracy 94.6 %. CONCLUSIONS: DW-MRI is reliable for diagnosing non-complicated APN. The high diagnostic agreement between DW-MRI and GE-MRI offers new perspectives in diagnostic management, enabling diagnosis of non-complicated APN without using ionising radiation or contrast media. KEY POINTS: • The diagnosis of acute pyelonephritis (APN) requires demonstration of renal involvement. • Hitherto magnetic resonance imaging required gadolinium enhancement (GE-MRI) to establish this diagnosis. • But diagnostic agreement between diffusion-weighted and GE-MRI offers new diagnostic opportunities. • Quantification of ADC values can help diagnose and monitor APN. • DW-MRI avoids ionising radiation and paramagnetic contrast medium administration.

Clinical Onset of Action of Incobotulinum Toxin A Preparation.

BACKGROUND: Many studies in vitro compared the onset of action, maximum efficacy, and duration of botulinum toxin type A (BoNT/A) preparations. OBJECTIVE: In this study, we analyzed the onset of action of BoNT/A preparation free of complexing proteins in patients with upper limb spasticity post stroke up to 30 days after treatment. METHODS: 75 patients affected by Biceps Brachii spasticity were enrolled. Outcome measures were instrumental muscle tone modification (myometric measurement), improvement of Modified Ashworth Scale (MAS), improvement of elbow's passive extension, and improvement of compound muscle action potential (cMAP) evaluated by electroneurography. We analyzed data at t0 (pre-injection), t1 (1 day after), t2 (7 days after), t3 (14 days after), and t4 (30 days after). RESULTS: All measurements decreased at t2, t3, and t4 with initial improvement at t2 and maximum improvement at t4; no statistical difference at t1 was found. CONCLUSION: This study demonstrated the onset of Incobotulinumtoxin A efficacy started after 7 days; this rapid action and efficacy of BoNT/A preparation could improve an intensive rehabilitation program after some days post-injection. Early clinical onset of action could be by the absence of complexing proteins in the preparation.

'Bench' MRI before transplant on harvested kidneys: a possible tool for diagnosis of acute pyelonephritis.

We present the first case in which magnetic resonance imaging (MRI) has been utilized to rule out lesions compatible with acute pyelonephritis in kidneys from a cadaveric organ donor before transplanting them. A 40-year-old female underwent diagnosis of brain death following a septic shock. The ecotomography of the kidneys showed areas compatible with micro-abscesses raising the hypothesis of acute pyelonephritis. Our radiologist proposed to perform a bench-MRI (maintaining kidneys within the sterile preservation bags constantly on ice); this did not show lesions except little cysts not relevant by the clinical point of view. We transplanted kidneys without infective complications and results were very good.

Preliminary results of a single-arm pilot study to assess the safety and efficacy of visnadine, prenylflavonoids and bovine colostrum in postmenopausal sexually active women affected by vulvovaginal atrophy.

This single-arm pilot study enrolled 47 post-menopausal women affected by vulvovaginal atrophy (VVA). The Vaginal Health Index Score (VHIS) was evaluated for all women and all completed the Female Sexual Function Index (FSFI) questionnaire at baseline (T0) and after 15 days of vaginal cream treatment with one application per day (T1). Following treatment there was a significant improvement in all VHIS parameters and total score (p < 0.0001). Similarly, there was a significant improvement on four FSFI domains (lubrication, orgasm, satisfaction and pain) and total score (p = 0.001). None of the patients reported any local or systemic side-effects during treatment.

Extradural motor cortex stimulation for advanced Parkinson disease. Report of two cases.

Motor cortex stimulation is a minimally invasive surgical procedure used for pain control. The authors report their results treating two patients with typical Parkinson disease. Unilateral motor cortex stimulation proved to be beneficial bilaterally. Motor cortex stimulation may represent a cost-effective alternative to deep brain stimulation.

Therapeutic extradural cortical stimulation for movement disorders: a review.

Extradural motor cortex stimulation was introduced in 1989 for control of central pain. In recent years this has been found useful in several patients with movement disorders. This paper attempts to bring together all the relevant literature, discuss mechanisms and lay out guidelines for future research and clinical applications.

Percutaneous radiologic gastrostomy: a 12-year series.

BACKGROUND/AIMS: Interventional radiologists have played a main role in the technical evolution of gastrostomy, from the first surgical/endoscopical approaches to percutaneous interventional procedures. This study evaluated the results obtained in a 12-year series. METHODS: During the period December 1996 to December 2008, 254 new consecutive gastrostomies and 275 replacement procedures were performed in selected patients. All of the cases were treated by a T-fastener gastropexy and tube placement. The procedures were assessed by analyzing indications, patient selection, duration of the procedures, and mortality. RESULTS: All 254 first gastrostomies were successful; replacement procedures were also successfully performed. One (0.2%) patient with severe neurologic disorders died after the procedure without signs of procedure-related complications, and seven (1.3%) major complications occurred (four duodenal lesions with peritoneal leakage, two gastric bleedings, and one gastric lesion). Minor complications were easily managed; three tube ruptures were resolved. CONCLUSIONS: This long-term series and follow-up showed that a group of interventional radiologist can effectively provide gastrostomy placement and long-term tube management. Percutaneous gastrostomy is less invasive than other approaches and it satisfies the needs even of high-risk patients.

Complete myocardial revascularization and sutureless technique for left ventricular free wall rupture: clinical and echocardiographic results.

Left ventricular free wall rupture (LVFWR) is one of the most dramatic complications of myocardial infarction. We present our mid-term clinical and echocardiographic results of LVFWR with patch and complete myocardial revascularization on viable tissue. From August 2000 to July 2005, 9 patients underwent surgery for LVFWR. Mean age was 68+/-S.D. 9.3 years. Mean interval time between AMI and LVFWR was 122.2+/-154.9 h. All patients presented for emergency surgery with cardiac tamponade at echocardiography. Three patients received IABP preoperatively. Eight had coronarography. Effective control of bleeding was achieved in all cases with a Teflon patch applied with Bioglue. Four patients had myocardial revascularization, all in ECC; two of them with cross-clamping. There was no operative death. Mean follow-up was 38.8+/-22.2 S.D. months. One further death occurred from myocardial infarction. All patients were in NYHA I-II. Survivors had follow-up transthoracic echocardiography: all patients had preserved left ventricular function with absence of restricted motion. There was no evidence of mitral regurgitation. Sutureless covering technique for LVFWR is related to excellent early and long-term clinical and echocardiographic results. Complete coronary artery bypass grafting improves long-term symptom-free survival. We have demonstrated that ECC and cross-clamping do not affect early survival.

Dissection of cervicocephalic arteries: early diagnosis and follow-up with magnetic resonance imaging.

Evaluate Magnetic Resonance (MR) and Magnetic Resonance Angiography (MRA) sensibility in the diagnosis and follow-up of dissection of Internal Carotid and Vertebral Artery (ICA/VA). We revalued MR examination of 36 patients, 24 men, 12 women, aged 18-69 years. All patients underwent brain TC and MR (GE 1 Tesla); in 16 subjects 3D Time-of-Flight (TOF-3D) MRA was performed and in 20 subjects a Contrast-Enhanced MRA (CEMRA) of neck and head arteries. Thirty-one patients underwent a MRA follow-up. Dissection involved ICA in 30 and VA in 8. MR showed ischemic signs in 25 cases, wall hematoma in 19, and was normal in 11. MRA showed 25 vessels stenosis, 12 occlusions, and 9 aneurysm. Follow-up MRA showed 6 cases of complete resolution of stenosis, 17 partial resolution, 2 aneurysmal dissecanting, 6 luminal alteration unchanged, 1 aneurysma enlarged. MRA represented a non-invasive technique as investigation in suspected cervicocephalic arteries dissection.

[Magnetic resonance diagnosis of traumatic penile fracture].

PURPOSE: To report our experience with MRI in the preoperative evaluation of patients with traumatic penile fractures. MATERIALS AND METHODS: Between January 1998 and December 2001, we performed MRI examinations on five patients (aged 29-48 years; mean age 40 years) with suspected traumatic fracture of the penis occurred during sexual intercourse. In all cases, T1-weighted SE, T2-weighted FSE and GRE sequences in the axial, coronal and sagittal planes were acquired. The study was performed without IV administration of paramagnetic contrast agents and in conditions of detumescence. A small-sized surface coil was used in four cases and a body coil was used in one case. All patients had suspected penile fracture with indications for surgical repair. The MR examination was performed within 12 to 48 hours of the trauma and was requested to aid surgical planning. RESULTS: The MR image quality was adequate in all cases. The examination documented unilateral rupture of the corpus cavernosum in all patients. This finding was associated with haematoma located both subcutaneously and inside the corpus cavernosum itself. In no case was there rupture of both corpora cavernosa. In only one patient was there a suspicion of injuries to the urethral corpus spongiosum, which was confirmed by surgery along with the other MR findings. DISCUSSION AND CONCLUSIONS: Many imaging methods are available to evaluate traumatic penile lesions: ultrasound, colour-Doppler ultrasound, urethrography, cavernosography, angiography and MRI. In agreement with the literature, our experience shows that MRI is useful in evaluating penile injuries owing to its multiplanar capabilities, its good spatial resolution and its excellent tissue contrast resolution. These characteristics enabled a more adequate surgical approach. In our view, MRI can be regarded as an emerging method to obtain helpful diagnostic information, with no risks for the patient.

Alucinación verbal y estructura de la psicosis: La especificidad de las alucinaciones verbales / Verbal hallucination and psychosis structure - Specificity of verbal hallucinations

J. Lacan ha establecido el valor paradigmático de la alucinación verbal en la estructura de la psicosis. En el curso de la historia de la psiquiatría y de acuerdo a las principales concepciones teóricas vigentes se llegó a reconocer la importancia semiológica del fenómeno en el contexto de un debate doctrinal acerca de su naturaleza y modo de producción. Se revisan diferentes momentos de esta historia hasta llegar a establecer las razones por las cuales la alucinación verbal perdió su valor específico, subordinada a la disociación mental y al delirio

Alucinación verbal y estructura de la psicosis: La especificidad de las alucinaciones verbales / Verbal hallucination and psychosis structure - Specificity of verbal hallucinations

J. Lacan ha establecido el valor paradigmático de la alucinación verbal en la estructura de la psicosis. En el curso de la historia de la psiquiatría y de acuerdo a las principales concepciones teóricas vigentes se llegó a reconocer la importancia semiológica del fenómeno en el contexto de un debate doctrinal acerca de su naturaleza y modo de producción. Se revisan diferentes momentos de esta historia hasta llegar a establecer las razones por las cuales la alucinación verbal perdió su valor específico, subordinada a la disociación mental y al delirio