Modified National Early Warning Score as Early Predictor of Outcome in COVID-19 Pandemic.

COVID-19 represented an important challenge to the Italian healthcare system (IHCS). Our main aim was to obtain evidence to support the use of modified national early warning score (m-NEWS) as an interdisciplinary, common, and universal scoring scale to quickly recognize patients with a risk of clinical deterioration before admission and during hospitalization. As a secondary goal, we tried to find a score threshold that can trigger patients' immediate medical review as a part of an optimal triaging protocol for an emergency setting where healthcare resources are overloaded. We performed a retrospective observational study. We included in our study all patients treated for COVID-19 infection in surgical departments between 01 March 2020 and 16 April 2020. Patients with negative test results for SARS-COV-2 were excluded. m-NEWS was obtained twice a day. Patients' m-NEWS were analyzed in order to verify the correlation between m-NEWS (at admission and m-NEWS variation 24 h after admission) and outcome (positive outcome-survival, negative outcome-death, or intensive care unit (ICU) transfer). We included a population-based sample of 225 SARS-COV-2-infected patients. Overall, the average age at hospitalization was 71 (ranging from 40 to 95). 144 (64%) patients were males and 81 (36%) females. m-NEWS values lower or equal to 7 were associated with the majority of the "recovered" population (100/132 75.75%) and at the same time with the minority of the "non-recovered" population (25/93 26.88%). For our sample, age is statistically correlated to the outcome but a triage protocol based solely on this variable is less effective than m-NEWS, which showed to be a reliable and easy-to-use score for first patient evaluation. Our observations pave the way towards further studies aiming at optimizing territorial and community healthcare management protocols.

The "Pandemic" of Disinformation in COVID-19.

In recent years, mass media and social networks have played an important role in disseminating information regarding public health. During the COVID-19 epidemic, misinformation and fake news have represented an important issue generating confusion and insecurity among the population. In our analysis, we investigate the role of mass media as a critical element during the SARS-CoV-2 outbreak that has influenced the public perception of risk.

[Surgical complications of the diverticular disease. A rare case of sigmoid-vaginal fistula]. / Le complicanze chirurgiche della malattia diverticolare: un raro caso di fistola sigmoido-vaginale.

The Authors report on a rare case of diverticular disease complicated by a sigmoid- vaginal fistula with personal considerations based on a review of literature. A 75 year old patient becomes to our observation suffering the lost of smelly vaginal secretions without fever or abdominalgia. In anamnesis hysterectomy cholecystectomy appendectomy and visceral adhesions lysis. Colonoscopy RX barium enema, gynaecological examination, vaginal buffer show diverticulis of colon sigma with sigmoid-vaginal fistula. After laparotomy, visceral adhesions lysis, it was done sigmoid- vaginal fistula resection with healing. Diverticular disease is a XX century pathology with incidence (for some authors) of 50% of population. Symptomatic forms affect 30-50% of patients (variable percentage based on age); the 1% of these need surgery. The colonic anatomical-functional disorder is the principal cause of diverticular disease that recognize the main localization in colon-sigma. Diverticulitis with pericolic inflammation are frequent complications; possible evolutions are local tamponed peritonitis, mechanical intestinal occlusion, hemorrhage from colonic wall and fistulas. Sigmoid-vaginal fistula is the most frequent in women previously treated with laparohysterectomy. The colonoscopy and RX barium enema are gold standard for instrumental diagnosis; the vaginography is diriment, urography excludes urological diseases. The surgical treatment is the fistula resection, with or without colonic resection. In consideration of the necessity of conservative surgery and on the basis of this case, the authors suggest, if it's possible, the simple fistula resection, although the literature report an high number of relapses.

[Nasogastric tubes: a lot of bother]. / Il tubo naso-gastrico: un grande fastidio.

The insertion of the nasogastric tube is one of the procedure that produces the most discomfort for the patients and practitioners. The AA, with the make use of their clinical experience and the data of the literature, report some personal reflections about the management of the nasogastric tube. The AA also analyse some variables (choice of the tube, approach to the patient, insertion of the tube, examination of the position, fixation and removal) that can influence on discomfort of the patient. The choice of the most right SNG is an important moment for the correct insertion; an effect we need to adjust the material and diameter of the tube to the prearranged use. The common practice demonstrates that the collaboration with the patient, obtained by "direct" and "indirect" strategies, gives more possibilities to immediately success of this procedure. The literature explains that it is possible to decrease the discomfort with topical anesthesia; still there are some points of view to clarify. From analyse of the different methods to check the position of SNG, the pH test of the aspirating fluid is the best solution. Once examination of right placement, we need to fix in different points (at least two). From personal experience the removal of SNG is better tolerate that the insertion because the patient is more conscious to be on the mend. The principal recommendation is to abstain from insertion of SNG if it is not closely necessary!

[A rare case of intestinal carcinoid tumour. Clinical considerations and therapeutic approach]. / Su di un raro caso di tumore carcinoide ileale. Considerazioni cliniche e di trattamento.

The AA report on a case of intestinal carcinoid tumour. The characters of these tumours to permit a specific clinical and therapeutic approach.

[Amyand's hernia. Case report]. / Ernia di Amyand. Caso clinico.

The authors report a case of Amyand's hernia and describe the pathophysiology, the diagnosis and the therapy in occurrence of this surgical condition.

Blunt rectal trauma Case report and literature review.

Blunt colorectal traumas are rare clinical entities with a challenging diagnostic and operative management. We describe the case of a 40-year-old man, victim of an accidental fall from a height of four meters who was subsequently diagnosed to have a blunt rectal trauma. A first CT scan showed fracture of the skull and an extensive subcutaneous haematoma of the lower back associated with a fracture of the left transverse processes of lumbar vertebrae. No other visceral abdominal lesions were recognized and patient was admitted to our department for observational studies. After 48 hours from admission the patient presented a subcutaneous emphysema suspicious for hollow viscus injuries. A digital rectal examination detected a laceration both of the posterior rectal wall and the superior anal margin. The patient was successfully managed with spur colostomy, transanal evacuation of the retroperitoneal haematoma and primary repair of both the sphincteric muscle and the rectal wall. As soon as the patient achieved full recovery we performed a reversal colostomy. Diagnosis and management of rectal blunt trauma is still a matter of debate and no definitive recommendation treatments are available. The surgical treatment should be tailored on patient medical conditions and clinicians should maintain a high index of suspicious because a delay in diagnosis can result in higher morbidity and mortality rate. KEY WORDS: Colorectal blunt injury, Colostomy, Laparoscopy, Trauma.

Cutaneous metastasis from lung cancer. Case report.

UNLABELLED: Lung cancer is the most common neoplasm diagnosed worldwide. Metastatic presentation of the disease is frequent. Apart from the usual sites of metastatic disease (bone, adrenals, liver, brain), a particular site for metastases is represented by skin. The case we report is about a 66 year-old man with cutaneous metastasis from lung cancer. A 66 year-old man, with a previous history of abdominal aortic aneurism, chronic obstructive pulmonary disease, cardiopathy, diabetes mellitus, was admitted to our institution for left lower lobe lung cancer. After accurate preoperative staging, patient underwent a thoracotomic left lower lobectomy. Histological examination revealed a squamocellular carcinoma: G2-3, pT2bN0. Patient underwent oncological evaluation for the scheduled follow up. After 6 months patient went back to our observation for the appearance of a skin nodule, firm, dischromic, painful and ulcerated, localized in right iliac fossa. Biopsies demonstrated the nodule to be squamocellular carcinoma. Patient underwent a CT scan of the abdomen and thorax, which revealed the absence of infiltration of the deep fascial and muscular planes by the neoplasm. Patient underwent surgical removal of the lesion. Final histological examination confirmed the lesion to be metastasis of squamocellular lung cancer. Metastases from lung cancer occur in about 2,5-7,5% of cases. Median survival for these patients is 2,9 months. The most common type of neoplasm, according to Japanese Authors, is adenocarcinoma followed by squamocellular carcinoma. Some studies demonstrated the adequacy of surgery followed by chemotherapy, in case of single lesion. In case of multiple cutaneous metastases, many Authors suggest only chemotherapy, although the ideal scheme hasn't been discovered yet. Cutaneous metastases from lung cancer are rare; however the appearance of skin lesions, in patients with a positive oncological history, requires much attention. Accurate evaluation of the patient is paramount in choosing the adequate therapeutic algorithm. KEY WORDS: Chemotherapy, Lung Cancer, Skin Metastases.