Improved growth of preterm infants receiving mother's own raw milk compared with pasteurized donor milk.

AIM: To determine whether growth, feeding tolerance and infectious events of preterm infants is related to the proportion of intake of mother's own raw milk (maternal milk) versus pooled pasteurized banked breast milk (donor milk). METHODS: This is a prospective observational study of 55 premature infants born less than 32 weeks of gestational age admitted to the neonatal intensive care unit at the Children's Hospital of Toulouse during two 6-month periods from 2003 to 2005. Enrolled infants were exclusively on enteral feeds with maternal milk ± donor milk. RESULTS: Mean gestational age was 28.6 weeks (SD 1.5) and mean birth weight 1105 grams (SD 282). During the time of exclusively breast milk feeds, weight gain (g/kg/day) was correlated to the proportion of maternal milk consumed (p = 0.0048, r = 0.4). Necrotizing enterocolitis was inversely correlated to the amount of maternal milk. The amount of maternal milk did not impact on infectious events. CONCLUSION: Mother's own raw milk improves weight gain compared with donor milk in preterm infants. Lactation strategies should be sought that helps mothers to increase their milk production.

Role of low-mechanical index CEUS in the differentiation between low and high grade bladder carcinoma: a pilot study.

PURPOSE: To assess the efficacy of low-mechanical index contrast-enhanced ultrasonography (CEUS) in the differentiation of a series of histologically proven bladder lesions identified via conventional cystoscopy and biopsied. MATERIALS AND METHODS: 36 patients (mean age: 62 years; range 45 - 72 years) with bladder lesions previously detected by color power Doppler ultrasonography (CDUS) were prospectively examined with low-mechanical index contrast-enhanced US after bolus administration of 2.4 ml of Sonovue (Bracco, Milan, Italy). All lesions were evaluated in real-time continuous scanning for 2 minutes and the videos were registered. Two ultrasound (US) experts evaluated the videos by consensus and assigned a score to the enhancement pattern. Subsequently, a specific sonographic quantification software (Qontrast, Bracco, Milan, Italy) based on pixel by pixel signal intensity over time was used to obtain contrast-enhanced sonographic perfusion maps for each lesion. Time-intensity curves (TICs) of each lesion were then extracted from the region of interest positioned within the lesion and in the closest bladder wall. The sensitivity and specificity of CDUS and CEUS were compared using McNemar's test. All patients subsequently underwent conventional cystoscopy with biopsy or transurethral resection. RESULTS: 22 high-grade and 14 low-grade transitional cell carcinomas (TCCs) were histologically diagnosed (mean diameter 2.1 cm; range: 1 - 4.5 cm). The sensitivity and specificity of CDUS were 86.4% (19 / 22; 95% CI = 66.7 - 95.3%) and 42.9% (6 / 14; 95% CI = 21.4 - 67.4%), respectively. The sensitivity and specificity of CEUS were 90.9% (20 / 22; 95% CI = 72.2 - 97.5%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. The sensitivity and specificity of CEUS using TICs were 95.4% (21 / 22; 95% CI = 78.2 - 99.2%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. There was no significant difference between the sensitivity of CDUS versus CEUS, CDUS versus TIC, and CEUS versus TIC (p > 0.05; McNemar's test). The specificity of CEUS and TIC was significantly higher than that of CDUS (p < 0.05; McNemar test). CONCLUSION: CEUS is a reliable noninvasive method for differentiating low- and high-grade bladder carcinomas since it provides typical enhancement patterns as well as specific contrast-sonographic perfusion curves. However, further studies involving larger patient populations is mandatory to confirm these promising results.

New models of care and multidimensional solutions for oncological patients in the post-acute SARS-COV-2 period: a "Second Phase" also for cancer patients.

In Italy, SARS-CoV-2 outbreak registered a high transmission and disease rates. During the acute phase, oncologists provided to re-organize services and prioritize treatments, in order to limit viral spread and to protect cancer patients. The progressive reduction of the number of infections has prompted Italian government to gradually loosen the national confinement measures and to start the "Second phase" of measures to contain the pandemic. The issue on how to organize cancer care during this post-acute SARS-CoV-2 phase appears crucial and a reassessment of healthcare services is needed requiring new models of care for oncological patients. In order to address major challenges in cancer setting during post-acute SARS-CoV-2 phase, this work offers multidimensional solutions aimed to provide a new way to take care of cancer patients.

Contributi scientifici in memoria di Antonio Fusco.

Come si leggerà nell'Introduzione della sezione propriamente scientifica del Volume, il presente testo nasce dalla volontà e, soprattutto, dall'esigenza culturale di omaggiare il fu Prof. Antonio Fusco. Un debito scientifico ed umano che trova il suo locus naturale in questa prima parte del testo stesso, cui farà poi seguito la parte propriamente scientifica. In siffatta parentesi dovuta per le ragioni appena menzionate, il lettore, l'amico o l'allievo dell'opera del Prof. Fusco potranno trovare un suo sintetico Curriculum Vitae, correlato da una specifica ed accurata prosa, svolta dal già Magnifico Rettore Carlo Cipolli; il quale, oltre che evidenziare, ricordando, i meriti del collega oramai scomparso, aggiunge alsuo scritto un elemento che sarebbe imprescindibile a non trasformare lo stesso in una mera sequenza di parole: l'amicizia e l'affetto per un amico che, oramai, non c'è più. A fine lettura, evidente risuonerà il fatto che la vita di ognuno, se mossa dalla passione per ciò per cui si è predisposti cognitivamente e psicologicamente, può essere ricca di riconoscimenti, riconoscenze e soddisfazioni che, lungi dal divenire un cuscino di allori su cui adagiarsi, per una mente creativa come quella del Prof. Fusco hanno funto solo da motivazioni ad agire instancabilmente guardando sempre al futuro. Il lavoro di una vita che, materialmente, è sancito da un supporto poco più di cm 25x15: una targa. Una materialità evidente che, con grande commozione e riconoscenza, è stata affissa il 25 ottobre 2019 sull'aula fronte l'Aula Magna del Campus "La Folcara", a testimonianza che quello spirito creativo in continua evoluzione non si ferma; non si arresta neppure con la fine biologica di chi lo ha "posseduto". Rimangono le opere ed il pensiero del Prof. Fusco e restano gli affetti. A tal proposito, il lettore troverà una breve e sentita sezione su Testimonianze; coloro i quali hanno avuto modo, nell'arco della vita accademica ed umana, personale, di Fusco di conoscerlo. Ecco, allora, che i ricordi saranno i veri protagonisti di questa parentesi. Dopo di ciò, prima dei contributi prettamente scientifici dei lavori, tenutisi in occasione del Convegno Internazionale Psicologia, Arte, Letteratura. Antiche e Nuove Tendenze, seguiranno i saluti delle autorità che in quei due giorni si sono succedute a rappresentare non solo l'istituzione affiliata, ma anche la relazione di stima e di affetto che le legava al compianto Professore. Si passerà, infine, al volume tradizionalmente inteso.

Prevention of overweight in preschool children: results of kindergarten-based interventions.

OBJECTIVE: Given the increasing prevalence of pediatric obesity, we evaluated two kindergarten-based strategies for reducing overweight in preschool children in the Haute-Garonne Department in France. METHODS: Kindergartens (n=79) were randomly assigned to one of the two strategies and followed for 2 years. In the first group (Epidémiologie et prévention de l'obésité infantile, EPIPOI-1), parents and teachers received basic information on overweight and health, and children underwent screening to identify those with overweight (body mass index (BMI) > or = 90th percentile) or at risk for overweight (BMI between 75 and 90th percentile), who were then followed up by their physicians. EPIPOI-2 children, in addition, received kindergarten-based education to promote healthy practices related to nutrition, physical activity and sedentary behaviors. Data on control children from non-intervention kindergartens (n=40) were retrieved from medical records at the Division of School Health. RESULTS: At baseline, groups differed significantly on age and school area (underprivileged/not). Owing to a significant interaction between school area and group, analyses were stratified by school area. At baseline, groups did not differ on overweight prevalence and BMI z-scores for any school area. After intervention, prevalence of overweight, BMI z-score and change in BMI z-score were significantly lower in intervention groups compared with controls in underprivileged areas. Using multilevel analysis adjusted for potential confounders, a significant effect on overweight prevalence at the end of the study was noted for EPIPOI-1 in underprivileged areas only (odds ratio and 95% confidence interval: 0.18 (0.07-0.51). In non-underprivileged areas, the gain in BMI z-score was lower in EPIPOI-2 group compared with control and EPIPOI-1. CONCLUSION: Our results suggest that simple measures involving increasing awareness on overweight and health, and periodic monitoring of weight and height with follow-up care when indicated, could be useful to reduce overweight in young children from underprivileged areas. A reinforced strategy with an education component, in addition, may be indicated in children in non-underprivileged areas.

Inter-observer agreement in clinical decision-making for abnormal cardiotocogram (CTG) during labour: a comparison between CTG and CTG plus STAN.

OBJECTIVE: To compare inter-observer agreement for clinical decision-making with cardiotocography (CTG) and combined CTG with ST-segment analysis (STAN). DESIGN: Experimental study. SETTING: Three hospital obstetrics departments in France. POPULATION: Thirty randomly selected nonreassuring CTG recordings during labour of women with singleton term pregnancies in cephalic position. METHODS: Seven obstetricians independently assessed the tracings, displayed in a random order on their computers, on two separate sessions, the first without and the second with STAN information. The observers received clinical information about the labour as the tracings continued and were asked whether they would intervene. For analysis, we considered that intervention was justified for the neonates with pH < 7.05 and that nonintervention was justified for those with a pH > 7.10 after spontaneous delivery. MAIN OUTCOME MEASURES: Kappa values and rates of inter-observer agreement for intervention and for nonintervention. RESULTS: Kappa for inter-observer agreement was 0.50 (0.29-0.69) with CTG, and 0.67 (0.48-0.81) with CTG + STAN. The rate of inter-observer agreement for the decision to intervene was 73% (68-77%) with CTG and 70% (66-75%) with CTG + STAN (P = 0.4), and for the nonintervention decision it was 48% (42-54%) and 69% (64-74%), respectively (P < 0.0001). The rate of agreement for justified intervention was 94% (91-97%) with CTG and 85% (80-90%) with CTG + STAN (P < 0.001) and for justified nonintervention, 56% (48-63%) with CTG and 84% (79-89%) with CTG + STAN (P < 0.0001). CONCLUSIONS: In cases with abnormal CTG, ST analysis may improve consistency in clinical decision-making and decrease unnecessary interventions, but may also lead on rare occasions to unjustified decisions not to intervene.

[TSH, FT4 and T3T evaluation in normal and preterm hospitalized newborns]. / Evaluation des taux de TSH, T4L, T3T des nouveau-nés prématurés et à terme hospitalisés.

UNLABELLED: Thyroid hormones are essential for foetus and newborn development. Preterm newborns present low levels for thyroid hormones. These low levels are related with disorder in psychomotor and neurological development. In the literature, several studies concerning newborns treated with thyroid hormone have been realized in different conditions; however, there is no consensus about preterm newborn supplementation benefit. OBJECTIVE: The aim of the study was to defined hormonal values used for normal and preterm newborns. MATERIAL AND METHODS: We reported TSH, T3T and T4L levels for 195 normal or preterm newborns, eutrophic or small for gestational age (SGA). RESULTS: A positive correlation was found between hormonal level and gestational age. This work allowed us to define a threshold for preterm newborn according to their gestational age. CONCLUSION: Owing to lack of consensus, those values are useful for clinical and biological follow-up of thyroid function for newborns at risk (SGA and preterm before 32 weeks) during the first year of life. Finally, it would be interesting to study systematic supplementation of thyroid hormone for those infants in a prospective study.

Diagnostic value of qualitative and strain ratio elastography in the differential diagnosis of non-palpable testicular lesions.

The purpose of this study was to evaluate prospectively the accuracy of qualitative and strain ratio elastography (SE) in the differential diagnosis of non-palpable testicular lesions. The local review board approved the protocol and all patients gave their consent. One hundred and six patients with non-palpable testicular lesions were consecutively enrolled. Baseline ultrasonography (US) and SE were correlated with clinical and histological features and ROC curves developed for diagnostic accuracy. The non-palpable lesions were all ≤1.5 cm; 37/106 (34.9%) were malignant, 38 (35.9%) were benign, and 31 (29.2%) were non-neoplastic. Independent risk factors for malignancy were as follows: size (OR 17.788; p = 0.002), microlithiasis (OR 17.673, p < 0.001), intralesional vascularization (OR 9.207, p = 0.006), and hypoechogenicity (OR, 11.509, p = 0.036). Baseline US had 89.2% sensitivity (95% CI 74.6-97.0) and 85.5% specificity (95% CI 75.0-92.8) in identifying malignancies, and 94.6% sensitivity (95% CI 86.9-98.5) and 87.1% specificity (95% CI 70.2-96.4) in discriminating neoplasms from non-neoplastic lesions. An elasticity score (ES) of 3 out of 3 (ES3, maximum hardness) was recorded in 30/37 (81.1%) malignant lesions (p < 0.001). An intermediate score of 2 (ES2) was recorded in 19/38 (36.8%) benign neoplastic lesions and in 22/31 (71%) non-neoplastic lesions (p = 0.005 and p = 0.001 vs. malignancies). None of the non-neoplastic lesions scored ES3. Logistic regression analysis revealed a significant association between ES3 and malignancy (χ2  = 42.212, p < 0.001). ES1 and ES2 were predictors of benignity (p < 0.01). Overall, SE was 81.8% sensitive (95% CI 64.8-92.0) and 79.1% specific (95% CI 68.3-88.4) in identifying malignancies, and 58.6% sensitive (95% CI 46.7-69.9) and 100% specific (95% CI 88.8-100) in discriminating non-neoplastic lesions. Strain ratio measurement did not improve the accuracy of qualitative elastography. Strain ratio measurement offers no improvement over elastographic qualitative assessment of testicular lesions; testicular SE may support conventional US in identifying non-neoplastic lesions when findings are controversial, but its added value in clinical practice remains to be proven.

Ureteral injuries during gynecologic procedures.

The reported incidence of iatrogenic ureteral injuries ranges from 0.05 to 30%. These injuries are particularly secondary to gynecologic surgical procedures. Simple abdominal hysterectomy has proved to be the most common procedure leading to such injures. Because some ureteral injuries may be symptomless, leading to silent kidney loss, the incidence may be too low, and a figure of up to 2.5% after gynecologic operations has been suggested. The incidence continues to be about ten cases during abdominal surgery for one case during vaginal surgery. Different risk factors may influence the ureteral injuries rate. An operation at the pelvic brim, distorted anatomy, removal of the adnexa or of ovarian neoplasm, may facilitate the occurrence of an ureteral trauma. The management of ureteral trauma is positively influenced by an early recognition of the trauma. Conventional technique or ureteroneocystostomy or end to end anastomosis with ureteral stent to treat the injury proved successful. Extensive reconstruction draws upon the entire therapeutic armamentarium of the urologist. Surgical options mainly include creation of bladder tubes and autotransplantation. The most important factor influencing the management of ureteral injury is the presence of associated complications. Blandy et al. sustained to attempt repair of these complicated iatrogenic injuries as soon the diagnosis has been made.

[Uretero-arterial fistula as a complication of vascular surgery]. / Fistola uretero-protesica come complicanza della chirurgia vascolare.

Urinary fistulae between ureter and iliac arteries are very uncommon. A case of fistula connecting ureter and bypass between iliac and femoral arteries is reported. This kind of surgical complication, due to arterial lesion during coxo-femoral arthroprosthesis implant has never been reported in the literature.

[TB-test in the diagnosis of "closed" tuberculosis of the urinary tract. Preliminary study]. / Il TB-test nella diagnosi della tubercolosi "chiusa" dell'apparato urinario. Studio preliminare.

BACKGROUND: Tuberculosis (TBC) is a disease that is found throughout the world with a particularly high incidence in under developed countries. Genitourinary tuberculosis has been reported in 8-10% of all cases in developed countries and in 20% in Third World countries. This study aimed to describe a method of diagnosis applicable to so-called "closed" forms of tuberculosis affecting the urinary tract, namely those with negative results for KB bacteriological and culture assay, but in which suspected diagnosis based on clinical grounds and diagnostic procedures call for further analysis; these forms account for 10% of the total cases. METHODS: A prospective study was carried out in order to tritade the antigenic fraction A60 of the group of thermostable macromolecular antigens (TMA); the latter belong to the pool of liposoluble antigens forming the cell wall and represent the main component of tuberculin and purified protein derivative (PPD). The identification and assay of antigen A60, which can stimulate both the antibody and cell-mediated response, was performed using the ELISA method in order to identify IgG and IgM specific antibodies (TB-test). Twenty-nine patients were selected (11 males, 18 females) with a clinical history of recurrent symptomatic manifestations of upper and lower urinary tract infections resistant to common antibiotic treatment. Urinary tests showed that 96.5% of patients presented an acid urinary pH associated with pyuria, and the urographic imaging revealed calico/pyelic lesions of the excretory tracts. RESULTS: Seven patients (24%) showed a form of urinary TBC of an areactive type (AA) or with intermediate reactivity (RI.AI); six patients (20.64%) showed reactive TBC or in the process of resolution; fifteen patients (51.6%) were negative to the TB-test, and after one year's follow-up still showed no positivity to assays for Koch's bacillus. CONCLUSIONS: The authors affirm that the TB-test, a rapid and relatively inexpensive diagnostic method, is a valid aid for the diagnosis of "closed" forms of urinary tract TBC.

[Pseudomyxoma peritonei associated with mucinous cystadenoma of the appendix]. / Pseudomixoma peritoneale associato a cistoadenoma mucinoso dell'appendice.

The authors report a case of a male 86 years old patient with peritoneal pseudomyxoma associated to cystoadenoma of the appendix. Preoperative CT scan showed the presence of a mass in the appendiceal site containing a gelatinous fluid collection and calcifications. Notwithstanding, diagnosis of pseudomyxoma was preoperatively considered less probable due to the rarity of the affection and the advanced age. At laparatomy was revealed the presence of the large mass observed at CT scan, involving the caecum and occupying the retroperitoneal space along the ascending colon. Mucinous ascites was present without invasive mucinous implants in the peritoneum. Operation consisted in a right hemicolectomy with total removal of the retroperitoneal mass and evacuation of the mucinous ascites. Histology confirmed the clinical diagnosis of pseudomyxoma peritonei associated to cystoadenoma of the appendix. The case is of paradigmatic interest as being quite correspondent to the classical Ronnett's definition of pseudomyxoma: a clinicopathological entity characterized by mucinous ascites and non-invasive mucinous implants with a characteristic distribution and containing histologically benign mucinous epithelium derived from an appendiceal mucinous adenoma and having a benign course. According to such definition, the authors stress the importance of an appropriate classification of the observed cases of pseudomyxoma, under whose term is often collected a heterogeneous group of pathological lesions, in order to better evaluate the prognosis and treatment.

Bladder cancer: innovative approaches beyond the diagnosis.

Bladder carcinoma (BC) is the most common urinary malignant tumor. In the light of the unsuccessful current therapies and their side effects, new pharmacological strategies are needed. In addition to the well known therapeutic possibilities described in the first section, we focused our attention on very recent and innovative tools to approach this target (new drug candidates from epigenetic modulators to endothelin receptor inhibitors, improved technological formulations, active principles from plants, and dietary components). Then, in the last paragraph, we analyzed the etiology of recurrent BC, with particular attention to cellular microenvironment. In fact, the incidence of recurrence is up to 90%, and 25% of tumours show progression towards invasiveness.

Laparoscopic partial nephrectomy for endophytic hilar tumors: feasibility and outcomes.

OBJECTIVE: To analyze feasibility and outcomes of laparoscopic partial nephrectomy (LPN) for endophytic hilar tumors in low-intermediate (ASA I-II) risk patients. METHODS: This is a single centre retrospective study. From May 2009 to September 2011, 208 LPNs were performed at our institution. Overall 11 (5.2%) elective LPNs were for hilar tumors not visible on kidney surface. Hilar tumor was defined as a mass located in the renal hilum and in contact with a major renal vessel on preoperative imaging. Procedures were carried out by a single experienced surgeon (G.G.) via retroperitoneal approach by clamping the only main renal artery. RESULTS: Mean (range) age of patients was 45.3 years (38.2-64.1), tumor size 1.6 cm (1.2-2.0), warm ischemia time 24 min (19-32), operative time 140 min (110-200) and estimated blood loss 270 ml (100-750). Two collecting system injuries were observed and repaired intraoperatively. No conversion to open surgery was required. Final pathological examination revealed 10 renal cell carcinomas and 1 oncocytoma. A negative surgical margin was obtained in 10/11 (91%) patients. Renal function and serum hemoglobin were nearly unaltered pre and post-surgery. No tumor recurrence was observed at mean (range) follow-up of 34 months (15-43). CONCLUSIONS: In experienced hands, LPN represents a feasible, safe and effective treatment for selected patients diagnosed with endophytic hilar masses. A larger number of patients and longer follow-up are required to draw definitive conclusions.

Endothelial function and mechanical arterial properties in children born small for gestational age: comparison with obese children.

BACKGROUND: Early cardiovascular events preceding atherosclerosis have been reported in children born small for gestational age (SGA). AIMS: To describe in detail the mechanical and functional arterial properties of SGA children and to compare the data to those of obese children in order to gain a better understanding of the severity of the dysfunction. A control group was required to overcome the lack of normal values. METHODS: Three groups of 7- to 15-year-old children were included. Sixty children born SGA without obesity, 49 children with obesity and not SGA, and 55 controls underwent complete carotid and brachial arterial measurements using ultrasound and flow-mediated dilation. Biological measurements were performed in the obese and SGA groups. RESULTS: Mean blood pressure and intima-media thickness were lower in SGA children than in the obese group (p < 0.001 and p = 0.004, respectively), but not different from the control group. Flow-mediated dilation was lower in SGA than in obese children and in controls (p < 0.001). CONCLUSION: These data show that children born SGA have endothelial dysfunction with normal intima-media thickness.

Novel model of placental tissue explants infected by cytomegalovirus reveals different permissiveness in early and term placentae and inhibition of indoleamine 2,3-dioxygenase activity.

Human cytomegalovirus (HCMV) is the most common cause of viral intrauterine infection. Placental infection suggests hematogenous spread and permissiveness may vary according to the age of pregnancy. We set up and investigate permissivity of early and term placenta to HCMV with an ex vivo model of placental histocultures and evaluate the activity profile of IDO. Fourteen first trimester placentae were obtained following elective abortion and twelve term placentae after elective caesarean section. Fresh placental chorionic villi were isolated, washed and distributed on collagen sponge gels after overnight incubation with the virus. The culture medium was collected and fresh medium renewed regularly. Histology and immunohistochemistry showed preserved villous integrity in cultured placental histocultures. Infection could be seen in tissue sections of both early and term placentae, although early placentae were more permissive. Indoleamine 2,3-dioxygenase (IDO) is highly expressed in the placenta and is known to prevent maternal immune rejection. Constitutive IDO activity was higher in early, compared to term placentae and HCMV infection inhibited IDO activity in early placentae. IFN-γ-induced IDO activity was suppressed by HCMV in both early and term placentae. Our work shows a novel method of placenta organ culture. Our findings suggest that HCMV infects early placentae more strongly than term placentae. Early placental dysfunction through the inhibition of IDO activity may reveal a possible mechanism for miscarriages.

[Evidence versus experience in neonatal practice: the example of extremely premature infants]. / Niveaux de preuves versus pratiques cliniques: l'exemple de l'extrême prématurité

We focused on current nutritional and ventilation strategies of extremely preterm infants and reviewed the evidence and the practical experience in four French neonatal intensive care units. The recommendations from reviews and the local clinical guidelines were compared and were overall in agreement. We wanted then to evaluate if different ventilatory and nutritional styles existed between four French intensive neonatal units, and if these approaches had an effect on short term outcomes. 399 infants delivered at a gestational age <28 weeks between January 2005 and December 2006 were retrospectively studied (unit I = 141, unit II = 97, unit III = 85, unit IV = 76). Data were collected from birth to discharge. The study groups were similar with regard to gestational age, birth weight, gender, prenatal steroids, rate of inborn. There were significant differences in ventilatory and nutritional strategies between the units. Incidence of NEC, IVH grade 3-4 and PVL were similar between the units. Mortality rate during the hospitalization stay was 14.9 %, 35.0 %, 29.4 % and 29 % (p<0.05). A national database would be useful to analyse differences in strategies and long term outcomes.