Intestinal perforation after surgical treatment for incisional hernia. iatrogenic or idiopathic?

Intestinal perforation (IP) is a life-threatening gastroenterological condition requiring urgent surgical care, which may present itself as an uncommon complication following incisional hernia repair surgery, most often because of iatrogenic traumatism occurring during the procedure. However, we report a case where a spontaneous onset can be hypothesised. A 60-years-old patient underwent repair of an abdominal laparocele, through rectus abdominis muscle plasty, 5 years after development of an incisional hernia due to exploratory laparotomy for the treatment of acute appendicitis. Xipho-pubic scar was excised and umbilicus and supra-umbilical hernia sac dissected, a linear median incision was performed along the sub-umbilical linea alba, reaching preperitoneal plane to assess any intestinal loop adherence to the abdominal wall. After limited viscerolysis, abdominal wall defect was corrected by 'rectus abdominis muscle plasty' and umbilicus reconstruction by Santanelli technique. Postoperative course was uneventful until Day 29, with sudden onset of epigastric pain, fever and bulge. Sixty cubic centimeter pus was drained percutaneously and cavity was rinsed with a 50% H2O2 and H2O V-V solution until draining clear fluid. Symptoms recurred two days later, while during rinsing presented dyspnoea. X-Ray and CT scan diagnosed IP, and she underwent under emergency an exploratory laparotomy, leading to right hemicolectomy extended to last ileal loops and middle third of the transverse, right monolateral salpingo-ovariectomy and a temporary ileostomy by general surgeon. Twenty-three days later an ileostomy reversal surgery was performed and 8 days after she was discharged. At latest follow-up patient showed fair conditions, complaining abdominal pain and diarrhoea, attributable to the extensive intestinal resection. IP following incisional hernia repair, is reported as uncommon and early postoperative complication. In our case, the previous regular postoperative course with late onset lead us to hypothesise a possible idiopathic etiopathogenesis, because of a strangulation followed by gangrene and abscess formation, which might begin before the incisional hernia repair and unnoticed at the time surgery was performed

Post-LGM valley fills from the northern coast of Tuscany: depositional facies and stratigraphic architecture

The stratigraphic architecture of three adjacent valley bodies of post-LGM age buried beneath the northern coast of Tuscany is illustrated in detail. Above a gravel fluvial deposit, the valley fills exhibit a distinctive succession of coastal plain to estuarine facies, punctuated by an aggradational stacking pattern of millennial-scale depositional cycles with distinctive climatic signature. Radiocarbon dates document that the three valleys were active simultaneously and that rapidly created accommodation during transgression was filled under conditions of very high sediment supply

Middle to late Holocene environmental evolution of the Pisa coastal plain (Tuscany, Italy) and early human settlements

A cross-disciplinary (sedimentological, geochemical, micropalaeontological and archaeological) examination of 12 continuous cores, up to 20m long, integrated with stratigraphical, geomorphological and historical investigations, allows for reliable delineation of the middle-late Holocene environmental evolution in the Pisa old town area, with special emphasis on the Etruscan age transition. Depositional facies were identified through integration of sedimentological and micropalaeontological (benthic foraminifers, ostracods, phytoclasts and palynomorphs) data, while sediment dispersal patterns were reconstructed on the basis of geochemical analyses. Facies architecture was chronologically constrained by combined archaeological and radiocarbon dating. The turnaround from early Holocene, transgressive conditions to the ensuing (middle-late Holocene) phase of sea-level highstand is witnessed by a prominent shallowing-upward succession of lagoonal, paludal and then poorly drained floodplain deposits supplied by two river systems (Arno and Serchio). This 'regressive' trend, reflecting coastal progradation under nearly stable sea-level conditions, was interrupted by widespread swamp development close to the Iron-Etruscan age transition. The expansion of vast, low-lying paludal areas across the alluvial plain was mostly induced by the intricate, short-term evolution of the meandering Arno and Serchio river systems. These changes in the fluvial network, which occurred during a period of variable climate conditions, strongly influenced the early Etruscan culture (7th-5th century BC) in terms of human settlement and society behaviour. Conversely, a strong impact of human frequentation on depositional environments is observed at the transition to the Roman age (from the 1st century BC onwards), when the wetlands were drained and the modern alluvial plain started to form. The palaeoenvironmental reconstruction fits in with the original geographical descriptions mentioned in Strabo's Chronicles, and provides chronologically constrained data of fluvial evolution from the Pisa old town area. © 2013 Elsevier Ltd and INQUA

MAPPA cores: an interdisciplinary approach

In the urban and periurban area of Pisa, 18 cores ranging in depth between 7 and 15 m were performed and analysed through an interdisciplinary approach, which led to an improved stratigraphic log representation. The acquired data also improved our knowledge about the palaeoenvironmental and human settlement evolution of Pisa area over the past 6000 years, evidencing the mutual interaction existing between landscape and human activities

Device-related infection in de novo transvenous implantable cardioverter-defibrillator Medicare patients

BACKGROUND: Cardiac device infection is a serious complication of implantable cardioverter-defibrillator (ICD) placement and requires complete device removal with accompanying antimicrobial therapy for durable cure. Recent guidelines have highlighted the need to better identify patients at high risk of infection to assist in device selection. OBJECTIVE: To estimate the prevalence of infection in de novo transvenous (TV) ICD implants and assess factors associated with infection risk in a Medicare population. METHODS: A retrospective cohort study was conducted using 100% Medicare administrative and claims data to identify patients who underwent de novo TV-ICD implantation (7/2016-12/2017). Infection within 720 days of implantation was identified using ICD-10 codes. Baseline factors associated with infection were identified by univariable logistic regression analysis of all variables of interest, including conditions in Charlson and Elixhauser comorbidity indices, followed by stepwise selection criteria with a p≤0.25 for inclusion in a multivariable model and a backwards, stepwise elimination process with p≤0.1 to remain in the model. A time-to-event analysis was also conducted. RESULTS: Among 26,742 patients with de novo TV-ICD, 519 (1.9%) developed an infection within 720 days post-implant. While more than half (54%) of infections occurred during the first 90 days, 16% of infections occurred after 365 days. Multivariable analysis revealed several significant predictors of infection: age <70 years, renal disease with dialysis, and complicated diabetes mellitus. CONCLUSION: The rate of de novo TV-ICD infection was 1.9% and identified risk factors associated with infection may be useful in device selection

I carotaggi MAPPA: un’integrazione interdisciplinare

Una consistente campagna di acquisizione di dati di sottosuolo (18 carotaggi con profondità da 7 a 15 m) condotta con approccio interdisciplinare, finalizzato a una rappresentazione integrata del log stratigrafico, ha permesso di incrementare in modo significativo le conoscenze del contesto paleoambientale ed insediativo della zona urbana e suburbana della città di Pisa durante gli ultimi 6000 anni circa e di valutare il reciproco condizionamento fra l’ambiente naturale e le caratteristiche dell’insediamento uman

Interleukin-15 Plays a Central Role in Human Kidney Physiology and Cancer through the γc Signaling Pathway

The ability of Interleukin-15 (IL-15) to activate many immune antitumor mechanisms renders the cytokine a good candidate for the therapy of solid tumors, particularly renal cell carcinoma. Although IL-15 is being currently used in clinical trials, the function of the cytokine on kidney's components has not been extensively studied; we thus investigated the role of IL-15 on normal and tumor renal epithelial cells. Herein, we analyzed the expression and the biological functions of IL-15 in normal renal proximal tubuli (RPTEC) and in their neoplastic counterparts, the renal clear cell carcinomas (RCC). This study shows that RPTEC express a functional heterotrimeric IL-15Rαβγc complex whose stimulation with physiologic concentrations of rhIL-15 is sufficient to inhibit epithelial mesenchymal transition (EMT) commitment preserving E-cadherin expression. Indeed, IL-15 is not only a survival factor for epithelial cells, but it can also preserve the renal epithelial phenotype through the γc-signaling pathway, demonstrating that the cytokine possess a wide range of action in epithelial homeostasis. In contrast, in RCC in vitro and in vivo studies reveal a defect in the expression of γc-receptor and JAK3 associated kinase, which strongly impacts IL-15 signaling. Indeed, in the absence of the γc/JAK3 couple we demonstrate the assembly of an unprecedented functional high affinity IL-15Rαβ heterodimer, that in response to physiologic concentrations of IL-15, triggers an unbalanced signal causing the down-regulation of the tumor suppressor gene E-cadherin, favoring RCC EMT process. Remarkably, the rescue of IL-15/γc-dependent signaling (STAT5), by co-transfecting γc and JAK3 in RCC, inhibits EMT reversion. In conclusion, these data highlight the central role of IL-15 and γc-receptor signaling in renal homeostasis through the control of E-cadherin expression and preservation of epithelial phenotype both in RPTEC (up-regulation) and RCC (down-regulation)

The potential benefits of low-molecular-weight heparins in cancer patients

Cancer patients are at increased risk of venous thromboembolism due to a range of factors directly related to their disease and its treatment. Given the high incidence of post-surgical venous thromboembolism in cancer patients and the poor outcomes associated with its development, thromboprophylaxis is warranted. A number of evidence-based guidelines delineate anticoagulation regimens for venous thromboembolism treatment, primary and secondary prophylaxis, and long-term anticoagulation in cancer patients. However, many give equal weight to several different drugs and do not make specific recommendations regarding duration of therapy. In terms of their efficacy and safety profiles, practicality of use, and cost-effectiveness the low-molecular-weight heparins are at least comparable to, and offer several advantages over, other available antithrombotics in cancer patients. In addition, data are emerging that the antithrombotics, and particularly low-molecular-weight heparins, may exert an antitumor effect which could contribute to improved survival in cancer patients when given for long-term prophylaxis. Such findings reinforce the importance of thromboprophylaxis with low-molecular-weight heparin in cancer patients