Follow-up strategies for patients with splenic trauma managed non-operatively : the 2022 World Society of Emergency Surgery consensus document

Background In 2017, the World Society of Emergency Surgery published its guidelines for the management of adult and pediatric patients with splenic trauma. Several issues regarding the follow-up of patients with splenic injuries treated with NOM remained unsolved. Methods Using a modified Delphi method, we sought to explore ongoing areas of controversy in the NOM of splenic trauma and reach a consensus among a group of 48 international experts from five continents (Africa, Europe, Asia, Oceania, America) concerning optimal follow-up strategies in patients with splenic injuries treated with NOM. Results Consensus was reached on eleven clinical research questions and 28 recommendations with an agreement rate >= 80%. Mobilization after 24 h in low-grade splenic trauma patients (WSES Class I, AAST Grades I-II) was suggested, while in patients with high-grade splenic injuries (WSES Classes II-III, AAST Grades III-V), if no other contraindications to early mobilization exist, safe mobilization of the patient when three successive hemoglobins 8 h apart after the first are within 10% of each other was considered safe according to the panel. The panel suggests adult patients to be admitted to hospital for 1 day (for low-grade splenic injuries-WSES Class I, AAST Grades I-II) to 3 days (for high-grade splenic injuries-WSES Classes II-III, AAST Grades III-V), with those with high-grade injuries requiring admission to a monitored setting. In the absence of specific complications, the panel suggests DVT and VTE prophylaxis with LMWH to be started within 48-72 h from hospital admission. The panel suggests splenic artery embolization (SAE) as the first-line intervention in patients with hemodynamic stability and arterial blush on CT scan, irrespective of injury grade. Regarding patients with WSES Class II blunt splenic injuries (AAST Grade III) without contrast extravasation, a low threshold for SAE has been suggested in the presence of risk factors for NOM failure. The panel also suggested angiography and eventual SAE in all hemodynamically stable adult patients with WSES Class III injuries (AAST Grades IV-V), even in the absence of CT blush, especially when concomitant surgery that requires change of position is needed. Follow-up imaging with contrast-enhanced ultrasound/CT scan in 48-72 h post-admission of trauma in splenic injuries WSES Class II (AAST Grade III) or higher treated with NOM was considered the best strategy for timely detection of vascular complications. Conclusion This consensus document could help guide future prospective studies aiming at validating the suggested strategies through the implementation of prospective trauma databases and the subsequent production of internationally endorsed guidelines on the issue.Peer reviewe

Phylogenetic ctDNA analysis depicts early-stage lung cancer evolution.

The early detection of relapse following primary surgery for non-small-cell lung cancer and the characterization of emerging subclones, which seed metastatic sites, might offer new therapeutic approaches for limiting tumour recurrence. The ability to track the evolutionary dynamics of early-stage lung cancer non-invasively in circulating tumour DNA (ctDNA) has not yet been demonstrated. Here we use a tumour-specific phylogenetic approach to profile the ctDNA of the first 100 TRACERx (Tracking Non-Small-Cell Lung Cancer Evolution Through Therapy (Rx)) study participants, including one patient who was also recruited to the PEACE (Posthumous Evaluation of Advanced Cancer Environment) post-mortem study. We identify independent predictors of ctDNA release and analyse the tumour-volume detection limit. Through blinded profiling of postoperative plasma, we observe evidence of adjuvant chemotherapy resistance and identify patients who are very likely to experience recurrence of their lung cancer. Finally, we show that phylogenetic ctDNA profiling tracks the subclonal nature of lung cancer relapse and metastasis, providing a new approach for ctDNA-driven therapeutic studies

Lo Scaffolding psicologico alla Relazione Sanitaria in Pediatria. Alcune proposte metodologiche.

Lo Scaffolding Psicologico alla Relazione Sanitaria è una proposta metodologica volta a favorire il riconoscimento dei ruoli assunti dai partecipanti alla visita medica. Nel contributo si presentano alcune esperienze cliniche quali esempio di applicazione in diversi contesti pediatrici

L'influenza dei fattori psicologici nello sviluppo degli attacchi di Angioedema Ereditario in l'età evolutiva

L’Angioedema Ereditario da carenza di C1 Inibitore (C1-INH-HAE)(Cicardi et al., 2014) è una malattia rara che costringe i pazienti a confrontarsi con un’estrema variabilità interindividuale ed intraindividuale delle sue manifestazioni, e che compromette la qualità di vita delle persone che ne sono affette e delle loro famiglie (Banerji, 2013; Caballero et al., 2014). Nonostante i progressi della ricerca nell’individuazione dell’origine genetica, le cause dell’insorgenza dei sintomi restano ancora poco chiare. Recenti lavori scientifici annoverano lo stress psicologico tra i potenziali triggers degli attacchi di angioedema in base a dati auto-riferiti dai pazienti. La connessione tra stress psicologico ed attacchi tuttavia non è mai stata esplorata. (Fouche at al., 2013; Zotter at al., 2014). Obiettivo del contributo è approfondire il rapporto tra processi psicologici, stress e regolazione emotiva nelle manifestazioni di Angioedema Ereditario in età evolutiva. Inoltre, si intende osservare se tali aspetti assumano caratteristiche peculiari in questi pazienti oppure se riflettano condizioni comuni a giovani affetti da diverse patologie croniche

Semi-synthetic derivatives of natural isoflavones from Maclura pomifera as a novel class of PDE-5A inhibitors

Natural (iso)flavonoids have been recently reported to inhibit cyclic nucleotide phosphodiesterases (PDEs) and induce vasorelaxation, albeit the results described in the literature are discordant. The cGMP-selective isoform PDE-5A, in particular, represents the target of sildenafil and its analogues in the treatment of erectile dysfunction (ED) and pulmonary hypertension by promoting relaxation in vascular smooth muscle through the activation of the NO/cGMP pathway. We undertook this study to verify if osajin and pomiferin, two natural prenylated isoflavones and major constituents of Maclura pomifera extracts previously investigated for their anticancer, antibacterial and antidiabetic properties, show inhibitory activity on PDE-5A. These two isoflavones were isolated from the plant extracts and then synthetically modified to obtain a set of semi-synthetic derivatives with slight and focused modifications on the natural scaffold. The compounds were at first screened against PDE-5A in vitro and, based on the encouraging results, further tested for their relaxant effect on isolated rat artery rings. Computational docking studies were also carried out to explore the mode of interaction with the target protein. The obtained data were compared to the behaviour of the well-known PDE-5A inhibitor sildenafil. Our results demonstrate that semi-synthetic derivatives of osajin and pomiferin show an inhibitory effect on the isolated enzyme that, for some of the compounds, is accompanied by a vasorelaxant activity. Based on our findings, we propose the here described isoflavones as potential lead compounds for the development, starting from natural scaffolds, of a new class of PDE-5A inhibitors with vasorelaxant properties

Biliary Sepsis Due to Recurrent Acute Calculus Cholecystitis (ACC) in a High Surgical-Risk Elderly Patient: An Unexpected Complication

Acute calculus cholecystitis (ACC) is increasing in frequency within an ageing population, in which biliary tract infection, including cholecystitis and cholangitis, is the second most common cause of sepsis, with higher morbidity and mortality rates. Patient’s critical conditions, such as septic shock or anaesthesiology contraindication, may be reasons to avoid laparoscopic cholecystectomy—the first-line treatment of ACC—preferring gallbladder drainage. It can aid in patient’s stabilization with also the benefit of identifying the causative organism to establish a targeted antibiotic therapy, especially in patients at high risk for antimicrobial resistance such as healthcare-associated infection. Nevertheless, a recent randomized clinical trial showed that laparoscopic cholecystectomy can reduce the rate of major complications compared with percutaneous catheter drainage in critically ill patients too. On the other hand, among the possibilities to control biliary sepsis in non-operative management of ACC, according to recent meta-analysis, endoscopic gallbladder drainage showed better clinical success rate, and it is gaining popularity because of the potential advantage of allowing gallstones clearance to reduce recurrences of ACC. However, complications that may arise, although rare, can worsen an already weak clinical condition, as happened to the high surgical-risk elderly patient taken into account in our case report

Stress and Psychological Factors in the Variable Clinical Phenotype of Hereditary Angioedema in Children: A Pilot Study

Hereditary angioedema due to C1 inhibitor (SERPING1) deficiency (C1-INH-HAE) is characterized by unpredictable and variable attacks of cutaneous andmucosal edema carrying amajor impact on daily life. While stress and psychological factors are usually suggested as trigger factors of HAE, they have not been sufficiently investigated. Our aim is to study, for the first time in a group of pediatric patients, the role of psychological stress and emotion regulation competence in the variability of attacks ofC1-INH-HAE. The study involved 12 children aged 6–14with a diagnosis of C1-INH-HAE [a diagnosis of C1-INH-HAE must be based on presence of 1 major (1–3) clinical criterion and 1 laboratory criterion] as well as their parents in the following: (1) a qualitative analysis of parent interviews on disease variability and (2) a quantitative evaluation of the psychological profile, perceived stress levels, and emotion regulation competence of the young patients. In the interviews, 91% of parents believe emotional and stress factors are involved in triggering C1-INH-HAE. Fifty-five percent of the young patients report a limitation in their daily activities [Child Behavior Checklist (CBCL)], 83% of them experience an above-average number of stressful events [Coddington Life Events Scale (CLES)], and 91% of them manifest deficits in recognizing and naming emotions [Alexithymia Questionnaire for Children (AQC); Level of Emotional Awareness Scale for Children (LEAS-C)]. Our data show that parents believe psychological stress to be involved in the onset of HAE attacks and children show high levels of stress and broad deficits in the emotion regulation competence. Whether stress is a trigger or a secondary effect of the disease experience, we suggest that improving patients’ emotion regulation competence may increase their resilience to stress, ultimately leading to a better management of the illness

Hereditary Angioedema and Psychological Stress an Exploratory Study” oral presentation at SAM, Skin and Allergy Meeting

Hereditary Angiooedema (HAE) is characterized by a deficit or by a malfunctioning of C1- 1nh; its symptoms vary greatly from one individual to another. Some studies suggest that some of the attacks of HAE may be triggered or affected by stress and emotional states (Zotter et al.,2014), however this link has never been examined in depth. Moreover, recent research has highlighted the influence of the neurological correlatives of stress in theactivation of the compliment cascade, a system already compromised in those suffering from HAE [1] [2]. Aims With this pilot study we intend to explore the connection between stress, emotional states and the variability of the attacks, in a sample of 11 individuals aged between 4 and 17 with HAE, together with their parents. It is a preliminary study, which aims to explore whether emotions have a direct or indirect influence on the development of HAE. Methods We adopt a multi method approach, using widely -used, internationally recognized tests, listed below: - Semi-structured interviews with parents to explore their interpretation on the variability of the attacks; - CBCL to exclude cases of psychopathology; - CLES to evaluate the perceived level of stress; - AQC on alexithymia; - LEAS-C on emotional awareness; - TEMAS on the functions of personality; - A diary of symptoms, noting the frequency, intensity and the location of the attacks. Results Although 92% of parents believed that emotional states played an important role in the triggering of attacks, the young patients were unable or had difficulty articulating their emotional states, more in general with their processes of emotion regulation (De Steno et al., 2013). This may well be connected to the high levels of stress experienced by nearly all the patients seen in the CLES test. These high levels of stress, in 9 out of 11 cases, correlated with the frequency of the attacks. Finally, from the CBCL results no personality disorder emerged connected to HAE. Conclusions. We believe that by encouraging skills aimed at expressing emotions caused by stress, prove useful in the treatment and management of individuals suffering from HAE. The results of this pilot study highlighted the need for further research on the role of psychological factors connected to HAE

Surgical site infection prevention and management in immunocompromised patients: a systematic review of the literature

Abstract Background Immunocompromised patients are at higher risk of surgical site infection and wound complications. However, optimal management in the perioperative period is not well established. Present systematic review aims to analyse existing strategies and interventions to prevent and manage surgical site infections and other wound complications in immunocompromised patients. Methods A systematic review of the literature was conducted. Results Literature review shows that partial skin closure is effective to reduce SSI in this population. There is not sufficient evidence to definitively suggest in favour of prophylactic negative pressure wound therapy. The use of mammalian target of rapamycin (mTOR) and calcineurin inhibitors (CNI) in transplanted patient needing ad emergent or undeferrable abdominal surgical procedure must be carefully and multidisciplinary evaluated. The role of antibiotic prophylaxis in transplanted patients needs to be assessed. Conclusion Strict adherence to SSI infection preventing bundles must be implemented worldwide especially in immunocompromised patients. Lastly, it is necessary to elaborate a more widely approved definition of immunocompromised state. Without such shared definition, it will be hard to elaborate the needed methodologically correct studies for this fragile population

Serial 2-point ultrasonography plus D-Dimer vs whole-leg color-coded doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis - A randomized controlled trial

Context Patients with suspected deep vein thrombosis ( DVT) of the lower extremities are usually investigated with ultrasonography either by the proximal veins ( 2-point ultrasonography) or the entire deep vein system ( whole- leg ultrasonography). The latter approach is thought to be better based on its ability to detect isolated calf vein thrombosis; however, it requires skilled operators and is mainly available only during working hours. No randomized comparisons are yet available evaluating the relative values of these 2 strategies. Objective To assess if the 2 diagnostic strategies are equivalent for the management of symptomatic outpatients with suspected DVT of the lower extremities. Design, Setting, and Patients A prospective, randomized, multicenter study of consecutive symptomatic outpatients ( n= 2465) with a first episode of suspected DVT of the lower extremities who were randomized to undergo 2- point or whole- leg ultrasonography. Data were taken from ultrasound laboratories of 14 Italian universities or civic hospitals between January 1, 2003, and December 21, 2006. Patients with normal ultrasound findings were followed up for 3 months, with study completion on March 20, 2007. Main Outcome Measure Objectively confirmed 3- month incidence of symptomatic venous thromboembolism in patients with an initially normal diagnostic workup. Results Of 2465 eligible patients, 345 met 1 or more exclusion criteria and 22 refused to participate; therefore, 2098 patients were randomized to either 2- point ( n= 1045) or whole- leg ( n= 1053) ultrasonography. Symptomatic venous thromboembolism occurred in 7 of 801 patients ( incidence, 0.9%; 95% confidence interval [ CI], 0.3%1.8%) in the 2- point strategy group and in 9 of 763 patients ( incidence, 1.2%; 95% CI, 0.5%- 2.2%) in the whole- leg strategy group. This met the established equivalence criterion ( observed difference, 0.3%; 95% CI, - 1.4% to 0.8%). Conclusion The 2 diagnostic strategies are equivalent when used for the management of symptomatic outpatients with suspected DVT of the lower extremities. Trial Registration clinicaltrials. gov Identifier: NCT0035309