Role of prophylactic central compartment lymph node dissection in clinically N0 differentiated thyroid cancer patients: Analysis of risk factors and review of modern trends

In the last years, especially thanks to a large diffusion of ultrasound-guided FNBs, a surprising increased incidence of differentiated thyroid cancer (DTC), "small" tumors and microcarcinomas have been reported in the international series. This led endocrinologists and surgeons to search for "tailored" and "less aggressive" therapeutic protocols avoiding risky morbidity and useless "overtreatment". Considering the most recent guidelines of referral endocrine societies, we analyzed the role of routine or so-called prophylactic central compartment lymph node dissection (RCLD), also considering its benefits and risks. Literature data showed that the debate is still open and the surgeons are divided between proponents and opponents of its use. Even if lymph node metastases are commonly observed, and in up to 90 % of DTC cases micrometastases are reported, the impact of lymphatic involvement on long-term survival is subject to intensive research and the best indications of lymph node dissection are still controversial. Identification of prognostic factors for central compartment metastases could assist surgeons in determining whether to perform RLCD. Considering available evidence, a general agreement to definitely reserve RCLD to "high-risk" cases was observed. More clinical researches, in order to identify risk factors of meaningful predictive power and prospective long-term randomized trials, should be useful to validate this selective approach

Fixation-free incisional hernia repair in the elderly: our experience with a tentacle-shaped implant

Background: Incisional hernia in aged patients represents a challenge even for experienced surgeons. Besides increased risk of complications due to comorbidities, mesh fixation and assuring a sufficient mesh overlap of the defect are the main issues in carrying out the repair. Aims: In order to assure broader coverage of the abdominal wall and a tension- and fixation-free repair, a specifically designed prosthesis was developed for the surgical treatment of incisional hernias. The results of a fixation-free incisional hernia repair carried out in elderly patients using a tentacle-shaped implant are reported herewith. Methods: A tentacle-shaped flat mesh with a large central body and integrated arms was used to repair incisional hernia in 23 elderly patients. The mesh was placed fixation-free and secured in place through the friction exerted by the tentacles. All tentacle straps were positioned with a special passer needle. Implant placement was preperitoneal in 18 patients and retromuscular sublay in five. Results: In a follow-up of 18 to 59 months (mean 36 months), four seromas occurred. Postoperative fast track helped avoid the typical complications affecting this patient subset. No infection, hematoma, chronic pain, mesh dislocation or recurrence have been reported to date. Discussion: The tentacle strap system allowed for reduced skin incision thus minimizing surgical trauma and ensuring easier and faster implant placement. Conclusion: The tentacle arms of the implant ensured mesh stability and broad defect overlap. Besides a very low complication rate, none of the typical postoperative complications of aged patients occurred

Nodular thyroid disease in the elderly. Novel molecular approaches for the diagnosis of malignancy

Abstract Epithelial thyroid cancers (TC) comprise two differentiated histotypes (DTC), the papillary (PTC) and the follicular (FTC) thyroid carcinomas which, following dedifferentiation, are assumed to give rise to the poorly differentiated thyroid carcinomas and the rare, but highly aggressive and invariably fatal, anaplastic thyroid carcinomas. Although thyroid cancer mortality has not been changed, its annual incidence has increased over the last two decades, mainly because of the improved ability to diagnose malignant transformation in small non-palpable thyroid nodules. Despite DTC patients have a favorable prognosis, aggressive disease is more frequently observed in the elderly showing a higher disease-specific mortality. Of relevance is the high prevalence of nodular thyroid disease in aged patients being higher than 90%, in women older than 60 year, and 60% in men older than 80 year. This implies a careful evaluation of thyroid nodules in this group of patients in order to exclude malignancy. In fact, despite the tremendous progress in the comprehension of the underlying molecular mechanisms deregulated in DTC progression, several aspects of their clinical management remain to be solved and novel diagnostic strategies are sorely needed. Here, we will attempt to review new molecular approaches, which are currently being exploited in order to ameliorate the diagnosis of thyroid nodules

Improvement of urinary tract symptoms and quality of life in benign prostate hyperplasia patients associated with consumption of a newly developed whole tomato-based food supplement: a phase II prospective, randomized double-blinded, placebo-controlled study

Background: Benign prostatic hyperplasia (BPH) is the most common urologic disease among elderly men. The diagnosis of BPH is usually driven by lower urinary tract symptoms (LUTS) that can significantly affect patients’ quality of life. This phase II prospective, randomized double-blinded, placebo-controlled study aimed to determine the efficacy and safety of a novel whole tomato-based food supplement on LUTS of patients diagnosed with BPH. Methods: Forty consecutive patients with histologically proved BPH were randomized 1:1 to receive daily for 2 months a sachet (5 g) of a newly developed whole tomato food supplement (WTFS) (treatment = Group A) or placebo (Group B). Patients were asked to fill the International Prostatic Symptom Score (IPSS) questionnaire before and after treatment. Results: All but 1 patient in Group B successfully completed the scheduled regimen. No side effects were recorded. Unlike placebo, treatment significantly reduced (P < 0.0002) LUTS since mean IPSS decreased from 9.05 ± 1.15 to 7.15 ± 1.04 (paired t-test, two-tailed P-value < 0.001), and improved life quality (P < 0.0001). A trend toward a reduction of total PSA levels was observed in WTFS treated patients (8.98 ng/mL ± 1.52 vs 6.95 ± 0.76, P = 0.065), with changes being statistically significant only in the subgroup of patients with baseline levels above 10 ng/mL (18.5 ng/mL ± 2.7 vs 10.3 ± 2.1, P = 0.009). Conclusions: The new WTFS may represent a valid option for the treatment of symptomatic BPH patients. Unlike pharmacological treatments, the supplement is side effects free and highly accepted among patients

Assessing the potential of marine Natura 2000 sites to produce ecosystem-wide effects in rocky reefs: A case study from Sardinia Island (Italy)

A number of policy measures have been adopted to cope with ongoing ocean degradation. Marine protected areas (MPAs) are among them. MPAs and their coverage have increased worldwide, including in EU waters. Natura 2000 (Nat2000) sites are at the core of the EU biodiversity conservation strategy and have been established to protect habitats and species included in two EU directives. Besides their specific objectives, their potential to contribute to an ecosystem-wide conservation and their complementarity with other national and supranational initiatives (e.g. nationally established MPA networks, the Marine Strategy Framework Directive, the Convention on Biological Diversity Ecosystem-Based Approach) have been called into question. Using visual censuses on rocky reefs, the biomass of whole fish assemblages and of a set of ecologically important species (widely used as indicators of coastal marine ecosystem health) have been assessed to evaluate the potential ecosystem-wide effectiveness of Nat2000 marine sites located along the coasts of Sardinia (Italy). The assessment was performed in six fully protected MPAs, in 12 Nat2000 sites established or extending at sea, and in 18 adjacent unprotected control sites. Results show that the highest fish biomasses are observed in fully protected MPAs. The values observed at Nat2000 sites do not differ or only slightly differ from those observed at control sites. This shows that Nat2000 sites may not presently contribute to effectively protect fish and the related rocky reef ecosystems. These results do not dismiss at all the role of Nat2000 sites relative to the objectives for which they have been established. However, they show that to achieve ecosystem-wide benefits it is crucial to rethink and broaden the scope of Nat2000 sites and adapt their management to that. By providing sounder and more comprehensive management plans, and implementing more consistent ecosystem-wide conservation measures, Nat2000 marine sites could become an extraordinary tool at the EU scale, capable of delivering wider ecological benefits

COVID-19 ICU mortality prediction: a machine learning approach using SuperLearner algorithm

Background: Since the beginning of coronavirus disease 2019 (COVID-19), the development of predictive models has sparked relevant interest due to the initial lack of knowledge about diagnosis, treatment, and prognosis. The present study aimed at developing a model, through a machine learning approach, to predict intensive care unit (ICU) mortality in COVID-19 patients based on predefined clinical parameters. Results: Observational multicenter cohort study. All COVID-19 adult patients admitted to 25 ICUs belonging to the VENETO ICU network (February 28th 2020-april 4th 2021) were enrolled. Patients admitted to the ICUs before 4th March 2021 were used for model training (“training set”), while patients admitted after the 5th of March 2021 were used for external validation (“test set 1”). A further group of patients (“test set 2”), admitted to the ICU of IRCCS Ca’ Granda Ospedale Maggiore Policlinico of Milan, was used for external validation. A SuperLearner machine learning algorithm was applied for model development, and both internal and external validation was performed. Clinical variables available for the model were (i) age, gender, sequential organ failure assessment score, Charlson Comorbidity Index score (not adjusted for age), Palliative Performance Score; (ii) need of invasive mechanical ventilation, non-invasive mechanical ventilation, O2 therapy, vasoactive agents, extracorporeal membrane oxygenation, continuous venous-venous hemofiltration, tracheostomy, re-intubation, prone position during ICU stay; and (iii) re-admission in ICU. One thousand two hundred ninety-three (80%) patients were included in the “training set”, while 124 (8%) and 199 (12%) patients were included in the “test set 1” and “test set 2,” respectively. Three different predictive models were developed. Each model included different sets of clinical variables. The three models showed similar predictive performances, with a training balanced accuracy that ranged between 0.72 and 0.90, while the cross-validation performance ranged from 0.75 to 0.85. Age was the leading predictor for all the considered model

A prospective cohort analysis of the prevalence and predictive factors of delayed discharge after laparoscopic cholecystectomy in Italy: the DeDiLaCo Study

Background: The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge &gt;24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC. Methods: This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units. Results: A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged &gt;24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge &gt;24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (&gt;24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P &lt;0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P&lt;0.0001), operative time &gt;60 min (P&lt;0.0001), drain placement (P&lt;0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P&lt;0.0001) were independent predictors of delayed discharge &gt;24 hours. Conclusions: The majority of delayed discharges &gt;24 hours after LC in our study were unrelated to the surgery itself. ASA class &gt;II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge