Fibrin Sealants and Axillary Lymphatic Morbidity. A Systematic Review and Meta-Analysis of 23 Clinical Randomized Trials

Background: use of fibrin sealants following pelvic, paraaortic, and inguinal lymphadenec- tomy may reduce lymphatic morbidity. The aim of this meta-analysis is to evaluate if this finding applies to the axillary lymphadenectomy. Methods: randomized trials evaluating the efficacy of fibrin sealants in reducing axillary lymphatic complications were included. Lymphocele, drainage output, surgical-site complications, and hospital stay were considered as outcomes. Results: twenty-three randomized studies, including patients undergoing axillary lymphadenectomy for breast cancer, melanoma, and Hodgkin’s disease, were included. Fibrin sealants did not affect axillary lymphocele incidence nor the surgical site complications. Drainage output, days with drainage, and hospital stay were reduced when fibrin sealants were applied (p < 0.0001, p < 0.005, p = 0.008). Conclusion: fibrin sealants after axillary dissection reduce the total axillary drainage output, the duration of drainage, and the hospital stay. No effects on the incidence of postoperative lymphocele and surgical site complications rate are found

Cytokine storm and histopathological findings in 60 cases of COVID-19-related death: from viral load research to immunohistochemical quantification of major players IL-1\u3b2, IL-6, IL-15 and TNF-\u3b1

This study involves the histological analysis of samples taken during autopsies in cases of COVID-19 related death to evaluate the inflammatory cytokine response and the tissue localization of the virus in various organs. In all the selected cases, SARS-CoV-2 RT-PCR on swabs collected from the upper (nasopharynx and oropharynx) and/or the lower respiratory (trachea and primary bronchi) tracts were positive. Tissue localization of SARS-CoV-2 was detected using antibodies against the nucleoprotein and the spike protein. Overall, we tested the hypothesis that the overexpression of proinflammatory cytokines plays an important role in the development of COVID-19-associated pneumonia by estimating the expression of multiple cytokines (IL-1\u3b2, IL-6, IL-10, IL-15, TNF-\u3b1, and MCP-1), inflammatory cells (CD4, CD8, CD20, and CD45), and fibrinogen. Immunohistochemical staining showed that endothelial cells expressed IL-1\u3b2 in lung samples obtained from the COVID-19 group (p < 0.001). Similarly, alveolar capillary endothelial cells showed strong and diffuse immunoreactivity for IL-6 and IL-15 in the COVID-19 group (p < 0.001). TNF-\u3b1 showed a higher immunoreactivity in the COVID-19 group than in the control group (p < 0.001). CD8 + T cells where more numerous in the lung samples obtained from the COVID-19 group (p < 0.001). Current evidence suggests that a cytokine storm is the major cause of acute respiratory distress syndrome (ARDS) and multiple organ failure and is consistently linked with fatal outcomes

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10&nbsp;years; 78.2% included were male with a median age of 37&nbsp;years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Evaluation of appendicitis risk prediction models in adults with suspected appendicitis

Background Appendicitis is the most common general surgical emergency worldwide, but its diagnosis remains challenging. The aim of this study was to determine whether existing risk prediction models can reliably identify patients presenting to hospital in the UK with acute right iliac fossa (RIF) pain who are at low risk of appendicitis. Methods A systematic search was completed to identify all existing appendicitis risk prediction models. Models were validated using UK data from an international prospective cohort study that captured consecutive patients aged 16–45 years presenting to hospital with acute RIF in March to June 2017. The main outcome was best achievable model specificity (proportion of patients who did not have appendicitis correctly classified as low risk) whilst maintaining a failure rate below 5 per cent (proportion of patients identified as low risk who actually had appendicitis). Results Some 5345 patients across 154 UK hospitals were identified, of which two‐thirds (3613 of 5345, 67·6 per cent) were women. Women were more than twice as likely to undergo surgery with removal of a histologically normal appendix (272 of 964, 28·2 per cent) than men (120 of 993, 12·1 per cent) (relative risk 2·33, 95 per cent c.i. 1·92 to 2·84; P < 0·001). Of 15 validated risk prediction models, the Adult Appendicitis Score performed best (cut‐off score 8 or less, specificity 63·1 per cent, failure rate 3·7 per cent). The Appendicitis Inflammatory Response Score performed best for men (cut‐off score 2 or less, specificity 24·7 per cent, failure rate 2·4 per cent). Conclusion Women in the UK had a disproportionate risk of admission without surgical intervention and had high rates of normal appendicectomy. Risk prediction models to support shared decision‐making by identifying adults in the UK at low risk of appendicitis were identified

Attitudes of Italian Infertile Women Toward Ethical and Regulatory Limits of Medically Assisted Procreation (MAP)

Objective: Outline the views of Italian women, with fertility problems, on Medically Assisted Procreation. Methods: We have collected the opinions of 448 infertile women. The items used in the questionnaire were created with a qualitative method based on the Medically Assisted Procreation's most important bioethics issues and on the basis of the limits imposed by Law. The questions of the first part of the questionnaire were open; in the second part was closed ("Yes/No"); for each method they were asked whether they would introduce a legal limit to prohibit it. The tests have been standardized with test-retest method. Results: We found that much of the disputes that have, over time, been made to Law 40 of 2004 by Italian Courts, are shared by patients with infertility problems. Italian women do not share the legal limit for Medically Assisted Procreation in over 43 women, heterologous in-semination with seed donation and egg donation. Moreover, our sample show that Italian women do not share legal limit to pre-implantation genetic diagnosis and cryopreservation of embryos. Moreover, it emerges that many Italian infertile patients disagree with the Medically Assisted Procreation for homosexual couples. Conclusion: It will be important, in the event of a legislative reform in Italy on the Medically Assisted Procreation, also consider the point of view of women with infertility problems

Personalised healthcare: The DiMA clinical model

Large-scale application of Personalized Medicine requires a multi-disciplinal environment allowing synergic cooperation among different competences. Strict collaboration between medical and medical sciences, as informatics, ethics, politics, are needed to face the challenges of one-sized healthcare. In spite of the increasing interest, how this system can be globally realized remains tentative. Yet, a relatively small, Personalised Healthcare Service is providing a proof-of principle organizational model to guide implementation into clinical practice

Clinical applications of personalized medicine: A new paradigm and challenge

The personalized medicine is an emergent and rapidly developing method of clinical practice that uses new technologies to provide decisions in regard to the prediction, prevention, diagnosis and treatment of disease. A continuous evolution of technology and the developments in molecular diagnostics and genomic analysis increased the possibility of an even more understanding and interpretation of the human genome and exome, allowing a “personalized” approach to clinical care, so that the concepts of “Systems Medicine” and “System Biology” are actually increasing. The purpose of this study is to evaluate the personalized medicine about its indications and benefits, actual clinical applications and future perspectives as well as its issues and health care implications. A careful review of the scientific literature on this field that highlighted the applicability and usefulness of this new medical approach as well as the fact that personalized medicine strategy is even more increasing in numerous fields of applications

Post-mortem magnetic resonance foetal imaging: a study of morphological correlation with conventional autopsy and histopathological findings

The aim of the present study is to offer our experience concerning post-mortem magnetic resonance (PMMR) in foetal death cases and an evaluation of the differences between the findings acquired by PMMR and by forensic autopsy. Fifteen foetuses were recruited from July 2014 to December 2015. These had suffered intrauterine death in women in the 21st to 38th week of gestation who were treated in the emergency department for non-perception of foetal movements. We performed a PMMR on foetuses, 3&nbsp;±&nbsp;1&nbsp;days on average from the time of death, and then a complete forensic autopsy was performed. All 15 foetuses were examined with a whole-body study protocol, starting from the skull, down to and including the lower limbs. The total time of examination ranged from 20 to 30&nbsp;min in each case. The external evaluation and description of post-mortem phenomena (maceration), record of the weight and detection and the various measurements of foetal diameters were evaluated before performing autopsy. A complete histopathological study was performed in each case. Out of 15 cases examined, eight were negative for structural anatomical abnormalities and/or diseases, both in the preliminary radiological examination and the traditional autopsy. In the remaining seven cases, pathological findings were detected by PMMR with corresponding results at autopsy. PMMR can provide useful information on foetal medical conditions and result in improved diagnostic classification. It may enable the planning of a more suitable technique before proceeding to autopsy, including focusing on certain aspects of organ pathology otherwise not detectable. The association between PMMR, post-mortem examination and related histological study of the foetus–placenta unit could help reduce the percentage of cases in which the cause of foetal death remains unexplained. Lastly, it may allow a selective sampling of the organ in order to target histological investigations

One-stage immediate implant-based breast reconstruction,using biological matrices after conservative mastectomies:preliminary experience of the University Hospital of Tor Vergata

Aim. Aim of our study was to achieve one-stage immediate implant based breast reconstruction, using biological matrices after conservative mastectomies, evaluate patients outcome and complications, in patients suffering from stage Tis-T1-T2 (<3 cm) breast cancer who underwent conservative mastectomy and reconstructive surgery. Methods. The inclusion criteria were: aged 20-65 years; nonsmokers; no diabetes or systemic connective disease; BMI<30; Patients should not be subjected to post-mastectomy radiotherapy; informed consent. During our study, through a randomization system, we used two different types of acellular dermal matrices (ADM): SurgiMend® and Tutomesh®. Results. From February 2012 to March 2014, 22 patients were enrolled, for a total of 38 reconstructions (average age 49 years). Ten patients did not have any mesh-related complications. Four patients showed a dehiscence with bilateral implant exposure, which required removal of the implants; minor wound dehiscence (healing within a month) was observed in 4 patients; 2 patients presented an asymmetry of the inframammary folds and a hematoma was found in two patients. Conclusion. The introduction of the ADM has helped to overcome several reconstructive limitations, allowing an immediate prosthetic reconstruction, after a conservative mastectomy. Complications have been drastically reduced due to an accurate selection of patients. In conclusion, one-stage breast reconstruction with acellular biological matrices, in selected patients, may be a new and realistic frontier in breast surgery, with the real possibility of providing women with breast cancer, a better quality of life compared to the traditional two-stage reconstruction