An atypical death from Rapunzel syndrome: a case report

Trichotillomania is a psychiatric disorder characterized by recurring urges to pulling out hairs, eyelashes, or down in other parts of the body. Trichophagia, which is the urge to ingesting the pulled-out hairs, can cause Rapunzel syndrome, an unusual disorder where gastric trichobezoars can be found in the small intestine. Trichobezoars, amorphous masses composed of undigested food formed by hairs, can obstruct the gastrointestinal tract up to simulating symptoms typical of bowel obstruction. Rapunzel syndrome, named after Grimm's tale, may cause death, especially in the pediatric population, being it seldom over the age of 6; moreover, developing countries and environmental and familiar issues are listed as uncertain risk factors. The present case report deals with the death of a 4-year-old female occurred after lunch and following a series of vomit events; while no traumatic or pathological findings were revealed at the external examination, the autopsy revealed three large trichobezoars localized in the stomach and the small intestine. Despite death was due to gastrointestinal obstruction for multiple trichobezoars and collateral bronchoaspiration of dietary material, histological findings were totally non-specific, meaning that it is sometimes difficult to conclude that death is related to the primary pathological condition

Deciphering the Reactive Pathways of Competitive Reactions inside Carbon Nanotubes

: Nanoscale control of chemical reactivity, manipulation of reaction pathways, and ultimately driving the outcome of chemical reactions are quickly becoming reality. A variety of tools are concurring to establish such capability. The confinement of guest molecules inside nanoreactors, such as the hollow nanostructures of carbon nanotubes (CNTs), is a straightforward and highly fascinating approach. It mechanically hinders some molecular movements but also decreases the free energy of translation of the system with respect to that of a macroscopic solution. Here, we examined, at the quantum mechanics/molecular mechanics (QM/MM) level, the effect of confinement inside CNTs on nucleophilic substitution (SN2) and elimination (syn-E2 and anti-E2) using as a model system the reaction between ethyl chloride and chloride. Our results show that the three reaction mechanisms are kinetically and thermodynamically affected by the CNT host. The size of the nanoreactor, i.e., the CNT diameter, represents the key factor to control the energy profiles of the reactions. A careful analysis of the interactions between the CNTs and the reactive system allowed us to identify the driving force of the catalytic process. The electrostatic term controls the reaction kinetics in the SN2 and syn/anti-E2 reactions. The van der Waals interactions play an important role in the stabilization of the product of the elimination process

Agredir para vencer: l’Inno della “Divisione Mista Frecce”

La recente scoperta di un documento inedito della guerra civile spagnola è stata l’occasione per riflettere ancora una volta su questa travagliata epoca della recente storia europea. Il testo in questione è un inno che appartenne alla Divisione Mista “Frecce”, uno speciale reparto italo-spagnolo che partecipò al conflitto che sconvolse la penisola iberica tra il 1936 ed il 1939. L’attenta analisi e contestualizzazione storica del documento ci ha permesso di realizzare un breve ma esaustivo approfondimento su questa poco conosciuta pagina di storia. Uno dei principali obiettivi sarà quello di fornire al lettore un’interpretazione di questo ‘reperto’, non solo dal punto di vista testuale, ma anche musicale ed iconografico.The recent discovery of an unpublished document of the Spanish Civil War has been the occasion to reflect once more on this troubled period of the recent European history. The document at issue is a collection of lyrics which belonged to the Divisione Mista Frecce, a special Italo-Spanish detachment that took part in the conflict that shook the Iberian peninsula between 1936-1939. Thanks to a careful analysis and a historical contextualization of the document we have been allowed to make a short though exhaustive investigation into this little known page of the history. One of the major objectives is to provide the reader with an interpretation of this “find”, not only from the textual point of view, but from the musical and iconographic ones as well

medical prescription vs defensive medicine results of a questionnaire answered by members of the latina board of physicians surgeons and dentists

"Defensive Medicine" is intended as health practitioners' behaviour aimed at limiting any medical - legal disputes and in addition to limiting a doctor's responsibilities; specifically, DM is implemented by prescribing diagnostically useless tests, or by avoiding procedures that are potentially beneficial for the patient, but burdened by risk. The final effect of this medical conduct is to nullify the efficiency of health care, as well as increase times and costs. Our Group asked doctors registered with the Professional Board of Latina to answer a questionnaire aimed at investigating the perception of this issue and their behaviour in this regard, both in terms of prescriptions and insurance coverage. The results show a general attitude of distrust towards a disputed doctor and a series of behaviours aimed at avoiding such situations; the doctors interviewed asked for increased protection and less pressure in order to better carry out their work. ---------- Per "Medicina Difensiva" si intende una condotta, posta in essere dal personale sanitario, volta a limitare eventuali contenziosi medico – legali e finalizzata a limitare le responsabilità del medico; nello specifico, la MD si realizza attraverso prescrizione di esami inutili dal punto di vista diagnostico, ovvero tramite evitamento di procedure potenzialmente benefiche per il paziente, ma gravate da rischio. L'effetto finale di questa condotta medica è quello di vanificare l'efficienza dell'operato sanitario, aumentandone anche tempistiche e costi. Il Nostro Gruppo ha somministrato ai medici iscritti presso l'Ordine Professionale di Latina un questionario, volto ad indagare la percezione del problema esposto e il comportamento adottato a riguardo, sia in termini di prescrizioni che di copertura assicurativa. I risultati mostrano un atteggiamento generale di diffidenza nei confronti del contenzioso medico ed una serie di comportamenti volti ad evitare tali situazioni; i medici intervistati richiedevano una maggior tutela e una minore pressione, al fine di svolgere al meglio il proprio operato. ---------- "Medicina Defensiva" significa un comportamiento llevado a cabo por el personal de salud, dirigido a limitar cualquier disputa médicolegal y dirigido a limitar las responsabilidades del médico; específicamente, la MD se lleva a cabo prescribiendo pruebas innecesarias desde el punto de vista del diagnóstico, o evitando procedimientos que son potencialmente beneficiosos para el paciente, pero cargados por el riesgo. El efecto final de esta conducta médica es anular la eficacia de la atención médica, lo que también aumenta el tiempo y los costos. Nuestro Grupo ha entregado a los doctores inscritos en la Orden Profesional de Latina un cuestionario, dirigido a investigar la percepción del problema expuesto y el comportamiento adoptado al respecto, tanto en términos de prescripciones como de cobertura de seguro. Los resultados muestran una actitud general de desconfianza hacia el conflicto médico y una serie de comportamientos dirigidos a evitar tales situaciones; los médicos entrevistados requieren una mayor protección y menos presión, para realizar mejor su trabajo

Bronchoscopic Intra-Pleural Instillation of Fibrin Glue and Autologous Blood to Manage Persistent Air Leaks after Lung Resection

Background: Persistent air leak is a common complication after lung resection causing prolonged length of stay and increased healthcare costs. Surgical intervention can be an option, but other more conservative approaches should be considered first. Here, we describe the use of flexible bronchoscopy to apply fibrin glue and autologous blood sequentially to the damaged lung. We named the technique "flexible thoracoscopy". Methods: Medical records from patients with persistent air leaks after lung resection were collected retrospectively. Depending on the type of aerostasis that was performed, two groups were created: flexible thoracoscopy and surgery (thoracotomy). Flexible thoracoscopy was introduced at our institution in 2013. We entered the pleural space with a bronchoscope following the same surgical pathway that was used for tube thoracostomy. Perioperative characteristics and outcomes were analyzed using R software (ver. 3.4.4). Results: From 1997 to 2021, a total of 23 patients required an intervention for persistent air leaks. Aerostasis was performed via flexible thoracoscopy in seventeen patients (69%) and via thoracotomy in six patients (31%). The median age was 70 years (22-82). Twenty patients were males (87%). There was no difference in age, sex distribution, BMI, comorbidities and FEV1%. An ASA score of 3 was more represented in the flexible thoracoscopy group; however, no evidence of a difference was found when compared to the thoracotomy group (p = 0.124). Length of in-hospital stay and chest tube duration was also similar between groups (p = 1 and p = 0.68, respectively). Conclusions: Aerostasis achieved either by flexible thoracoscopy or by thoracotomy showed similar results. We believe that flexible thoracoscopy could be a valid alternative to facilitate minimally invasive treatments for persistent air leaks. Further studies are needed to confirm these results

Report on first international workshop on robotic surgery in thoracic oncology

A workshop of experts from France, Germany, Italy, and the United States took place at Humanitas Research Hospital Milan, Italy, on February 10 and 11, 2016, to examine techniques for and applications of robotic surgery to thoracic oncology. The main topics of presentation and discussion were robotic surgery for lung resection; robot-assisted thymectomy; minimally invasive surgery for esophageal cancer; new developments in computer-assisted surgery and medical applications of robots; the challenge of costs; and future clinical research in robotic thoracic surgery. The following article summarizes the main contributions to the workshop. The Workshop consensus was that since video-assisted thoracoscopic surgery (VATS) is becoming the mainstream approach to resectable lung cancer in North America and Europe, robotic surgery for thoracic oncology is likely to be embraced by an increasing numbers of thoracic surgeons, since it has technical advantages over VATS, including intuitive movements, tremor filtration, more degrees of manipulative freedom, motion scaling, and high-definition stereoscopic vision. These advantages may make robotic surgery more accessible than VATS to trainees and experienced surgeons and also lead to expanded indications. However, the high costs of robotic surgery and absence of tactile feedback remain obstacles to widespread dissemination. A prospective multicentric randomized trial (NCT02804893) to compare robotic and VATS approaches to stages I and II lung cancer will start shortly

Erratum to nodal management and upstaging of disease. Initial results from the Italian VATS Lobectomy Registry

[This corrects the article DOI: 10.21037/jtd.2017.06.12.]

Early Hospital Discharge on Day Two Post Robotic Lobectomy with Telehealth Home Monitoring: A Pilot Study

Despite the adoption of enhanced recovery programs, the reported postoperative length of stay after robotic surgery is 4 days even in highly specialized centers. We report preliminary results of a pilot study for a new protocol of early discharge (on day 2) with telehealth home monitoring after robotic lobectomy for lung cancer. All patients with a caregiver were discharged on postoperative day 2 with a telemonitoring device if they satisfied specific discharge criteria. Teleconsultations were scheduled once in the afternoon of post-operative day 2, twice on postoperative day 3, and then once a day until the chest tube removal. Post-discharge vital signs were recorded by patients at least four times daily through the device and were available for consultation by two surgeons through phone application. In case of sudden variation of vital signs or occurrence of adverse events, a direct telephone line was available for patients as well as a protected re-hospitalization path. Primary outcome was the safety evaluated by the occurrence of post-discharge complications and readmissions. Secondary outcome was the evaluation of resources optimization (hospitalization days) maintaining the standard of care. During the study period, twelve patients satisfied all preoperative clinical criteria to be enrolled in our protocol. Two of twelve enrolled patients were successively excluded because they did not satisfy discharge criteria on postoperative day 2. During telehealth home monitoring a total of 27/427 vital-sign measurements violated the threshold in seven patients. Among the threshold violations, only 1 out of 27 was a critical violation and was managed at home. No postoperative complication occurred neither readmission was needed. A mean number of three hospitalization days was avoided and an estimated economic benefit of about EUR 500 for a single patient was obtained if compared with patients submitted to VATS lobectomy in the same period. These preliminary results confirm that adoption of telemonitoring allows, in selected patients, a safe discharge on postoperative day 2 after robotic surgery for early-stage NSCLC. A potential economic benefit could derive from this protocol if this data will be confirmed in larger sample

New "lethal highs": a case of a deadly cocktail of GHB and Mephedrone.

Drug scenes within several countries have changed in recent years to incorporate a range of licit psychoactive products collectively known as ‘‘legal highs’’: these in combination with substances already in use can cause major health problems and even death. Consumption of Gammahydroxybutyric acid (GHB) spread from 1980s to 2000s, when several nations have enacted laws that have made it illegal. Cases of GHB-caused or related deaths are often described in association with alcohol or traditional drugs (heroin, cocaine, amphetamine); few cases of acute lethal toxicity due to Mephedrone have been recently reported; we describe the first case of fatality due to concomitant consumption of GHB and Mephedrone. A 43 years old man died during a drugs-based party: the two substances were not detected at toxicological screening, but were identified by further analysis on the basis of circumstantial data reported by a survivor. Through our work we aim to bring to the attention in the emerging rol