Tumori dell’intestino tenue: nostra esperienza in urgenza

I tumori dell’intestino tenue sono neoplasie relativamente rare. Sintomi di natura aspecifica ed esami diagnostici di basse sensibilità e validità sono complessivamente responsabili di una diagnosi ritardata e, in caso di malignità, di malattia spesso avanzata e per lo più incurabile con l’intervento. Uno studio retrospettivo è stato effettuato in 42 casi con presentazione clinica di acuzie, dal 1972 al 2001; l’età media dei pazienti è stata di 52 anni (range 14-79 anni); c’è stata una lieve prevalenza del sesso femminile (57.1% vs 42.9%). La presentazione acuta più comune è stata l’occlusione (57.1%), seguita da sanguinamento gastrointestinale (23.8%), perforazione (14.3%) e occlusione/perforazione (4.8%). I tumori benigni si sono presentati nel 38.1% (16 casi), l’adenoma rappresenta il tipo più comune; le forme maligne sono state il 61.9% (26 casi), l’adenocarcinoma e i linfomi rappresentano l’istotipo più comune. La chirurgia radicale è stata possibile solo nel 57% delle forme maligne (24 pazienti): la morbidità è stata del 4.8% (2 casi: 1 deiscenza anastomotica e 1 ascesso subfrenico); la mortalità è stata del 14.3%. Dal nostro studio retrospettivo possiamo affermare che la sopravvivenza per le lesioni maligne è strettamente dipendente dalla precocità della diagnosi TNM e dalla possibilità di una procedura chirurgica radicale, prima che la lesione diventi non resecabile, come è accaduto nel 42% dei nostri casi. Un indice di sospetto estremamente elevato nella valutazione di sintomi, spesso aspecifici, integrato con studi diagnostici specifici, potrebbe rappresentare l’approccio più appropriato. La prognosi per le forme benigne è invece eccellente in tutti i casi

Comparison of quality control for trauma management between Western and Eastern European trauma center

<p>Abstract</p> <p>Background</p> <p>Quality control of trauma care is essential to define the effectiveness of trauma center and trauma system. To identify the troublesome issues of the system is the first step for validation of the focused customized solutions. This is a comparative study of two level I trauma centers in Italy and Romania and it has been designed to give an overview of the entire trauma care program adopted in these two countries. This study was aimed to use the results as the basis for recommending and planning changes in the two trauma systems for a better trauma care.</p> <p>Methods</p> <p>We retrospectively reviewed a total of 182 major trauma patients treated in the two hospitals included in the study, between January and June 2002. Every case was analyzed according to the recommended minimal audit filters for trauma quality assurance by The American College of Surgeons Committee on Trauma (ACSCOT).</p> <p>Results</p> <p>Satisfactory yields have been reached in both centers for the management of head and abdominal trauma, airway management, Emergency Department length of stay and early diagnosis and treatment. The main significant differences between the two centers were in the patients' transfers, the leadership of trauma team and the patients' outcome. The main concerns have been in the surgical treatment of fractures, the outcome and the lacking of documentation.</p> <p>Conclusion</p> <p>The analyzed hospitals are classified as Level I trauma center and are within the group of the highest quality level centers in their own countries. Nevertheless, both of them experience major lacks and for few audit filters do not reach the mmum standard requirements of ACS Audit Filters. The differences between the western and the eastern European center were slight. The parameters not reaching the minimum requirements are probably occurring even more often in suburban settings.</p

Initial evaluation of the "Trauma surgery course"

BACKGROUND: The consequence of the low rate of penetrating injuries in Europe and the increase in non-operative management of blunt trauma is a decrease in surgeons' confidence in managing traumatic injuries has led to the need for new didactic tools. The aim of this retrospective study was to present the Corso di Chirurgia del Politrauma (Trauma Surgery Course), developed as a model for teaching operative trauma techniques, and assess its efficacy. METHOD: the two-day course consisted of theoretical lectures and practical experience on large-sized swine. Data of the first 126 participants were collected and analyzed. RESULTS: All of the 126 general surgeons who had participated in the course judged it to be an efficient model to improve knowledge about the surgical treatment of trauma. CONCLUSION: A two-day course, focusing on trauma surgery, with lectures and life-like operation situations, represents a model for simulated training and can be useful to improve surgeons' confidence in managing trauma patients. Cooperation between organizers of similar initiatives would be beneficial and could lead to standardizing and improving such courses

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

chirurgia endovascolare:endograftsdisponibili per il trattamento dell'aneurisma aortico

Rassegna di tutti gli endografts utilizzati ,loro caratteristiche, uso, utilit

Aortic rupture of acute aortic dissection type treated with thoracic endovascular aortic repair (TEVAR)

Acute aortic dissection (AAD) is one of the most frequent aortic emergencies, which occurs to the vascular specialist. Endovascular reconstruction of the true lumen using minimally invasive stent grafting or stenting has become increasingly popular and widespread among institutions. The aim of this paper is to report a case series composed by twenty-eight patients, who underwent endovascular intervention for acute type B aortic dissections complicated by rupture using thoracic endovascular aortic repair (TEVAR)

il paziente chirurgico complesso

gli autori prendendo in rassena i principali sistemi di punteggio relativi allo score di gravità dei pazienti,focalizzano il buon risultato terapeutico come funzione di un sistema comune gestionale più che alle singole capacità professionali

Surgical management of trauma: from the "golden hour" to the "Golden Day"

The treatment of the "trauma" has individualized objective therapeutic to reach in the first phase of clinical management defined by Mattox in the concept of the Golden Hour, that consist to transport the patient to the fittest hospital and to recognize and to treat the priorities "ABCDE", identifies in ATLS Guideline. The evolution of the organization for the treatment of the trauma has developed the concept of Trauma System to whose apex there are of the structures devoted define Trauma Center, with specificity of structures and functions, personal devoted fully grown with a specific run. In the Trauma Center is possible to get a therapeutic planning according to the priorities of the case in few times so that to not only achieve the objective to treat in emergency the vital lesions, but to do the necessary treatments precociously to prevent the compliances of the patient, that is checked in environment then multidisciplinary intensive care. This systematic treatment by objective it allows to identify some Guideline of surgical treatment for priority in once defined Golden Day