Adapting response to a measles outbreak in a context of high vaccination and breakthrough cases: an example from Vaud, Switzerland, January to March 2024.

A measles outbreak with 51 cases occurred in the canton of Vaud, Switzerland, between January and March 2024. The outbreak was triggered by an imported case, and 37 (72.5%) subsequent cases were previously vaccinated individuals. Epidemiological investigations showed that vaccinated measles cases were symptomatic and infectious. In a highly vaccinated population, it is important to raise awareness among healthcare professionals to suspect and test for measles virus when an outbreak is declared, irrespective of the vaccination status of the patients

Incidence of human granulocytic anaplasmosis in returning travellers with fever.

Although tick-borne pathogens have been reported as an important cause of imported fever, the incidence of Anaplasma phagocytophilum, the causative agent of human granulocytic anaplasmosis (HGA), in travellers is unknown. We conducted a prospective cohort study to investigate the aetiologies of fever in returning travellers (November 2017-July 2019). Polymerase chain reaction for msp2 gene amplification and indirect immunofluorescence assay for A. phagocitophilum were performed in all returning travellers with undifferentiated non-malarial fever. Among 141 travellers included, 8 patients were diagnosed with probable or confirmed HGA. The overall incidence rate of HGA was 19.9 cases/1000 person-week of travel. The main destination of travel was Asia, accounting for 62.5% patients with HGA. Co-infections were found in 37.5% of patients with HGA. Diagnosis of HGA and empirical treatment with doxycycline should be considered in travellers with fever

Emergency hernia repair in the elderly. multivariate analysis of morbidity and mortality from an Italian registry

Purpose The incidence of inguinal hernia is higher in elderly because of aging-related diseases like prostatism, bronchitis, collagen laxity. A conservative management is common in elderly to reduce surgery-related risks, however watchful waiting can expose to obstruction and strangulation. The aim of the present study was to assess the impact of emergency surgery in a large series of elderly with complicated groin hernia and to identify the independent risk factors for postoperative morbidity and mortality. The predictive performance of prognostic risk scores has been also assessed. Methods This is a prospective observational study carried out between January 2017 and June 2018 in elderly patients who underwent emergency surgery for complicated hernia in 38 Italian hospitals. Pre-operative, surgical and postoperative data were recorded for each patient. ASA score, Charlson's comorbidity index, P-POSSUM and CR-POSSUM were assessed. Results 259 patients were recruited, mean age was 80 years. A direct repair without mesh was performed in 62 (23.9%) patients. Explorative laparotomy was performed in 56 (21.6%) patients and bowel resection was necessary in 44 (17%). Mortality occurred in seven (2.8%) patients. Fifty-five (21.2%) patients developed complications, 12 of whom had a major one. At univariate and multivariate analyses, Charlson's comorbidity index >= 6, altered mental status, and need for laparotomy were associated with major complications and mortality Conclusion Emergency surgery for complicated hernia is burdened by high morbidity and mortality in elderly patients. Preoperative comorbidity played a pivotal role in predicting complications and mortality and therefore Charlson's comorbidity index could be adopted to select patients for elective operation

Metabolic Syndrome (MetS), Systemic Inflammatory Response Syndrome (SIRS), and Frailty: Is There any Room for Good Outcome in the Elderly Undergoing Emergency Surgery?

Background: Patients with MetS or SIRS experience higher rates of mortality and morbidity, across both cardiac and noncardiac surgery. Frailty assessment has acquired increasing importance in recent years as it predisposes elderly patients to a worse outcome. The aim of our study was to investigate the influence of MetS, SIRS, and with or without frailty on elderly patients undergoing emergency surgical procedures. Methods: We analyzed data of all patients with nonmalignant diseases requiring an emergency surgical procedure from January 2017 to December 2020. The occurrence of MetS was identified using modified definition criteria used by the NCEP-ATP III Expert Panel: obesity, hypertension, diabetes, or if medication for high triglycerides or for low HDL cholesterol was taken. Systemic inflammatory response syndrome (SIRS) was evaluated according to the original consensus study (Sepsis-1). The frailty profile was investigated by the 5-modified Frailty Index (5-mFI) and the Emergency Surgery Frailty Index (EmSFI). Postoperative complications have been reported and categorized according to the Clavien–Dindo (C–D) classification system. Morbidity and mortality have been mainly considered as the 30-day standard period definition. Results: Of the 2,318 patients included in this study, 1,010 (43.6%) fulfilled the criteria for MetS (MetsG group). Both 5-Items score and EmsFI showed greater fragility in patients with MetS. All patients with MetS showed more frequently a CACI index greater than 6. The occurrence of SIRS was higher in MetSG. LOS was longer in patients with MetS (MetSG 11.4 ± 12 days vs. n-MetSG 10.5 ± 10.2 days, p = 0.046). MetSG has a significantly higher rate of morbidity (353 (35.%) vs. 385 (29.4%), p = 0.005). The mortality rate in patients with MetS (98/1010, 10%) was similar to that in patients without it (129/1308, 10%). Considering patients with MetS who developed SIRS and those who had frailty or both, the occurrence of these conditions was associated with a higher rate of morbidity and mortality. Conclusion: Impact of MetS and SIRS on elderly surgical patient outcomes has yet to be fully elucidated. The present study showed a 43.6% incidence of MetS in the elderly population. In conclusion, age per se should be not considered anymore as the main variable to estimate patient outcomes, while MetS and Frailty should have always a pivotal role

Perforated peptic ulcer (PPU) treatment: an Italian nationwide propensity score-matched cohort study investigating laparoscopic vs open approach

BackgroundPerforated peptic ulcer (PPU) remain a surgical emergency accounting for 37% of all peptic ulcer-related deaths. Surgery remains the standard of care. The benefits of laparoscopic approach have been well-established even in the elderly. However, because of inconsistent results with specific regard to some technical aspects of such technique surgeons questioned the adoption of laparoscopic approach. This leads to choose the type of approach based on personal experience. The aim of our study was to critically appraise the use of the laparoscopic approach in PPU treatment comparing it with open procedure.MethodsA retrospective study with propensity score matching analysis of patients underwent surgical procedure for PPU was performed. Patients undergoing PPU repair were divided into: Laparoscopic approach (LapA) and Open approach (OpenA) groups and clinical-pathological features of patients in the both groups were compared.ResultsA total of 453 patients underwent PPU simple repair. Among these, a LapA was adopted in 49% (222/453 patients). After propensity score matching, 172 patients were included in each group (the LapA and the OpenA). Analysis demonstrated increased operative times in the OpenA [OpenA: 96.4 +/- 37.2 vs LapA 88.47 +/- 33 min, p = 0.035], with shorter overall length of stay in the LapA group [OpenA 13 +/- 12 vs LapA 10.3 +/- 11.4 days p = 0.038]. There was no statistically significant difference in mortality [OpenA 26 (15.1%) vs LapA 18 (10.5%), p = 0.258]. Focusing on morbidity, the overall rate of 30-day postoperative morbidity was significantly lower in the LapA group [OpenA 67 patients (39.0%) vs LapA 37 patients (21.5%) p = 0.002]. When stratified using the Clavien-Dindo classification, the severity of postoperative complications was statistically different only for C-D 1-2.ConclusionsBased on the present study, we can support that laparoscopic suturing of perforated peptic ulcers, apart from being a safe technique, could provide significant advantages in terms of postoperative complications and hospital stay

Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study)

Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure

Bilan de santé chez le voyageur asymptomatique au retour des tropiques [Screening the asymptomatic traveler returning from the tropics]

When travelling to a tropical country, the tourist can be exposed to different pathogens that can cause symptoms after a long period of latency. The physician should be informed about the geographical distribution of these diseases (schistosomiasis, Chagas disease, strongyloidiasis), the situations in which an exposure can occur and the presentation of an acute or chronic infection, in order to diagnose them in the presence of symptoms. Moreover, a screening should be offered to certain groups of people considered more at risk of contracting a cosmopolitan illness (HIV) whilst travelling. A specific screening in the returning traveler is thus only justified under particular circumstances that are to be determined by a detailed history or specific signs (screening for schistosomiasis when bathing in fresh water in an endemic area)

LAPAROSCOPIC REPAIR OF AN INCISIONAL HERNIA L2 ZONE - W2 (EUROPEAN HERNIA SOCIETY CLASSIFICATION) INTRAPERITONEAL ONLAY MESH REINFORCEMENT (IPOM-PLUS) IN EMERGENCY

The laparoscopic repair of incarcerated incisional hernias is still debated in the literature. The recent EAES/EHS guidelines state that laparoscopic surgery is not contraindicated and may be considered in selected patients with incarcerated hernia. This video shows the case of an 83-year-old woman with an incarcerated incisional hernia in the left iliac fossa (L2 zone – W2) successfully managed laparoscopically with an intraperitoneal onlay mesh reinforcement (IPOM-plus)

LA CONVERSIONE IN OPEN DI INTERVENTI LAPAROSCOPICI PER OCCLUSIONE MECCANICA INTESTINALE SU BASE ADERENZIALE NON COMPORTA AUMENTO DI MORBIDITÀ E MORTALITÀ

Obiettivi: Il ricorso alla laparoscopia nel trattamento dell’occlusione intestinale su base aderenziale (ASBO) è oggi offerto come prima scelta in pazienti selezionati. L’alto tasso di conversione in open, riportato in letteratura, e il rischio di una lesione iatrogena intraoperatoria continuano a rappresentare elementi di criticità nei confronti di tale procedura. Lo scopo di questo studio è quello di valutare le conseguenze della conversione in open nei pazienti con ASBO trattati inizialmente per via laparoscopica. Materiali e metodi: Dalla revisione di un database di 114 pazienti con diagnosi di ASBO che hanno richiesto un trattamento chirurgico nel periodo gennaio 2015-febbraio 2018, sono stati estratti i dati di una serie consecutiva di 72 pazienti sottoposti a laparoscopia. Sono stati analizzati i dati relativi a caratteristiche demografiche (sesso, età, BMI), anamnestiche (numero di laparotomie pregresse), radiologici TC (calibro massimo medio del tenue) intraoperatori (durata dell’intervento, motivo della conversione) e post-operatorie (complicanze minori e maggiori sec. Clavien-Dindo). Sono stati messi a confronto i dati ed i risultati del gruppo di pazienti in cui il trattamento è stato completato per via laparoscopica (Lap) con quelli dei pazienti che hanno necessitato di conversione laparotomica (Conv). Risultati: L’approccio laparoscopico è stato adottato in 72 pazienti consecutivi (63%). La procedura laparoscopica non è stata condotta a termine in 24 pazienti con un tasso di conversione del 33%. Nessuna conversione si è verificata a seguito di una lesione iatrogena. I motivi della conversione sono risultati: impossibilità ad identificare/risolvere la causa di occlusione (n.13 pazienti, 54%); necessità di eseguire una resezione del tenue (n.10 pazienti, 42%); impossibilità a continuare l’intervento in laparoscopia per motivi anestesiologici (n. 1 paziente, 4%). I due gruppi analizzati risultavano omogenei per sesso, età, BMI, numero di laparotomie pregresse, calibro massimo del tenue. Il gruppo di pazienti Conv ha avuto una degenza postoperatoria significativamente più lunga rispetto al gruppo Lap (7,7 vs. 5 giorni; p=0,0003), oltre ad una maggiore durata dell’intervento (178 vs. 85 min; p<0,0001). Un paziente nel gruppo Lap (2%, lesione misconosciuta) e 2 nel gruppo Conv (8%, lesione misconosciuta e deiscenza piano fasciale) hanno necessitato di reintervento. In entrambi i gruppi è stato registrato un decesso per cause non chirurgiche (2% vs. 4%). I 2 gruppi non hanno mostrato differenze statisticamente significative in termini di morbidità globale, complicanze minori, complicanze maggiori e mortalità. Conclusioni: La laparoscopia offre al paziente con ASBO i vantaggi di un decorso più breve. L’alto tasso di conversione non deve rappresentare un elemento a favore della scelta di un trattamento laparotomico, in quanto la conversione di per sé non comporta un più alto tasso di morbidità e mortalità

A CONSERVATIVE SURGICAL APPROACH TO GALLSTONE ILEUS: AN OUTCOME ASSESSMENT

Introduction: Gallstone ileus is a rare complication of cholelithiasis whose mainstay treatment is surgery1. However, there is no consensus about its most appropriate surgical strategy2. The objective of this study is to define whether a conservative surgical strategy could be considered adequate treatment for this condition Material and methods: The records of 19 patients with a diagnosis of gallstone ileus during the period 2005-2016 were reviewed. Data collected included: patient demographics, the type of surgery performed, operative time, and postoperative morbidity and mortality rates. Based on the surgical strategy undertaken, patients were divided into two groups: group 1 (G1) included those who had a definitive biliary procedure, and group 2 (G2) included those in which surgery was limited to the treatment of the intestinal obstruction. In G2, disease recurrence and the subsequent need to re-operate, and the risk of developing gallbladder carcinoma were evaluated Results: There were 13 females and 6 males, with an average age of 84 years. G2 included 84% (16/19) of the patients. The mean operative time was significantly shorter in G2 (97 vs. 228 minutes; pvalue = 0.0003). The overall postoperative morbidity rate was 37% (7/19), and was higher for G1: 67% (2/3) vs. 31% (5/16). However, the difference was not statistically significant (p-value= 0.52). No mortalities were reported. Upon follow-up, none of G2 patients had recurrent disease or developed gallbladder cancer Conclusion: A conservative surgical approach to gallstone ileus seems to be sufficient in elderly patients with co-morbidities that would benefit from a considerably shorter operative time and less extensive surgery References: 1. Clavien PA, Richon J, Burgan S, Rohner A. Gallstone Ileus. Br J Surg. 1990;77:737-742. 2. Kirchmayr W, Mu¨hlmann G, Zitt M, Bodner J, Weiss H, Klaus A. Gallstone ileus: rare and still controversial. ANZ J Surg. 2005;75:234- 238 Disclosure: No significant relationships