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Traumas are one of the most relevant pathological events in health care, because of clinical and prognostic relevance. Morbidity and mortality rates are strongly affected by the timely and correct approach to the patient (golden hour). The objective of this study was to investigate the possible influence of the diagnostic time and of the Injury Severity Score (ISS) on outcomes in trauma patients.Out of a total of 240,833 emergency patients, we observed, 447 polytrauma. All patients were assessed according to the Advanced Trauma Life Support (ATLS) guidelines, diagnosed by computed tomography (CT), and summarized using an adapted complex trauma card (italian version).Overall, 2.5% (11/447) of patients died during the assessment, whereas the remaining 436 patients were diagnosed at the Emergency room and afterwards hospitalised. In 76 out of 436 patients (17.43%) the outcome was poor. Particularly, the most significant complications involved the central nervous system, chest and abdomen lesions respectively, with an ISS of 41.7 ± 15.9. The mean time for the diagnostic assessment in patients with poor outcome was 115.2 ± 0.4 minutes.The immediate mortality percentage, as well as the delayed ones, was highest in patients involved in road accidents. The early management certainly plays a crucial role, reducing death rate and permanent disability.The high percentage of patients affected by haemodynamic instability (24.3%) demonstrates the existence of a criticality identifiable in the approach to the patient during the pre-hospital phase: a phase that is dramatically characterised by the exclusion of intensivists from rescue teams.Complex Trauma Card, Mortality, Multiple injuries, Polytrauma, Scores.Il Trauma rappresenta uno dei più importanti eventi patologici in sanità, in termini di rilevanza clinica e prognostica. I tassi di morbilità e mortalità sono fortemente influenzati dal pronto e corretto approccio al paziente (golden hour). Obiettivo di questo lavoro è stato analizzare la possibile influenza del tempo impiegato per la diagnosi e dell’ISS (Injury Severity Score) sull’outcome di questi pazienti.Abbiamo osservato, su un totale di 240.833 pazienti in emergenza, 447 (0,19%) politraumi. Tutti i pazienti sono stati valutati secondo le linee guida dell’Advanced Trauma Life Support (ATLS), diagnosticati mediante la tomografia computerizzata (TC), ed i dati riassunti usando la versione italiana di una Scheda del Trauma Complesso. In totale, il 2,5% (11/447) dei pazienti è morto durante tale valutazione, mentre i 436 pazienti restanti sono stati diagnosticati presso l’unità di emergenza e successivamente ospedalizzati.In 76 su 436 pazienti (17,43%) l’esito è stato sfavorevole. In particolare, le complicazioni più significative hanno coinvolto il sistema nervoso centrale (SNC), il torace e l’addome, rispettivamente, con un ISS di 41.66 ± 15.89. Il tempo medio utilizzato per la valutazioni diagnostiche nei pazienti con outcome sfavorevole è stato 115.20 ± 0,40 min.La percentuale di mortalità immediate, cosi come di quella a distanza, è stata registrata più alta tra i pazienti coinvolti in incidenti stradali. Una gestione precoce gioca certamente un ruolo cruciale nella riduzione del tasso di mortalità e di disabilità permanente.L’alta percentuale di pazienti affetti da instabilità emodinamica (24,3%), dimostra l’esistenza di una criticità identificabile nell’approccio al paziente durante la fase pre-ospedaliera: una fase che è drammaticamente caratterizza dall’esclusione quasi totale dei rianimatori dalle squadre di soccorso.

The possibility of a relation between high myopia and lens opacity was studied. For this research, the Lens Opacity Meter 701 was used. The lens opacity values measured in 91 high-myopic eyes were compared with those measured in a control group of 106 emmetropic eyes. This comparison showed that myopic had always higher lens opacity values than emmetropic ones, and this result was statistically significant after the age of 20.

Several non motor symptoms (NMS) can precede the onset of the classical motor Parkinson's Disease (PD) syndrome. The existence of pre-­motor and even pre-­clinical PD stages has been proposed but the best target population to be screened to disclose PD patients in a pre-­clinical, thus asymptomatic, stage is still matter of debate. The REM sleep behavior disorder (RBD) often affects PD patients at different stages of the disease and could precede the onset of motor symptoms by several years. However, RBD could also precede other synucleinopathies (namely, dementia with Lewy bodies and multisystem atrophy), and less frequently could be related to other neurological conditions or remain idiopathic. Moreover, not all PD patients exhibit RBD. Despite these caveats, RBD probably represents the best feature to disclose pre-­motor PD patients given its high-­risk of developing a full motor syndrome. Other clinical clues in the pre-­motor stages of PD undergoing active investigation include hyposmia, depression, and autonomic dysfunction. Effective biomarkers are needed in order to improve the diagnostic accuracy in the pre-­motor stage of PD, to monitor disease progression and to plan both pharmacological and non-­pharmacological intervention. Functional imaging, in particular radionuclide methodologies, has been often used to investigate dopaminergic and non-­dopaminergic features as well as cortical functioning in patients with RBD in its idiopathic form (iRBD) and/or associated with PD. Recently, new tracers to image ?-­synuclein pathologies are under development. Functional imaging in pre-­motor PD, and in particular in iRBD, could improve our knowledge about the underlying mechanisms and the neurodegenerative progress of PD.

Radioimmunoguided surgery is a new technology capable of detecting minimal neoplastic lesions using radiocolloids. We used this technique in two fields: to detect sentinel lymph nodes in breast cancer and to remove non-palpable breast lesions. Radioimmunoguided surgery was employed in 135 women; in 32 for sentinel lymph nodes and in 103 for radioguided occult lesion localization using a radioactive tracer (Technetium Tc99m) injected subdermally for sentinel nodes, or near to the non-palpable lesions under US guidance. In our experience these two applications of radioimmunoguided surgery are useful and accurate for determining the nature of lesions and for providing definitive treatment in a single surgical intervention.

Transoral endoscopic thyroidectomy by vestibular approach (TOETVA) represents an innovative and scarless technique for thyroid surgery. The procedure is conducted via a three-port technique at the oral vestibule using a 10mm port for the 30° endoscope and two additional 5mm ports for the dissecting and coagulating instruments. Patients meeting the following criteria can be considered as candidates for TOETVA: (a) an ultrasonographically (US) estimated thyroid diameter =10cm; (b) US-estimated gland volume =45mL; (c) nodule size =50mm; (d) presence of a benign tumor, such as a thyroid cyst or a single- or multinodular goiter; (e) Bethesda 3 and/or 4 categories, and (f) papillary microcar-cinoma without the evidence of metastasis. Beyond the classic complications of thyroid surgery, namely cervical hematoma, recurrent laryngeal nerve injury and hypoparathyroidism, novel consequences can occur as mental nerve (MN) injury. In this paper, leading experts in the field report on their current clinical experience with the TOETVA approach for thyroid gland surgery, with emphasis given to tips and tricks to avoid and manage MN injury.

Cortical sources of resting state electroencephalographic (EEG) rhythms are abnormal in subjects with mild cognitive impairment (MCI). Here, we tested the hypothesis that these sources in amnesic MCI subjects further deteriorate over 1 year. To this aim, the resting state eyes-closed EEG data were recorded in 54 MCI subjects at baseline (Mini Mental State Examination I = 26.9; standard error [SE], 0.2) and at approximately 1-year follow-up (13.8 months; SE, 0.5; Mini Mental State Examination II = 25.8; SE, 0.2). As a control, EEG recordings were also performed in 45 normal elderly and in 50 mild Alzheimer's disease subjects. EEG rhythms of interest were delta (2-4 Hz), theta (4-8 Hz), alpha1 (8-10.5 Hz), alpha2 (10.5-13 Hz), beta1 (13-20 Hz), and beta2 (20-30 Hz). Cortical EEG sources were estimated using low-resolution brain electromagnetic tomography. Compared with the normal elderly and mild Alzheimer's disease subjects, the MCI subjects were characterized by an intermediate power of posterior alpha1 sources. In the MCI subjects, the follow-up EEG recordings showed a decreased power of posterior alpha1 and alpha2 sources. These results suggest that the resting state EEG alpha sources were sensitive-at least at the group level-to the cognitive decline occurring in the amnesic MCI group over 1 year, and might represent cost-effective, noninvasive and widely available markers to follow amnesic MCI populations in large clinical trials.

The aim of this study was to assess the efficacy of fissurectomy with skin advancement flap in healing chronic anal fissures without hypertonia of the internal anal sphincter. Twenty-six consecutive patients who failed healing after well-practiced topical medical therapy were enrolled. Anorectal manometry was performed preoperative and 6 months postoperatively. All patients were treated with fissurectomy and advancement flap through healthy skin tissue. All patients healed completely within 30 days from operation. The intensity and the duration of pain post-defecation was reduced significantly with respect to the preoperative values starting from the first defecation. One patient suffered urinary retention, two patients suffered infections, and two partial breakdowns were recorded. At 6 months the maximum resting pressure values were similar to those were detected preoperatively. One month after surgery, anal incontinence was reported in seven patients, four of whom complained about it preoperatively. At 12 months, only three subjects reported incontinence. No patients needed reoperation and no recurrences were detected. The fissurectomy, in combination with advancement flap, is a safe sphincter-saving procedure for the treatment of chronic anal fissures without hypertonia of internal anal sphincter that fails medical conservative treatment.

cytokines, an upregulation of adhesion molecules and MHC I and II molecules on mono/macrophages, and an expansion of inflammatory monocytes. This exaggerated inflammatory response is responsible for necrosis and organ failure and results in uncontrolled proliferation and phagocytic activity of histiocytes [2]. Hypertriglyceridemia (fasting, greater than or equal to 265 mg/100 ml) is one of the current diagnostic criteria for HLH [2]. Several studies link hypertriglyceridemia to inhibition of lipoprotein lipase (LPL) by tumor necrosis factor-α (TNF-α), and TNF-α is a powerful autocrine and paracrine regulator of adipose tissue [3]. Indeed, many different sources of intense and prolonged T-lymphocyte/macrophage activation may be associated with dyslipidemia (particularly with hypertriglyceridemia) through inappropriate release of TNF-a, IFN-g, GM-CSF and respectively, of IL-1/IL-6, leading to adipose tissue lipolysis with increased VLDL secretion, decreased VLDL clearance, increased hepatic fatty acid synthesis, and suppression of fatty acid oxidation with HIV infection being the wellknown paradigm of this mechanism (possibly enhanced by some antiretroviral drugs). In PubMed there are at least 70 papers in which the association leishmaniasis/(hemophagocytic or haemophagocytic) is present. Leishmania parasites have been found to be the most common protozoan trigger of acquired HLH. In a multicenter prospective study conducted to determine the frequency of HLH syndrome in children with VL, ten children out of 24 (41 %) with VL developed HLH syndrome [4]. HLH incidence in European adult population is about 1/800,000/year, with a reported prevalence of parasitic infections of 2.4 % (53 out of 2197 subjects), and of Leishmania spp. of 0.77 % (17 out of 2197) as a trigger. The clinical picture of VL with HLH initially can be indistinguishable from HLH of other etiology, potentially Dear Sir

AIM: Lateral internal sphincterotomy is considered the surgical treatment of choice for chronic anal fissure after failure of medical therapy but it risks continence. The aim of the study was to evaluate fissurectomy with advancement flap for anterior chronic anal fissure (CAAF) resistant to medical therapy. METHOD: Sixteen women with CAAF without hypertonia of the internal anal sphincter, unresponsive to previous medical treatment, were included in the study. Absence of hypertonia was defined as a maximum anal resting pressure (MRP) of less than 85 mmHg. All patients underwent fissurectomy with an advancement skin flap. RESULTS: Complete healing occurred in all patients within 30 days. The intensity and the duration of pain after defecation reduced from the first postoperative defecation. MRP before surgery and at 6 months showed no significant difference. At 1 month, four patients experienced a continence disturbance, two of whom had it preoperatively. At 12 months, two (12.5%) patients continued to experience a continence disturbance. CONCLUSION: Fissurectomy with skin advancement flap resulted in complete healing and full relief of symptoms in all patients. There was a low incidence of continence disturbance.

BACKGROUND: In patients affected by anterior chronic anal fissure (CAAF) with hypertonia of the internal anal sphincter (IAS), the role of IAS hypertonia remains unclear. The aim of this study was to evaluate the efficacy of fissurectomy combined with advancement flap and IAS injection of botulinum toxin in healing the CAAF with hypertonia of IAS resistant to medical therapy. METHODS: Ten consecutive patients were enrolled. Anorectal manometry was performed preoperatively and at 6 months. CAAF with hypertonia was defined as those associated with maximum resting pressure (MRP) values higher than 85 mmHg. All patients underwent fissurectomy and anoplasty with advancement skin flap combined with the intrasphincter injection of 30 UI of botulinum toxin. Complete healing, MRP changes, relief of symptoms and immediate and long-term complications were recorded. RESULTS: Complete healing was observed in all patients within 30 days of the operation. The intensity and duration of pain post-defecation was reduced significantly starting from the first defecation. In all subjects, the preoperative MRP values were significantly reduced at 6 months. One month after surgery, three patients reported anal incontinence, two of them had complained preoperatively. The only postoperative complications were minor. CONCLUSIONS: Fissurectomy combined with advancement flap and intrasphincter injection of botulinum toxin results in complete healing, significant MRP reduction and full relief of symptom in all patients, thus it represents a valid procedure in preventing the occurrence of anal incontinence.