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The Subdural Hematoma in the Elderly (SHE) score has been recently developed to assess the 30-day mortality in acute and chronic subdural hematomas in patients65 years and has shown good reliability. We aimed to validate the SHE score's accuracy to predict 30-day mortality on a homogeneous cohort of patients undergoing surgical chronic subdural hematoma evacuation at our Institution. We also investigated whether the SHE score could reliably predict the occurrence of 30-day chronic subdural hematoma recurrence needing surgery.We included patients from our prospectively collected database from January 2018 to January 2021. Patients with the availability of the following information were enrolled: age, Glasgow Coma Scale score on admission, hematoma volume, medical history, and outcome at 30 days. The SHE score was calculated for each patient, and the association between greater scores and 30-day mortality was investigated and its ability to predict 30-day and disease recurrence. Statistical significance was assessed for P0.05.Three hundred twenty-one patients were included. Of them, 40 (12.5%) displayed mortality within 30-day: specifically, 0% of the group of patients with SHE score = 0, 4.3% of SHE score = 1, 14.5% of SHE score = 2, 39.3% of SHE score = 3, and 37.5% of SHE score = 4, with a statistically significant linear trend between greater SHE scores and 30-day mortality rates (P0.001, area under the curve 0.75 [0.67-0.82]). No significant association of the SHE score with the risk of recurrence needing surgery was detected (P = 0.4).The SHE score proved helpful in predicting 30-day mortality in patients with chronic subdural hematomas, but no utility was observed to predict disease recurrence.

Aims: To report toxicity of a hypofractionated scheme of whole-breast (WB) intensity-modulated radiotherapy (IMRT) with simultaneous integrated boost (SIB) to the tumor bed (TB) using Tomotherapy® with Direct modality. Methods: Patients with early breast cancer, undergoing radiotherapy (RT) in 15 daily fractions to WB (prescription dose 40.05 Gy) and SIB to the TB (48 Gy), between 2013 and 2017, was analyzed. Primary endpoint was acute and intermediate toxicity assessed at the end and within 6 months from RT, according to Radiation Therapy Oncology Group (RTOG) scale. Secondary endpoints included early chronic toxicity at 12-months follow-up, using the Late Effects Normal Tissue Task Subjective, Objective, Management, and Analytic (LENT-SOMA) scale, and cosmesis using Harvard criteria. Results: The study population was of 287 patients. Acute and intermediate toxicity was collected among 183 patients with data available at the end of RT and within 6 months, 85 (46%) experienced G2 toxicity and 84 (46%) G1 toxicity, while 14 (8%) did not report toxicity at any time. A significant reduction of any grade toxicity was observed between the two time points, with the majority of patients reporting no clinically relevant toxicity at 6 months. At univariate analysis, age < 40 years, breast volume > 1000 cm3 and Dmax ≤ 115% of prescription dose were predictive factors of clinically relevant acute toxicity (G ≥ 2) at any time. At multivariable analysis, only age and breast volume were confirmed as predictive factors, with Relative Risks (95% Confidence Intervals): 2.02 (1.13–3.63) and 1.84 (1.26–2.67), respectively. At 12-month follow-up, 113 patients had complete information on any toxicity with 53% of toxicity G < 2, while cosmetic evaluation, available for 102 patients, reported a good–excellent result for 86% of patients. Conclusions: Hypofractionated WB IMRT with a SIB to the TB, delivered with TomoDirect modality, is safe and well-tolerated. Most patients reported no toxicity after 6 months and good–excellent cosmesis. Predictive factors of clinically relevant toxicity might be considered during treatment planning in order to further reduce side effects.

Purpose: We performed a retrospective study to determine the effectiveness and feasibility of articulating linear stapler in laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS), focusing on technical laparoscopic skills that could help pediatric surgeons to avoid intra- and postoperative complications. Methods: Retrospective cohort study of children younger than 18 years who underwent laparoscopic spleen surgery between January 2008 and March 2020. Age, sex, indication for surgery, operative time (OT), intra- and postoperative complications, and postoperative length of hospital stay (LHS) were analyzed. Data from parenchymal resection and vessels sealing techniques were obtained. Results: Thirty patients, 19 LTS and 11 LPS, were included. The mean age of the patients was 10.9 years, and 16 patients were male and 14 were female. For hematologic diseases, LTS was the elective surgery, associated with cholecystectomy in 5 cases. LPS was the common procedure for splenic cysts. The stapler was used in LTS to close the hilum vessels and in LPS for parenchymal resection. No statistically significant differences in OT were observed comparing LTS and LPS. Two conversions occurred in LTS; none in LPS. The mean LHS was 6 days in both groups. No recurrence or major complications appeared in both groups at 1-12 years of follow-up. In particular for LPS, there are no relapse of cyst neither reduction in splenic function. Conclusions: This study shows the effectiveness, feasibility, and safety of mechanic stapler in splenic surgery both for hilum vessels sealing and for parenchymal resection. The use of this device can reduce risk of hemorrhagic recurrences or major surgical complications improving the safety of the operation.

No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.

BACKGROUND: To the best of our knowledge, the association of physical impairment and cognitive decline has never been investigated in frail patients with acute myocardial infarction. AIM: The aim of our study is to assess the correlation between physical and cognitive dysfunction in frail patients with ST-elevation myocardial infarction (STEMI). METHODS: We examined consecutive frail patients with first STEMI treated with primary percutaneous coronary intervention (PPCI). All patients were evaluated via Mini Mental State Examination (MMSE) and 5-m gait speed test after PPCI. RESULTS: A total of 871 frail patients with suspected STEMI were admitted and 301 patients successfully completed the study. We found that the gait speed significantly correlated with the MMSE score (r: 0.771; p: < 0.001). The independent effects on MMSE score were confirmed in a linear multivariate analysis. CONCLUSIONS: Taken together, our findings indicate that an assessment of both cognitive and physical conditions should be included in the comprehensive geriatric evaluation of hospitalized older STEMI patients.

Objective: To compare different stereotactic body techniques—intensity-modulated radiotherapy with photons and protons, applied to radiotherapy of prostatic cancer—with simultaneous integrated boost (SIB) on the dominant intraprostatic lesion (DIL). Methods: Ten patients were selected for this planning study. Dosimetric results were compared between volumetric modulated arc therapy, intensity-modulated radiation therapy (IMRT), and intensity-modulated proton therapy both with two (IMPT 2F) and five fields (IMPT 5F) planning while applying the prescription schemes of 7.25 Gy/fraction to the prostate gland and 7.5 Gy/fraction to the DIL in 5 fractions. Results: Comparison of the coverages of the planning target volumes showed that small differences exist. The IMPT-2F-5F techniques allowed higher doses in the targets; conformal indexes resulted similar; homogeneity was better in the photon techniques (2%–5%). Regarding the organs at risk, all the techniques were able to maintain the dose well below the prescribed constraints: in the rectum, the IMPT-2F-5F and IMRT were more efficient in lowering the intermediate doses; in the bladder, the median dose was significantly better in the case of IMPT (2F–5F). In the urethra, the best sparing was achieved only by IMPT-5F. Conclusions: Stereotactic radiotherapy with SIB for localized prostate cancer is feasible with all the investigated techniques. Concerning IMPT, the two-beam technique does not seem to have a greater advantage compared to the standard techniques; the 5-beam technique seems more promising also accounting for the range uncertainty.

Purpose During the first peak of the COVID-19 pandemic, the activity of Emergency Departments worldwide changed dramatically, focusing on diagnosis and care of the Sars-Cov-2 associated disease. These major changes also involved the activity of the Emergency Radiology Department (ERD). This study aimed to analyse the impact of the COVID-19 pandemic on imaging studies, both in terms of the amount, frequency and subspecialty of different imaging modalities requested to the ERD of the Maggiore della Carità Hospital in Novara (Italy). Methods To this end, our observational study took into account the imaging studies requested by the emergency department during three-time spans. These were defined as phase 0 (pre-pandemic), phase 1 (pandemic peak with complete lockdown) and phase 2 (post-pandemic peak with partial lifting of restrictive measures), as derived from Italian urgent decrees by the President of the Council of Ministers (DPCM) which established the duration and entity of the lockdown measures throughout the pandemic. The dataset was processed and then compared with Pearson’s chi-squared test. Results During the pandemic peak, our data showed a significant drop in the total number of studies requested and a significant rise in computed tomography (CT) studies. In particular, a statistically significant increase in chest CT studies was found, probably due to the high sensitivity of this imaging method in identifying pulmonary involvement during respiratory tract infection of possible viral etiology (SARS-Cov-2). Moreover, we observed a statistically significant decrease of X-ray (XR) and ultrasound (US) studies during phase 1 compared to phase 0 and phase 2 probably due to a reduction in the numbers of ER visits for minor traumas given the mobility restrictions and people hesitancy in visiting the ER due to fear of contagion. Conclusions We can conclude that the activity of the ERD was heavily impacted by the SARS-Cov-2 pandemic. Further studies will be needed to estimate the impact of the pandemic on public health in terms of excess mortality related to delayed diagnosis and care of non-COVID diseases.

Background The aim of this study is to quantify the frequency content of the blood velocity waveform in different body regions by means of phase contrast (PC) cardiovascular magnetic resonance (CMR) and Doppler ultrasound. The highest frequency component of the spectrum is inversely proportional to the ideal temporal resolution to be used for the acquisition of flow-sensitive imaging (Shannon-Nyquist theorem). Methods Ten healthy subjects (median age 33y, range 24–40) were scanned with a high-temporal-resolution PC-CMR and with Doppler ultrasound on three body regions (carotid arteries, aorta and femoral arteries). Furthermore, 111 patients (median age 61y) with mild to moderate arterial hypertension and 58 patients with aortic aregurgitation, atrial septal defect, or repaired tetralogy of Fallot underwent aortic CMR scanning. The frequency power distribution was calculated for each location and the maximum frequency component, fmax, was extracted and expected limits for the general population were inferred. Results In the healthy subject cohort, significantly different fmax values were found across the different body locations, but they were nonsignificant across modalities. No significant correlation was found with heart rate. The measured fmax ranged from 7.7 ± 1.1 Hz in the ascending aorta, up to 12.3 ± 5.1 Hz in the femoral artery (considering PC-CMR data). The calculated upper boundary for the general population ranged from 11.0 Hz to 27.5 Hz, corresponding to optimal temporal resolutions of 45 ms and 18 ms, respectively. The patient cohort exhibited similar values for the frequencies in the aorta, with no correlation between blood pressure and frequency content. Conclusions The temporal resolution of PC-CMR acquisitions can be adapted based on the scanned body region and in the adult population, should approach approximately 20 ms in the peripheral arteries and 40 ms in the aorta. Trial registration This study presents results from a restrospective analysis of the clinical study NCT01870739 (ClinicalTrials.gov).

Endothelial dysfunction is a key hallmark of hypertension, which is a leading risk factor for cognitive decline in older adults with or without frailty. Similarly, hyperglycemia is known to impair endothelial function and is a predictor of severe cardiovascular outcomes, independent of the presence of diabetes. On these grounds, we designed a study to assess the effects of high-glucose and metformin on brain microvascular endothelial cells (ECs) and on cognitive impairment in frail hypertensive patients. We tested the effects of metformin on high-glucose-induced cell death, cell permeability, and generation of reactive oxygen species in vitro, in human brain microvascular ECs. To investigate the consequences of hyperglycemia and metformin in the clinical scenario, we recruited frail hypertensive patients and we evaluated their Montreal Cognitive Assessment (MoCA) scores, comparing them according to the glycemic status (normoglycemic vs. hyperglycemic) and the use of metformin. We enrolled 376 patients, of which 209 successfully completed the study. We observed a significant correlation between MoCA score and glycemia. We found that hyperglycemic patients treated with metformin had a significantly better MoCA score than hyperglycemic patients treated with insulin (18.32 ± 3.9 vs. 14.94 ± 3.8, p &lt, 0.001). Our in vitro assays confirmed the beneficial effects of metformin on human brain microvascular ECs. To our knowledge, this is the first study correlating MoCA score and glycemia in frail and hypertensive older adults, showing that hyperglycemia aggravates cognitive impairment.

Background Despite primary percutaneous coronary intervention (PPCI) is generally considered the best therapy in older frail adults with ST-segment elevation myocardial infarction (STEMI), the incidence of re-hospitalization for cardiovascular diseases remains significant in these patients. Aims We hypothesized that thrombus aspiration (TA) before PPCI could be a useful treatment for reducing mortality and rehospitalizations in frail patients undergoing PPCI for STEMI. Methods We conducted a study comparing PPCI alone vs TA + PPCI in frail STEMI patients. We examined a cohort of consecutive frail patients aged ≥ 65 years with first STEMI treated with PPCI between February 2008 and July 2015 at the Department of Cardiology of the “Cardarelli” Hospital in Naples, Italy. Results The study was completed by 389 patients (PPCI: 195, TA + PPCI: 194). At 1-month follow-up, the rate of death from any cause was 7.0% in patients treated with PPCI alone vs 3.0% in patients treated with TA + PPCI (p 0.036), whereas death from cardiovascular causes was 6.0% in the PPCI group vs 3.0% in the TA + PPCI group (p 0.028). Equally important, the rate of re-hospitalization due to heart failure was 7.5% in the PPCI group vs 4.0% in TA + PPCI group (p 0.025) and the rate of re-hospitalization due to acute coronary syndrome was 10.0% in the PPCI group vs 4.5% in the TA + PPCI group (p 0.016). Conclusion These results indicate the importance of TA in the treatment of STEMI in a group of high-risk patients such as elderly with frailty.

Purpose To evaluate stereotactic body radiation therapy (SBRT) for metachronous oligometastatic ovarian cancer patients in terms of local control, delay of systemic treatment, survival outcomes, and toxicity. Methods and Materials Retrospective data collection from a single institution was performed. The inclusion criteria were as follows: (1) oligorecurrent or oligoprogressive disease in ovarian cancer patients during or after systemic therapy; (2) surgery or other local therapies not feasible; and (3) relative contraindication to systemic therapy for reasons such as unavailability of additional chemotherapy lines or refusal of the patient. Tumor response and toxicity were evaluated using the Response Evaluation Criteria in Solid Tumors and the Common Terminology Criteria for Adverse Events version 4.03, respectively. A new systemic therapy regimen was started after an SBRT treatment course in 57 of 109 cases (52.3%). Local progression–free survival, progression-free survival, and overall survival were calculated via the Kaplan-Meier method. The systemic treatment–free interval was calculated in cases without concomitant systemic therapy. Results Between May 2012 and December 2016, 82 patients (156 lesions) underwent SBRT with a median dose of 24 Gy in 3 fractions. The median follow-up period was 17.4 months. Patients received a median of 3 systemic therapy regimens prior to SBRT. Concomitant systemic therapy was performed for 29 lesions (18.6%). Among 152 evaluable lesions, a complete radiologic response, partial response, stabilization, and progressive disease were observed in 91 (60%), 26 (17%), 24 (16%), and 11 (7%), respectively. No grade 3 or 4 acute or late toxicities were observed. The median systemic treatment–free interval after SBRT was 7.4 months, and 1 of 3 patients was disease free at 1 year after SBRT. The actuarial 2-year local progression–free survival, progression-free survival, and overall survival rates were 68%, 18%, and 71%, respectively. The pattern of failure was predominantly out of field. Conclusions SBRT for oligometastatic ovarian cancer showed good local control and a good toxicity profile. It might be an appealing alternative to other invasive local therapies to delay systemic therapy in the case of chemorefractory disease or intolerance to systemic agents.

Sinonasal mucosal melanoma is a rare and highly aggressive tumour. This tumour often carries a poor prognosis because of local invasion and early distant metastasis. It’s, in fact, an aggressive, fortunately rare, disease. It’s more common among population in their seventies, with a prolonged course due to innocuous symptoms. We report a case of sinonasal mucosal melanoma in a 56-years old male who presented with a brownish sinonasal mass involving right nasal fossa, swelling and spontaneous epistaxis. We report this case for the one-time reconstruction treatment performed by our team.

Background: L-Arginine is an amino acid which is involved in nitric oxide production regulating vascular tone and cardiovascular homeostasis. Hypertension is one of the most common comorbidities worldwide, and leads to endothelial dysfunction contributing to atherosclerosis, inflammation, and oxidative stress. Frailty is a syndrome of decreased physiological reserves with increased susceptibility to stressors leading to higher mortality, hospitalization, disability, and functional and cognitive impairment. Cognitive impairment is a very common feature in hypertensive frail older adults. Hence, it is very important to treat cognitive impairment to delay and/or prevent adverse events. Our study, thus, investigated the effects of 4-weeks supplementation of L-Arginine on global cognitive function. Methods: We studied 101 frail older patients from April 2020 to April 2021. All subjects were recruited from ASL (local health company of Italian Ministry of Health) Avellino, Italy. All patients fulfilled all of the following inclusion criteria: a previous diagnosis of hypertension, a confirmed frail status, age >65 years. The exclusion criteria were: age Results: We are reporting here the results in 52 patients who hitherto successfully completed the study. The cognitive screening was available at baseline (before treatment) and during a follow-up of 4 weeks. The non-treated group (n=27) had a Montreal Cognitive Assessment (MoCA) score 22.9±0.9 at basal and 23.4±1.0 at follow-up (p=0.06). The treated group (oral L-Arginine, 1.66 g, twice a day; n=25) displayed a MoCA score 23.1±0.7 at basal and 24.2±0.6 at follow-up (p Conclusions: Our data show a significant improvement in the MoCA score in the group treated with L-Arginine. More extensive studies are needed to verify the efficacy of L-Arginine in this population.

Background Invasive meningococcal disease is a serious global health threat in the world; in 2016, the European Centre for Disease Control and Prevention reported 3280 confirmed cases (including 304 deaths) of Invasive Meningococcal Diseases in Europe. In Italy, in 2017 were reported 200 cases 41% of which due to menB serogroup. From January 2013 the European Medicines Agency (EMA) has authorized the marketing of the meningococcal B vaccine 4CMenB. Methods The study aimed to evaluate and complement the safety profile of 4CMenB in high risk children accessing the vaccine service of the Bambino Gesù Children’s Hospital. All individuals aged six weeks or more receiving the meningococcal 4CMenB (Bexsero®) vaccine that approached the vaccine Centre at the Bambino Gesù Children’s Hospital in Rome, were asked to participate. All parents or caregivers of vaccinated individuals in the study period, were recruited and requested to answer to a questionnaire on adverse events following immunization (AEFI) observed after 7 days, starting from the date of vaccination. Results During the study period (October 2016–October 2017), we collected 157 completed questionnaires (out of 200 distributed). Of those 132 were first doses and 25 were booster administered doses. The median age of the study population was 4.5 years (range 0.29 to 26.8 years), the majority of subjects were high-risk individuals (64%) with chronic health conditions. Overall, 311 adverse events were reported in the 7 days after vaccine administration. In particular 147 events (47%) after administration of first dose and 58 (19%) after the booster doses. A large majority of those events, were of little clinical importance and concentrated in the 24 h after vaccine administration. No hospitalizations or Emergency Department access were reported. Conclusions Results of our study demonstrated that the Bexsero® vaccine is almost well tolerated, with a low incidence of severe AEFIs. Our results also shown that the occurrence of AEFIs is similar within healthy and high risk children.

Background and Aims Mild Cognitive Impairment (MCI) is a common finding in chronic kidney disease (CKD) patients. Indeed, CKD represents a relevant risk factor for developing dementia and MCI. Cholinesterase inhibitors, such as rivastigmine, are among the few drugs approved for the treatment of dementia and MCI. Rivastigmine is also used to treat vascular dementia because it protects subcortical brain structures. Data are scanty regarding the use of rivastigmine in CKD patients with MCI and are much needed to guide the therapy for MCI in this cohort of patients. Method This retrospective case-control study compared the effects of rivastigmine on cognitive functions in MCI patients with CKD (stage III-IV; n= 20) and without CKD (n=21, control group), comparable for the extent of cognitive impairment (indexed by Montreal Cognitive Assessment, MoCA), age (range 18-65 years), gender, weight, and comorbidities. Patients under treatment with rivastigmine and with a baseline MoCA score available were included in the study. Exclusion criteria were ictus, psychiatric or other neurological conditions, heart failure, liver failure, severe obesity, anemia, electrolyte disorders, cancer, dialysis, and other severe comorbidities. Laboratory test data (glycemia, cholesterol, hemoglobin, proteinuria, creatinine) were used to characterize the two populations. MCI was defined as a MoCA score between 21-26. The cognitive screening was available at baseline (before treatment) and during a follow-up in a range of three-six months after the start of the treatment. CKD was defined by eGFR < 60 mL/min/1.73m2. Results The follow-up timing for cognitive screening was not statistically different between the two cohorts. The control group (MCI without CKD) showed a small, significant improvement in the MoCA score after treatment (baseline MoCA: 22.9±0.5, follow-up MoCA: 23.5±0.5, p=0.02, t-test for paired data). At variance, the MCI-CKD group showed a significant improvement in the MoCA score (baseline MoCA=23±0.4, follow-up MoCA=24.3±0.4, p Accordingly, the extent of improvement of MoCA score after rivastigmine was inversely correlated to the eGFR (r = -0.23). Conclusion A significant improvement in MoCA score accompanied treatment with rivastigmine in the CKD group. More extensive population studies are needed to verify the greater efficacy of Acetylcholinesterase inhibitors in this population.

Osteomas are common benign bone tumors of the skull and facial structures involving primarily the cranial vault, mandible, external auditory canal, paranasal sinuses, nasal cavity, and orbit.1,2 These neoplasms are usually asymptomatic and account for 0.43% of tumor in population with an incidental finding on 1% of radiographs and on 3% of computed tomography (CT) scans. [1] These solid nodular sclerotic lesions usually arise from the outer table and are usually

Background The medical community has been deeply involved in fighting the Coronavirus disease 2019 (COVID-19) pandemic and, as a consequence, the care of non-COVID-19 patients has been impacted. However, the treatment of head and neck cancer patients is not deferrable, and an integrated strategy is required. The aim of the current article is to present the experience in the management of head and neck patients during the COVID-19 pandemic at the research hospital “Casa Sollievo della Sofferenza”. This review contains replicable and widely usable instructions on how to avoid delays in the diagnosis and treatment of head and neck tumors and to ensure a gradual return to elective procedures. Main text The Head and Neck Department of the research hospital “Casa Sollievo della Sofferenza” includes an Otolaryngology and a Maxillofacial Surgery Unit, both of which deal with the diagnosis and treatment of benign and malignant pathologies of the head and neck, as well as urgent/emergent consultations and surgical procedures that necessitate time sensitive operative management, such as cochlear implantation (CI). Given these premises and the complexity of the Department, the “COVID-19 organizing protocol” of the research hospital “Casa Sollievo della Sofferenza” was divided into two phases in accordance with the different stages of the pandemic and the priority of treatment. Special attention was given to the medical surveillance of health care workers and hospitalized patients, to the organization of the outpatient clinic and the operating setting as well as to the implementation of telehealth systems. Conclusions The COVID-19 pandemic is going to be a long-term situation with lasting effects on the public health and the entire society. Therefore, an efficient health care system has to adopt a double strategy: always being ready for a “new wave” of the pandemic and not forgetting non-COVID-19 patients, among whom head and neck cancer patients represent a priority. More than 1 year since the first outbreak in Wuhan, this review offers a unique and helpful perspective that incorporates awareness of the disease.

To evaluate molecular epithelial changes, we investigated whether a profile of survivin, cyclin dependent kinase inhibitor 2A (CDKN2A), epidermal growth factor receptor (EGFR), polo like kinase 1 (PLK1), p63, p40 (Δnp63 isoform), cyclin D1 (CCND1) and BCL2 apoptosis regulator (BCL2) proteins could predict malignant transformation. Different tissue segments (tumor adjacent epithelium; dysplasia and tumor) from a total of 109 patients were analyzed by immunohistochemistry. An increased expression of survivin (p

Acute pain is one of the most common symptoms in children admitted to the Pediatric Emergency Department (PED) and its management represents a real clinical challenge for pediatricians. Different painful procedures can be very stressful for young children and their perception of pain can be enhanced by emotional factors, such as anxiety, distress, or anger. Adequate procedural sedation reduces anxiety and emotional trauma for the patient, but it reduces also stress for operators and the time for procedures. We have reviewed the literature on this topic and the drugs covered in these papers were: midazolam, fentanyl, ketamine, and dexmedetomidine. There are several routes of administering for these drugs to provide analgesia and anxiolysis to children: oral, parenteral, or intranasal (IN). Intravenous (IV) sedation, since it involves the use of needles, can be stressful; instead, IN route is a non-invasive procedure and generally well tolerated by children and it has become increasingly widespread. Some medications can be administered by a mucosal atomizer device (MAD) or by drops. The benefits of the atomized release include less drug loss in the oropharynx, higher cerebrospinal fluid levels, better patient acceptability, and better sedative effects. IN midazolam has a sedative, anxiolytic and amnesic effect, but without analgesic properties. Fentanyl and ketamine are mainly used for pain control. Dexmedetomidine has anxiolytic and analgesic properties. In conclusion, IN analgo-sedation is a simple, rapid and painless option to treat pain and anxiety in the PED requiring brief training on the administration process and experience in sedation.

Background Since the first years of the 1980s, some authors described the use of mechanical stapler for the creation of anastomosis in biliary surgery. However, the use of these devices has not spread during the following decades, and nowadays most centers usually craft hand-sewn anastomosis. Methods We retrospectively collected data from medical records, surgical registries and computerized databases about the use of mechanical circular staplers for the creation of hepaticojejunostomy at our institution. Results From 2012 to 2020, 11 stapled hepaticojejunostomy for both neoplastic and non-neoplastic diseases were performed at our institution. The mean age of the patient was 74, with a sex distribution of 5 men and 6 women. The mean preoperative common bile duct diameter was 19 mm. Preoperative blood samples showed mean total bilirubin of 6.95 mg/dL. No intraoperative complications were reported. Two patients (18%) had minor postoperative complications (1 wound dehiscence and 1 episode of melena that required blood transfusions), while no major complications occurred. No patients developed biliary fistula or anastomotic dehiscence. No one dies within 30 days from surgery. The mean postoperative length of stay was 13 days. Conclusions According to our limited experience, stapled hepaticojejunostomy seems to be a safe and effective technique in selected patients.

Background: Long-term negative sequelae of esophageal atresia (EA) may induce poor growth and impaired nutritional status in childhood. We describe the nutritional profile and energy metabolism of children with repaired EA to identify malnutrition risk factors and optimize growth management. Methods: Twenty-one children (&gt, 4 years) were included, and anthropometric measurements, nutritional assessment, and energy metabolism were considered. The subjects were defined as undernourished if they met BMI &lt, &minus, 2 standard deviation (SD). To grade undernutrition, we defined the prevalence of underweight, stunting, and wasting (cut-off level of &lt, 2 SD). Medical records were reviewed for the type of EA and surgery and perinatal data. Results: Malnutrition was detected in 28.6% of children. Underweight was detected in 23.8% of patients (all with undernutrition p &lt, 0.01). Wasting was noted in 28.6% of patients, of these 5 children were undernourished (p &lt, 0.001) and stunting was noticed in only one patient with malnutrition (p = 0.5). Resting expenditure energy (REE) was lower in undernourished subjects compared to subjects with adequate nutritional status (p &lt, 0.001). Malnutrition was associated to: type of EA (p = 0.003, particularly type A and C), intervention including deferred anastomosis due to long-gap repair (p = 0.04) with/or without jejunostomy (p = 0.02), gastric pull-up (p = 0.04), primary anastomosis (p = 0.04), pyloromyotomy in long-gap (p &lt, 0.01), small for gestational age condition (p = 0.001). Conclusions: undernutrition risk factors, beyond the type of malformation, surgery, and perinatal factors, must be early considered to personalize nutritional programming. Energy metabolism is important to monitor the nutritional requirements. The management of nutritional issues is surely a contributory factor able to counteract the poor growth of children with EA.

Gastrointestinal stromal tumors (GISTs) are rare tumors of the gastrointestinal tract, which cover about 1-2% of gastrointestinal neoplasms with an unadjusted incidence of around 1/100,000/year. They are also the most common non-epithelial neoplasms of the gastrointestinal tract and they are associated with a high rate of malignant transformation. They are more common in the stomach (40-60%) while a minor part repeatedly involves jejunum/ileus (25-30%), duodenum (5%), colorectal (5-15%) and esophagus (

Primary Obstructive Megaureter (POM) is a common cause of hydronephrosis in children with spontaneous resolution in most cases. High-Pressure Balloon Dilatation (HPBD) has been proposed as a minimally invasive procedure for POM correction in selected patients. The aim of the paper is to review our experience with HPBD in patients with POM. We performed a retrospective study in a single Centre collecting data on patients’ demographics, diagnostic modalities, surgical details, results and follow-up. In particular, the endoscopic aspect of the orifice permitted the identification of 3 patterns: adynamic ureteral segment, stenotic ureteric ring and pseudoureterocelic orifice. We performed HPBD in 30 patients over 6 years. We had 23 patients with adynamic distal ureteral segment (type 1), 4 with stenotic ring (type 2) and 3 with ureterocelic orifice (type 3). In 3 patients (10%) the guidewire did not easily pass into the ureter requiring ureteral stenting or papillotomy. Post-operative course was uneventful. Five patients (3 pseudoureterocelic) required open surgery during follow-up. HPBD for the treatment of POM is a safe and feasible procedure and it can be a definitive treatment of POM. Complications are mainly due to double J stent and none of our patients had symptoms related to vescico-ureteral reflux. The aspect of the orifice, identified during cystoscopy, seems to correlate with the efficacy of the dilatation: type 1 and 2 are associated with good and excellent results respectively; type 3 do not permit dilatation in almost all cases requiring papillotomy. HPBD can be performed in selected patients of all paediatric ages as first therapeutic line. The presence of a pseudoureterocelic orifice or long stenosis might interfere with the ureteral stenting and seems associated with worse outcomes.

BACKGROUND : Admission hyperglycemia is common in subjects with acute myocardial infarction (AMI). Reperfusion therapy with primary percutaneous coronary intervention (PPCI) represents the leading therapeutic choice, in particular in ST-segment elevation myocardial infarction (STEMI). Despite this, mortality, re-hospitalizations and complications remain a relevant problem. Adenosine, a purine nucleoside, may reduce no-reflow. Therefore, we studied the effects of intravenous infusion of adenosine in addition to primary percutaneous coronary intervention (PPCI) in hyperglycemic patients with STEMI. METHODS : We evaluated 836 patients with STEMI and admission hyperglycemia (glycemia > 140 mg/dL). At the end, 399 patients were entered into the database. Patients were grouped on the basis of whether they received adenosine or not. RESULTS : A total of 199 patients received intravenous adenosine infusion and PPCI and 200 patients did not. Kaplan–Meier analysis demonstrated significant differences in all death, cardiac death, re-hospitalization for heart failure and for acute coronary syndrome in the adenosine treated group. CONCLUSIONS : The effects of intravenous infusion of adenosine and PPCI on clinical outcomes are significant but we need future larger studies with larger follow-up and statistical analysis to confirm our results.

We investigated the geographical character of the COVID-19 infection in China and correlated it with satellite- and ground-based measurements of air quality. Controlling for population size, we found more viral infections in those areas afflicted by high Carbon Monoxide, formaldehyde, PM 2.5, and Nitrogen Dioxide values. Higher mortality was also correlated with relatively poor air quality. Air pollution appears to be a risk factor for the incidence of this disease, similar to smoking. This suggests the detrimental impact of air pollution in these types of respiratory epidemics.Short summaryThere is a significant correlation between air pollution and COVID-19 spread and mortality in China.The correlation stands at a second-order administration level, after controlling for varying population densities and removing Wuhan and Hubei from the dataset.Living in an area with low air quality is a risk factor for becoming infected and dying from this new form of coronavirus.

In this paper, we first replicate estimates of [6] over a longer period from 1971 to 2015. We then extend the analysis estimating an additional specification in which a categorical variable is included to take into account if the four Asian countries adopted policies in support of the generation of energy from renewable sources. Most of the results of Asafu-Adjaye's analysis hold for Thailand and Philippines even when considering 20 years of additional data. The results for India and Indonesia are quite different from the original work in term of vector of cointegration and Granger-causality relationships. The Indian case is also different from other countries considered when we analyse the effects of the adoption of policies in favour of renewable energy sources. Keywords: Energy consumption, Economic growth, Granger causality, Replication, JEL classifications: C22, Q43, Q48

During the coronavirus disease of 2019 (COVID-19) emergency, in the pediatric surgical setting, it has been essential to avoid and contain infections as well as to protect both the patients and the surgical team. During this emergency, procedures and workflow were adapted to provide the safest possible environment for both the surgical team and the patients. Pediatric surgical activities were reorganized during the COVID-19 pandemic at the “Vittore Buzzi” Children’s Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), Italy. Resources were optimized in order to maintain high levels of care and quality of assistance. During the COVID-19 emergency, the pediatric surgical department at the “Vittore Buzzi” Children’s Hospital became an acute care surgical service. For the reorganization of surgical activities, institutional protocols were adapted in order to preserve the pediatric-specific characteristics of our service; five crucial points were specifically addressed. The pediatric surgical procedures carried out during the initial two months of the Italian lockdown are also reported. Continuity of care was maintained for children affected by severe diseases, such as tumors and neurosurgical conditions, whose treatment could not be deferred. Telemedicine and telecommunication were adopted as quick-support modalities for pre- and post-operative care. This reorganization allowed us to preserve the “pediatric specificity” and all care-related procedures offered at this high-quality/high-volume surgical care referral center.

The inferior alveolar nerve (IAN) is a sensitive branch of the mandibular nerve innervating the lower lip, the chin, the buccal mucosa and the teeths. Lesions of the IAN are reported to occur in the 64,4% of maxillo-facial procedures, leading to anesthesia, hypoestesia and/or neurogenic discomfort. An extensive segment of the nerve can be moreover removed during mandibular resection for benign or malignant pathologies. Nervous grafts can be used in these cases to restore the nerve continuity. In order to optimize the procedure and to allow a concomitant mandibular osseous reconstruction, the Authors identified several standardized steps. The technique described allows to perform confortable and safe nervous anastomoses and to reduce the risk of damage and tension during the flap insetting phases.

Squamous cell carcinoma (SCC) of the lip is one of the most commonly occurring oral cancers, mainly involving the lower lip. Despite a good prognosis in cases of early detection, survival rates drop dramatically in the presence of recurrence. While there are many studies in the literature regarding the management of primary tumours, the rate of recurrence in lower lip SCC is low and therefore there are few data and articles about them. We retrospectively reviewed patients affected by recurrent SCC of the lower lip treated surgically from 2011 to 2019 in a single centre. Data and results were compared with those in the literature. A total of 16 patients (mean [range] age: 78.1 [62-93] years) were eligible for inclusion. The disease-free survival rate at 2 and 5 years was 29.6% and the overall survival rate at 2 and 5 years was 14.4%. A significantly higher rate of failure and a worse prognosis was observed in patients with neck involvement. The prognosis of recurrent lower lip SCC is unfavourable with extremely low survival rates. This issue is probably linked to the oncological pathology but also to the advanced age of most patients, the presence of several comorbidities and, consequently, the high risk of perioperative mortality. For this reason, the analysis of data sets reported in the literature may help the surgeon in the management of recurrences and selection of patients.

Objective: To determine percentages of types A (flat) and B (concave) of the distal tibiofibular joint in patients with ankle fractures or chronic ligament instabilities, with syndesmosis lesions; check the shape of the fixation and position of the fibula in this joint; to identify poor fibular reduction and its frequency in types A and B; patients according to the AOFAS criteria. Methods: 104 patients surgically treated with syndesmosis fixation underwent clinical evaluation using AOFAS functional criteria and tomographic exams to classify the distal tibiofibular joint in types A or B and evaluated the poor position of the fibula in this joint. Results: Distal tibiofibular joint type A was present in 27 ankles and type B in 77. Non-anatomical reduction of the fibula (17 ankles) was more frequent in type A than in type B and more frequent in fractures than in instabilities. The AOFAS score was 91.79 points in the 87 patients with good reduction and 86.76 points in the 17 patients with poor fibula reduction. Conclusion: Distal tibiofibular joint type B was more frequent than type A (p=0.00001); there was poor reduction of the fibula in this joint in 17 ankles (16.34%). Poor fibula reduction was more frequent in fractures than in instabilities (p=0.006). The poor reduction was more constant in type A than in type B, without statistical significance (p=0.34). The AOFAS score was 91.79 points in patients with good reduction and 86.76 points in patients with poor fibula reduction in the distal tibiofibular joint. Level of Evidence IV; Therapeutic Studies; Case Series.

The aim of this paper is to analyze the factors determining the choice of energy policy setting in favor of renewable energy sources. We investigate if such determinants are different between countries at different stage of development. Finally, we study if the adoption of green energy policies is characterized by complementary or substitution effects. Our analysis aims at responding at two research questions: what are the factors influencing a country's choice for a specific type of energy policy? Is it possible to identify either complementary or substitute policy interventions based on a country's level of economic development? Moreover, are developing systematically different from developed countries in manage public and private resources for renewable energies? The empirical analysis employs a panel probit model estimated over a sample of 56 countries observed between 2004 and 2011. The results show that while context variables have the same impact in developed and developing countries, public operational variables play a different role. Governments in richer countries are bound to play only a role of an arbiter. On the contrary, governments of developing countries are more directly involved in the management of energy policies. Hence, a greater impact is recognized to policies with direct involvement of the government.

Background: The studies about injury to the anterior talo-fibular ligament (ATFL) are focused mainly on chronic symptoms and chronic instability, and the literature about the accuracy of magnetic resonance imaging (MRI) in acute injuries is quite lacking. Methods: This systematic review with meta-analysis analyzes the diagnostic accuracy of MRI on acute ATFL injury. Relative studies were retrieved after searching three databases (MEDLINE, SCOPUS, and Cochrane Central Register of Controlled Trails). Eligible studies were summarized. The quality of the included articles was assessed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Data were extracted to calculate pooled sensitivity and specificity of MRI. Results: Seven studies met our inclusion and exclusion criteria. For MRI, the pooled sensitivities and specificity in diagnosing acute ATFL injury were respectively 1.0 (95% CI: 0.58–1) and 0.9 (95% CI: 0.79–0.96). Pooled LR+ and LR− were respectively 10.4 (95% CI: 4.6–23) and 0 (95% CI: 0–0.82). Conclusion: This systematic review with meta-analysis investigated the accuracy of imaging for the diagnosis of acute ATFL injury. Our results demonstrated that MRI shows high diagnostic accuracy in the diagnosis of acute ATFL lesions. These results suggest that routine MRI in the case of suspected ATFL acute injury may be clinically useful, although this is not done in clinical practice due probably to high cost.

Introduction: Situs ambiguous (SA) is a rare clinical entity that includes a spectrum of abnormalities in which organs and vessels are opposed to their normal arrangement. SA is frequently associated with other malformations such as splenic alterations, biliary atresia and vascular abnormalities. We report two cases of patients with SA, polysplenia and choledochal cyst. This association has never been described to date. Case reports: Two patients, both males, came to our attention at the ages of 7 and 8 months after ultrasound identification of choledochal cysts. One patient, who had a prenatal suspicion of situs ambiguous and dextrocardia, presented with failure to thrive and increased hepatic enzymes. The other patient was asymptomatic, but prenatal evaluation showed gastric malposition. Post-natal laboratory tests were normal. Preoperative radiological diagnostic work-up showed polysplenia, intestinal anomaly of rotation and fixation, pre-duodenal portal vein in one baby. Both patients underwent surgical correction by cyst excision and Roux-en-Y hepaticojejunostomy. Follow-up (3 months and 3.5 years respectively) was uneventful. Biochemical hepatic parameters normalized soon after surgery. Discussion: Situs anomalies in children are often associated with other malformations. The most common are splenic and cardiac defects but intestinal malformations and hepatico-biliary abnormalities have been reported too. Above all, the BASM (biliary atresia splenic malformation) syndrome has been extensively examined, obtaining important information on the etiology of the cystic form of biliary atresia. Conclusions: A careful evaluation of patients with situs ambiguous is important to exclude associated anomalies and to plan the most appropriate surgical approach. The association with choledochal cyst should be taken into account. Keywords: Choledochal cyst, Situs ambiguous, Polysplenia