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Attacks on health care are part of the spectrum of threats that health care endures during conflict. Protecting health care services against attacks depends on understanding the nature and types of attacks that occur during conflict. The World Health Organisation has implemented the Surveillance System for Attacks on Health Care (SSA) in Ukraine since 2020, and the system has continued to monitor and report on attacks on health care during the war in Ukraine. This study aims to analyse the data reported through the SSA for the first 18 months of the war. This paper involves a retrospective, descriptive study based on the analysis of publicly available SSA data of all incidents of attacks on health care in Ukraine reported through the SSA between February 24th 2022 and August 24th 2023. Out of the 1503 verified attacks, 37% occurred in the initial six weeks of the war. Attacks involving violence with heavy weapons were among the most common incidents reported (83%). The reported attacks were associated with a total of 113 deaths and 211 injuries among health care workers and patients: 32 (2%) attacks were associated with a death of a health care worker or patient, and 63 (4%) were associated with an injury. Health transports facing attacks had a higher probability of experiencing casualties than other health resources (p<0.0001, RR 3.1, 95%CI 1.9-4.9). In conclusion, the burden of attacks on health care in Ukraine was high and sustained over the course of the first 18 months of the war. Reported casualties were not homogenously distributed among attack incidents, but occurred in a set of high-casualty incidents. Health transports were found to be particularly vulnerable. In addition to continued calls for a cessation of hostilities, prevention, protection, mitigation, and reconstruction strategies are urgently required., Competing Interests: The authors have declared that no competing interests exist. The authors are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the World Health Organization., (Copyright: © 2024 World Health Organization. Licensee Public Library of Science. This is an open access article distributed under the Creative Commons Attribution IGO License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/3.0/igo/. In any use of this article, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article’s original URL.)

Aim: The aim of our study is to evaluate the surface glycoprotein CD133 as marker of cancer stem cells, as independent prognostic pattern of survival and its positive expression ratio to a chemotherapy increased resistance., Methods: The study include our patient, affected by colorectal cancer (CRC) and underwent to surgery at University Hospital of Parma, with curative intent, with a follow up of 5 years; 47 cases were considered. All the cancer-case was considered independently by the histological grade. The monoclonal antibody CD133/1 (clone AC133-MAC, Miltenyi Bioetec, Auburn CA 95602, USA) that recognizes the epitope 1 of CD133 was utilized for the immunohistochemical process., Results: On the total of 47 patients taken in exam, 8 were excluded for lack of date, 13 were lost during the follow-up. The final number of patients included in the study was 26(17 males and 9 females), medium age of 72.2 years. 2 Stage I, 8 Stage II A, 1 II B, 2 III A, 5 III B, 5 IIIC and 3 IV. Despite for 1, 25 on 26 patients were positive to CD133 (96.5 %), with different dye intensity, directly related at the positive cell pull. The CD133 positivity wasn't therefore related at any other clinic-pathological characteristic., Conclusion: The results obtained from our study goes in the same direction with others, that confirm a high representation of CD133 on the colic tumoral epithelium. It will be appropriate to do prospected and randomized studies, with a larger casistic, utilizing similar methods and a patients populations with more uniform characteristics, to verify the real role of CD133 and other molecules potentially marker of tumoral stem cell (TSC).

Aim: Hypocalcaemia is the most frequent complication after total thyroidectomy. The incidence of postoperative hypocalcaemia is reported with different percentages in literature., Methods: We report 227 patients undergoing surgery for benign thyroid disease. After obtaining patient's informed consent, we collected and analyzed prospectively the following data: calcium serum levels pre and postoperative in the first 24 hours after surgery according to sex, age, duration of surgery, number of parathyroids identified by the surgeon, surgical technique (open and minimally invasive video-assisted thyroidectomy, i.e., MIVAT). We have considered cases treated consecutively from the same two experienced endocrine surgeons. Hypocalcaemia is assumed when the value of serum calcium is below 7.5 mg/dL., Results: Pre-and post-operative mean serum calcium, with confidence intervals at 99% divided by sex, revealed a statistically significant difference in the ANOVA test (p < 0.01) in terms of incidence. Female sex has higher incidence of hypocalcemia. The evaluation of the mean serum calcium in pre-and post-operative period, with confidence intervals at 95%, depending on the number of identified parathyroid glands by surgeon, showed that the result is not correlated with values of postoperative serum calcium. Age and pre-and postoperative serum calcium values with confidence intervals at 99% based on sex of patients, didn't show statistically significant differences. We haven't highlighted a significant difference in postoperative hypocalcemia in patients treated with conventional thyroidectomy versus MIVAT., Conclusion: A difference in pre- and postoperative mean serum calcium occurs in all patients surgically treated. The only statistical meaningful risk factor for hypocalcemia has been the female sex.

Aim: There are no common guidelines to identify the population at risk to develop hypocalcemia preoperatively or early in the postoperative course in thyroidectomized patients, therefore the authors suggest to examine the PTH value preoperatively., Methods: We divided 391 patients in two groups according to the preoperative PTH level (normal, ≤ 72 pg/mL vs. increased >73 pg/mL)., Results: In 92/391 cases (23.52%) preoperative PTH was increased (mean PTH level 112.4+/-24.8 pg/mL; normal range 12-72 pg/mL). Out of these, 43 (46.7%) had hypocalcaemia postoperatively. In 18 out of the 43 patients clinical hypocalcemia also developed. The mean follow-up was of 148+/-13 days. Of the 299 patients with normal preoperative PTH, 127 (42.47%) developed postoperative hypocalcemia (mean calcium level 7.4+/-0.33 mg/dL). In 30 patients it was also clinically evident. The difference in terms of incidence of symptomatic hypocalcemia was statistically significant (increased preoperative PTH 19.5% vs. normal preoperative PTH 10.03% , P=0.036)., Conclusion: All candidates to thyroidectomy should be investigated for preoperative PTH abnormalities.

Background: Mininvasive surgical techniques have been proposed to treat the patients affected by parathyroid adenoma starting by endoscopically-assisted parathyroidectomy up to video-assisted and radio-guided approaches., Patients and Methods: Our technique, minimally invasive video-assisted parathyroidectomy (MIVAP), in accord with Miccoli's technique, has been introduced in our center since 2006 after extensive experience with MIVAT (minimally invasive videoassisted thyroidectomy). From September 2006 to October 2008 we performed 32 MIVAP on 32 patients, 21 female and 11 males with a mean age of 53.4 years (range 25-77) affected by parathyroid adenoma. Patients have been divided in two groups in chronological order: Group A included the first 15 patients, Group B the second ones., Results: Mean operative time from incision to skin closure has been 47.4+/-14.2 minutes for group A and 34+/-10.3 minutes for group B (p<0.01). Postoperative pain, scored from 0 to 10 evaluated at time 0 and after 24 hours from the procedure, has been of 2.6+/-0.5 and 1.4+/-0.5 in group A (p<0.001) while in group B of 2.58+/-0.51 and 1.16+/-0.38 (p<0.001) respectively. The difference in postoperative pain was not significant between the two groups and the pain was controlled by the administration of paracetamol 1 g. On the other side, the comparison between postoperative pain in patients operated via traditional bilateral cervical exploration and MIVAP (2.61+/-0.5 vs 3.55+/-0.51 and 1.38+/-0.5 vs 2.16+/-0.61 at 0 and 24 hours respectively), was statistically significant (p<0.001) and in favour of MIVAP., Conclusions: We showed a shorter operative time between the A group and B group. 15 cases are sufficient as good learning curve if the surgeon is experienced in videoassisted neck procedure. The postoperative pain is lower in videoassisted procedure than cervical bilateral approach.

Introduction: The depth of the tumor invasion and nodal involvement are the two main prognostic factors in gastric cancer. Staging systems differ among countries and new tools are needed to interpret and compare results and to reduce stage migration. The node ratio (NR) has been proposed as a new prognostic factor., Materials and Methods: We retrospectively reviewed 282 patients who underwent curative resection for gastric cancer at Parma University Hospital between 2000 and 2007. TNM stage, NR, overall survival, survival according to nodal status, and survival according to the total number of nodes retrieved were calculated., Results: At univariate analysis, the TNM stage, number of metastatic nodes, NR, and depth of tumor invasion, but not the number of nodes retrieved, were significant prognosis factors. Patients with more than 15 nodes retrieved in the specimen survived significantly longer (p < 0.04). This was confirmed for all N or NR classes within N groups. There was a correlation between the number of nodes retrieved and N but not with the NR category. NR was an independent prognostic factor at Cox regression., Conclusion: NR is a reliable and sensitive tool to differentiate patients with similar characteristics, probably more so than the TNM system. NR is not strictly related to the number of nodes retrieved and this may potentially decrease the stage migration phenomenon. More trials are needed to validate this factor.

Background: The association between patients with surgically treatable thyroid disease and patients affected by PHPT is not just accidental., Materials: We report 591 patients who underwent total thyroidectomy in our center. Data, collected during the preoperative period according to our protocol for candidates to total thyroidectomy, included: type of thyroid disease, sex, age, type of surgical procedure, preoperative PTH and plasmatic calcium level. Calcium plasmatic level has been monitored at 24 hours after surgery on day 6 and monthly for 6 months., Results: On 591 cases, PTH above the normal range were present in 19.1% (113 patients), all asymptomatic for PHPT 30 were males (26.6%) and 83 females (73.4%), with a mean age of 62.97 +/- 12.51 years and 57.38 +/- 15.09 years ( p = 0.19). The mean preoperative PTH and calcium plasmatic level were 104.4 +/- 21.96 pg/ml and 119.7 +/- 37.93 pg/ml (p = 0.39) and 9.21 +/- 0.59 mg/dL e 9.37 +/- 0.87 mg/dl (p = 0.45) respectively. Intraoperative exploration proved a pathological parathyroid gland in 12 on 113 cases. In 9 of the 12 patients with parathyroid adenoma, hypocalcaemia developed. It resolved in 7 days for 4 patients and within 30 days for the others. No hypocalcaemia has been recorded at a 6 months follow up for the 97 considered (4 were lost at follow up)., Conclusion: Preoperative PTH measurement for all patients undergoing total thyroidectomy may offer a concrete tool to screen and identify the above-described category of patients, with no additional cost for further radiological investigations, because this class of patients will be submitted to bilateral cervical exploration associated with a total thyroidectomy.

Background: Total thyroidectomy is the treatment of choice for thyroid cancer and for selected benign thyroid conditions. The aging of the general population and the improvements in surgical technique induced an extension of the surgical indications to major thyroid surgery to older patients also on a short stay basis., Methods: From January 2004 to December 2006, 152 patients affected by thyroid carcinoma underwent total thyroidectomy on a short stay basis. We divided our series in 2 groups of patients according to the age (> or < of 65 yrs) and considered the outcome analysing several factors including: ASA score, mean operative time, mean hospital stay, tumour size, and post-operative complications., Results: The groups consisted of: 115 pts with a mean age of 46.81 +/- 11.63 years and 37 pts with a mean age of 74.53 +/- 3.71 years for the younger and older group respectively. The differences in ASA score and hospital stay were statistically significant between the groups (P < 0.007 and P < 0.004); neither postoperative haemorrage nor permanent hypocalcemia was observed. One permanent paralysis of the recurrent laryngeal nerve was noted at 12 months follow up; transient hypocalcemia, which resolved in all cases within 30 days from surgery, was reported in 23 and in 7 patients in the younger and older group respectively., Conclusions: Although a longer length of stay was noted in the older group and possibly related to a higher ASA score and a worse preoperative airways condition, total thyroidectomy for differentiated thyroid carcinoma may be safely carried out in older patients on a short stay basis if performed by an expert staff and in the setting of a multidisciplinary and exhaustive preoperative assessment.

Improvements in pre-hospital care and the development of integrated Trauma Systems have streamlined access for the severely injured to sophisticated, specialist Trauma Centre reception and resuscitation. We describe the initial care of a survivor of combined ruptures of the left ventricle and left atrium secondary to blunt injury. This case emphasises the contribution of such a Trauma System in achieving a favourable outcome for a severely injured trauma patient with injuries previously considered non-survivable.

The incidence of phylloides breast tumors is less than 1% in the population affected by breast cancers. The age at higher risk is between 35 and 45 years. These neoplasms are characterized by a proliferation of mesenchimal and epithelial cells. We present a rare case of giant malignant phylloides tumor (28 x 21 x 15 cm) with a complet substitution of the gland. The clinical presentation of phylloides tumors is heterogenous; the surgical treatment is a conservative one of the gland if the neoplastic lesion size is less than 5 cm with a free margin of 1 cm and a mastectomy if the diameter of lesion is more than 5 cm. Complementary therapies still remain controversial.

Celiac artery compression syndrome (CACS) and superior mesenteric artery syndrome (SMAS) are 2 rare diseases, widely described in literature. Their association has not been specifically investigated; in fact, few cases have been reported. For this reason we reviewed our experience from January 1974 to June 2004. We report 59 patients affected by CACS and 28 by SMAS. Coexistence of both syndromes in 8 patients was observed. These 8 patients were successfully treated with duodenojejunal bypass and decompression of the celiac trunk. In this paper, we analyze the pathogenesis, clinical presentation, diagnosis, and treatment of these syndromes, emphasizing their common aspects. The misdiagnosis of this association may justify in some cases the controversial results reported regarding the surgical treatment of these syndrome.