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The King’s Speech, directed by Tom Hooper, is a detailed description, even if fictional, about an effective therapeutic relationship. Through the film, the author intends to outline and highlight specific moments in clinical practice that are fundamental to the creation of the therapeutic alliance, the key for a successful treatment. After the study of the literature and the contributions of the various paradigms on the significance of the therapeutic relationship, the article emphasizes, through the analysis of the film, the importance of setting, motivation, selfdisclosure and humanity of the therapist as the basis for transforming the relationship in alliance. Il discorso del re, opera cinematografica del regista Tom Hooper, si propone come approfondita descrizione, seppur romanzata, di una relazione terapeutica efficace. Attraverso il film l’autore si propone di delineare e nominalizzare i momenti salienti che nella pratica clinica sono fondamentali per la creazione dell’alleanza terapeutica, chiave di volta per un buon esito del trattamento. Dopo uno studio della letteratura e dei contributi dei diversi paradigmi al costrutto di relazione terapeutica si mette in risalto, attraverso l’analisi del film, l’importanza del setting, della motivazione, della self-disclosure e dell’umanita del terapeuta come base per trasformare la relazione in alleanza.

Sutured and stapled intestinal anastomoses are perceived to be equally safe in elective intestinal surgery. However, our search of the literature failed to find any studies comparing hand-sewn and mechanical anastomoses in emergency intestinal surgery. Thus, we compared the short-term outcomes of patients with sutured as opposed to stapled anastomoses in emergency intestinal surgery. Between 1995 and 2001, 201 patients underwent emergency intestinal operations at the Department of Emergency Surgery of Sant’Orsola-Malpighi University Hospital. The outcomes of patients with sutured and stapled anastomoses were compared in a prospective analysis. Patients were randomly divided into a stapled group (106 anastomoses) with anastomoses made using linear and circular staplers, and a hand-sewn group (95 anastomoses) with anastomoses made by double-layer suturing. There were no significant differences between the groups in operative indications or other parameters. The operation times in the stapled group were significantly shorter than those in the hand-sewn group (P < 0.05), but there were no significant differences in anastomotic leak rates, morbidity, or postoperative mortality between the two groups. In emergency intestinal surgery comparable results can be achieved using mechanical and manual anastomoses.

Purpose: the aim of the present study was to measure patient perception in the early period after knee replacement surgery and to correlate health status with the surgery-related outcome. Methods: thirty-eight consecutive patients who underwent total knee replacement were evaluated before surgery; at the time Radiographic evaluation was used to assess limb alignment and the Oxford Knee Score (OKS) to assess objective outcome. Health outcome was measured with the three-level version of the EuroQol – five dimension (EQ-5D-3L) selfadministered questionnaire, a standardized instrument used to measure patient’s perception of health status. Evaluation was performed before surgery, at discharge from hospital, and six weeks after surgery. Results: the mean overall EQ-5D-3L scores were 10.23 before surgery, 8.34 at discharge from the hospital, and 6.52 at six weeks. The overall EQ-5D-3L score before surgery was greater than 8 points in 31 of the 38 patients, ranging from 5 to 8 points in 21 of the 38 patients at the discharge and greater than 8 points in six of the 38 patients six weeks after surgery. Patients with scores of over 8 points at six weeks also scored more than 10 points on the discharge assessment. Conclusions: analysis of early patient reports of performance after TKR showed marked changes in the level of satisfaction during the first six weeks after surgery. An EQ-5D-3L score of 8 or more at follow-up should be considered a sign that the patient has not achieved satisfaction and, accordingly, should be studied in the context of a personalized follow-up schedule in order to identify as soon as possible the causes of impairment. Level of Evidence: Level IV, prognostic case series.

Background: Despite advances in diagnostic modalities, small bowel tumours are notoriously difficult to diagnose and are often advanced at the time of definitive treatment. These malignancies can cause insidious abdominal pain and weight loss, or create surgical emergencies including haemorrhage, obstruction or perforation. The aim of the present study was to describe the clinical presentation, diagnostic work-up, surgical therapy and short-term outcome of 34 patients with primary and secondary small bowel tumours submitted for surgical procedures in an emergency setting and to look for a correlation between clinical presentation and the type of tumours. Methods: From 1995 to 2005, 34 consecutive surgical cases of small bowel tumours were treated at the Department of Emergency Surgery of St Orsola-Malpighi University Hospital, Bologna, Italy. Clinical and radiological charts of these patients were reviewed retrospectively from the department database. Results: All patients presented as surgical emergencies: intestinal obstruction was the most common clinical presentation (15 cases), followed by perforation (11 cases) and gastrointestinal bleeding (eight cases). Lymphoma was the most frequent histologic type (nine patients), followed by stromal tumours (eight patients), carcinoids (seven patients), adenocarcinoma (seven patients) and metastasis (three patients). Of the nine patients with lymphoma, eight were perforated, all patients with stromal tumours had bleeding, and all carcinoids patients had bowel obstruction. There were two patients with melanoma metastasis, both had bowel intussusception. Resection of the neoplasm was carried out in 32 patients and two patients were deemed unresectable and received a palliative procedure. Conclusions: The present study shows that there is a correlation between small bowel tumours and clinical emergency presentation: gastrointestinal stromal tumours (GIST) mostly bleed; carcinoids make an obstruction; lymphomas cause a perforation; and melanoma metastasis causes intussusception.

Background In some randomized trials successful laparoscopic cholecystectomy for cholecystitis is associated with an earlier recovery and shorter hospital stay when compared with open cholecystectomy. Other studies did not confirm these results and showed that the potential advantages of laparoscopic cholecystectomy for cholecystitis can be offset by a high conversion rate to open surgery. Moreover in these studies a similar postoperative programme to optimize recovery comparing laparoscopic and open approaches was not standardized. These studies also do not report all eligible patients and are not double blinded. Design The present study project is a prospective, randomized investigation. The study will be performed in the Department of General, Emergency and Transplant Surgery St Orsola-Malpighi University Hospital (Bologna, Italy), a large teaching institutions, with the participation of all surgeons who accept to be involved in (and together with other selected centers). The patients will be divided in two groups: in the first group the patient will be submitted to laparoscopic cholecystectomy within 72 hours after the diagnosis while in the second group will be submitted to laparotomic cholecystectomy within 72 hours after the diagnosis. Trial Registration TRIAL REGISTRATION NUMBER ISRCTN27929536 – The ACTIVE (Acute Cholecystitis Trial Invasive Versus Endoscopic) study. A multicentre randomised, double-blind, controlled trial of laparoscopic versus open surgery for acute cholecystitis in adults.

Background The Van Nuys Prognostic Index (VNPI) is a simple score for predicting the risk of local recurrence (LR) in patients with Ductal Carcinoma In Situ (DCIS) conservatively treated. This score combines three independent predictors of Local Recurrence. The VNPI has recently been updated with the addition of age as a fourth parameter into the scoring system (University of Southern California/ VNPI). Patients and methods Our database consisted of 408 women with DCIS. Applying the USC/VNPI we reviewed retrospectively 259 patients who were treated with breast conserving surgery with or without radiotherapy (RT). Of these patients 63.5% had a low VNPI score, 32% intermediate and 4.5% a high score. In the low score group, the majority of the patients underwent Conservative Surgery (CS) without RT while in the intermediate group, almost half of the patients received RT. Eighty-three percent (83%) of the patients with high VNPI were treated with Conservative Surgery plus RT. Nodal assessment by Sentinel Lymph Node Biopsy was obtained in 32 patients since 2002. Results Twenty-one Local Recurrences were observed (8%) with a mean follow up of 130 months: sixteen were invasive. No statistically significant differences in Disease Free Survival were reached in all groups of VNPI score between patients treated with Conservative Surgery or Conservative Surgery plus RT. However it was noted that the higher the VNPI score, the lower was the risk of local recurrence in the group treated additionally with RT, even though it was not statistically significant. Further analysis included those patients treated with Conservative Surgery alone and followed up. Disease-free survival (DFS) at 10 years was 94% with low VNPI and 83% in both intermediate and high score (P < 0.05). No significant differences were observed in the subgroups of VNPI. The Local Relapse rate after Conservative Surgery alone, increased with tumor size, margin width, and pathology classification (P < 0,05), while age was not found to be a significant factor. Lesions with only mammographic appearances are associated with lower DFS but it did not reach significance (P = ns), while assumption of estrogenic hormones and familial history of breast cancer are significant factors associated with a higher risk of local recurrence. After multivariate analysis including seven clinical and pathological factors, the only significant predictors of local recurrence remained margin width of surgical excision, previous therapy with estrogens (contraceptives or Hormone Replacement Therapy) and the Van Nuys pathologic classification. The overall survival breast cancer specific was 99% and no differences were observed between groups (P = ns). The comparison of patients treated with a total mastectomy and those conservatively treated showed a significantly better local relapse free survival rate obtained with mastectomy (98.2% vs. 89.7% at 10 years P = 0.02). However, the overall cause-specific survival did not prove any better outcome (98.7% in both groups). Of the 32 patients who underwent a Sentinel Lymph Node Biopsy, four were found to have micrometastases and all of them had a previous Directional Vacuum Assisted Biopsy. Conclusions Although in our series there is not a significant difference in LR rates by the parameter of age, the new USC/VNPI is still a simple and reliable scoring system for therapeutic management of DCIS. We did not find any statistically significant advantage in groups treated with the addition of RT. Obtaining wide surgical margins appears to be the strongest prognostic factor for local recurrence, regardless of other pathological factors or the addition of adjuvant radiation therapy. However, only prospective randomized studies can precisely predict the risk of LR of conservatively treated DCIS. The clinical significance of Sentinel Lymph Nodes micrometastases Immuno-Histo-Chemistry-detected found in DCIS patients remains uncertain. However, we hypothesize that the anatomical disruption after preoperative biopsy procedures increases the likelihood of epithelial cell displacement and the frequency of IHC-positive Sentinel Lymph Nodes, both of which are directly proportional to the degree of manipulation.

Surgisis IHM is an acellular biomaterial derived from porcine small intestinal submucosa (SIS) that induces site-specific remodeling in the organ or tissue into which it is placed. Previous animal studies have shown that the graft recipient mounts a helper T type 2-restricted immune response to the SIS xenograft without signs of rejection. The aims of this study were to evaluate the immune response to the SIS implant in a small series of humans and to examine the long-term clinical acceptance of the xenograft in these patients. Five consecutive male patients (mean age 56 years, range 34-68) who underwent inguinal hernioplasty with Surgisis IHM were assessed at 2 weeks, 6 weeks, and 6 months after implant for SIS-specific, alpha-1,3-galactose (alpha-gal) epitope and type I collagen specific antibodies. All five patients were also clinically assessed up to 2 years for signs of clinical rejection, hernia recurrence, and other complications. All 5 patients implanted with Surgisis IHM produced antibodies specific for SIS and alpha -gal with a peak between 2 and 6 weeks after implantation. By 6 months, all patients showed decreasing levels of anti-SIS antibodies. Two patients developed a transient, mild local seroma that resolved spontaneously. None of the patients showed any clinical signs of rejection, wound infection, hernia recurrence, or other complications in the follow-up out to 2 years. Thus, this study showed that in a small series of patients the SIS elicits an antibody response without clinical rejection of the xenograft and minimal postoperative complications.

Although at present nonabsorbable meshes are the preferred material for tension-free hernioplasty, some problems with their use are still to be addressed (i.e., chronic pain and infections). To address these disadvantages, a collagen-based material, the porcine small intestinal submucosa mesh, has recently been developed for hernia repair. The technique to use this material in performing an hernioplasty is described. A preshaped Surgisis Inguinal Hernia Matrix (IHM) is fashioned as appropriate, with a slit 2 cm from its inferior edge to accommodate the spermatic cord, placed for at least 10 min into a dish with room-temperature normosaline to be rehydrated and then transferred to the already prepared and dissected inguinal region. After drawing its tails around the cord, the mesh is sutured to the inguinal ligament with a continuous suture of PDS II 2/0, starting from the pubic tubercle laterally up to the deep orifice. The fixation of the mesh to the internal oblique abdominal muscle and the rectus sheath is accomplished with interrupted stitches. An extra stitch is placed between the two tails to close the new deep orifice. We conclude that an hernioplasty using Surgisis IHM is feasible with promising results.

BACKGROUND: Complicated hernias often involve contaminating surgical procedures in which the use of polypropylene meshes can be hazardous. Prostheses made of porcine dermal collagen (PDC) have recently been proposed as a means to offset the disadvantages of polypropylene meshes and have since been used in humans for hernia repairs. The aim of our study was to evaluate the safety and efficacy of incisional hernia repair using PDC as a mesh in complicated cases involving contamination. METHODS: A prospective study of hernia repair of complicated incisional hernias with contamination using PDC grafts was carried out at the Department of General, Emergency and Transplant Surgery of St Orsola-Malpighi University Hospital. RESULTS: From January 2004 up to the writing of this article, seven patients were treated for complicated incisional hernias with a PDC prosthesis. In six out of seven patients a bowel resection was carried out. There were not surgical complications. Morbidity was 14.2%. No recurrences and wound infections were observed. CONCLUSIONS: Incisional hernioplasty using PDC grafts is a potentially safe and efficient approach in complicated cases with contamination.

Although at present nonabsorbable meshes are the preferred material for tension-free hernioplasty, some problems with their use have yet to be addressed (i.e., chronic pain and infections). In order to address these disadvantages, a collagen-based material, the porcine small-intestinal submucosa mesh (Surgisis Inguinal Hernia Matrix, Cook Surgical, Bloomington, IN, USA), has recently been developed for hernia repair. With the aim of investigating the clinical safety and effectiveness of Surgisis IHM inguinal hernia repair, we report our experience of 45 consecutive hernioplasties with a medium-term follow-up. The surgical technique for the use of this material in hernioplasty is described in detail. Although some local (i.e., seromas) and general (i.e., hyperpyrexia), complications appeared in the immediate postoperative period (all of them disappeared spontaneously), no rejection or infection was observed after operations. At the 2-year follow-up, a low degree of pain and discomfort and no recurrences were observed. We conclude that the Surgisis IHM hernioplasty is feasible with promising results and, from a clinical perspective, seems safe and effective.

The aim of the study was to evaluate the use of Surgisis (Cook Biotech Inc.), a porcine derived extracellular matrix already used in tissue engineering, as a scaffold for neointestinal regeneration in a rat model. A 3-cm length of tubular Surgisis graft was interposed with bilateral anastomoses in the middle of an isolated ileal loop of Sprague Dawley rats with an ileostomy. The grafts were harvested and analyzed using histology and immunohistochemistry at 24 weeks after operation. Macroscopic examination revealed neither stenosis nor adhesions in the area surrounding the neointestine. The regenerated small bowel showed a mean shrinkage of 30.7% (range 20%-40%). Histologic and immunohistochemical evaluation showed a well-developed three layers of mucosa and smooth muscle and serosa in the regenerated bowel wall that were similar to those of the normal bowel with evident neovascularization. Also, the regeneration of smooth muscle fibers and innervation were evident. The preliminary results of this study showed that Surgisis allowed rapid regeneration of mucosa and smooth muscle and therefore may be a promising material for the creation of a neointestine.

Angiosarcoma (AS) is a rare, invasive malignancy originating from endothelial cells caused by many different clinical situations. AS following radiotherapy for breast cancer after conservative surgery is a rare but well-known association.The aim of this article is to describe a case of AS after breast conserving surgery and to review the literature to date.We report the case of an 84-year-old woman who developed AS four years after she was subjected to quadrantectomy for invasive ductal cancer, followed by 30 tangent field radiotherapy sessions. She presented with a one-month history or red papular skin eruptions on the operated breast. Skin lesions were submitted for biopsy, and they were positive for AS. The patients was subjected to surgical excision of the remaining breast including all AS lesions. She is alive with no evidence of disease after 10 months follow-up.Post-radiotherapy AS is rare neoplasm, but it should be considered in the case of patients with red lesions after breast conserving surgery and adjuvant radiotherapy.

Study Objective To evaluate the analgesic efficacy and safety of ropivacaine 0.2% when administered continuously via elastomeric pump after appendectomy. Design Prospective, randomized, double-blinded study. Setting Surgical ward of a university hospital. Patients 96 ASA physical status I and II patients of at least 14 years of age, undergoing appendectomy through a McBurney incision. Interventions Patients were randomly assigned into two groups: 500 mg of ropivacaine in 48 hours (10 mL of 0.2% ropivacaine 20 mg, starter dose plus 5 mL/h continuous wound infusion via elastomeric pump device; n=48) in the experimental group and 250 mL of normal saline, as placebo, in the control group. Measurements Postappendectomy pain, measured either with a simple verbal scale or with a visual analog scale, parenteral analgesic consumption, and global satisfaction were all measured. Main Results A reduction in postoperative pain was observed in the ropivacaine group. Degree of pain, with a simple verbal scale measurement of severe and unbearable, was significantly lower in the ropivacaine group than in the normal saline group from time 0 to 24 hours at rest and from time 0 to 36 hours on coughing. A significant lower pain intensity (visual analog scale) was found in the ropivacaine group both at rest and on coughing, beginning at three hours and continuing to 36 hours postoperatively. The mean number of rescue analgesic doses was significantly lower in the ropivacaine group. There were no statistically significant differences in the frequency of adverse events between the two groups. Conclusions Wound instillation with ropivacaine 0.2% is a useful, practical, and safe method for management of postoperative pain after appendectomy.

While polypropylene mesh remains the preferred prosthesis material for hernioplasties, there are some problems with infections, intestinal obstruction and fistulization, and migration particularly in immunodepressed patients. A new degradable and reabsorbable material, the porcine small intestinal submucosa (Surgisis) has been developed for hernia repairs in humans. This prospective study evaluated the safety and efficacy of Lichtenstein hernioplasty using the Surgisis inguinal hernia matrix soft-tissue graft as a mesh in ten immunodepressed subjects. Six subjects were HIV-positive in the immunodepressive phase, and the other four had undergone transplantation (three kidney, one liver). There were no intraoperative or postoperative complications, recurrences, or wound infections. Thus Lichtenstein's hernioplasty using the Surgisis inguinal hernia matrix soft-tissue graft in immunodepressed patients promises safety and efficacy.

Background Delirum is common in hospitalized elderly patients and may be associated with increased morbidity, length of stay and patient care costs. Delirium (acute confusional state) is defined as an acute disorder of attention and cognition. In elderly patients, delirium is often an early indicator of patho-physiological disturbances. Despite landmark studies dating back to the 1940s, the pathogenesis of Delirium remains poorly understood. Early investigators noted that Delirium was characterized by global cortical dysfunction that was associated predominantly with specific electroencephalographic changes. It's important to understand the risk factors and incidence of Delirium. Some of the risk factors are already identified in literature and can be summarized in the word "VINDICATE" which stands for: Vascular, Infections, Nutrition, Drugs, Injury, Cardiac, Autoimmune, Tumors, Endocrine. Aims of this study are: to re-evaluate the above mentioned clinical risk factors, adding some others selected from literature, and to test, as risk factors, a pattern of some genes associated to cognitive dysfunction and inflammation possibly related to postoperative Delirium. Design All patients admitted to our Emergency Unit who are meet our inclusion/exclusion criteria will be recruited. The arising of postoperative Delirium will select incidentally two groups (Delirium/non Delirium) and the forward analysis of correlate risk factors will be performed. As in a typical observational case/control study we will consider all the exposure factors to which our population are submitted towards the outcome (presence of Delirium). Our exposures are the following: ASA, Pain (SVS; VAS), Blood gas analysis (pH; Hb; pO2; pCO2), Residence pharmacological therapy (BDZ; hypnotics; narcotic drugs; alcohol; nitrous derivates), Body temperature, Arterial pressure, Heart frequency, Breath frequency, Na, K, Creatinin, Glicemia, Albumin, Hct, White blood cells, Glasgow Coma Scale (GCS), Cognitive state (SPMSQ), Functional state (ADL and IADL), Psychological Distress (HADS), Cumulative Illness Rating Scale (CIRS), Hypotension (classified in: light; moderate and severe and duration), Blood loss (classified in: < 2 lt and > 2 lt), Blood transfusions (< 2 lt and > 2 lt), Quantity of red cells and plasma transfusions, Visual VAS / SVS (timing: I-II-III post-operative day), Red cells and Plasma transfusions, Blood count evaluation and Saturation (O2%), Postoperative analgesia (Emilia-Romagna protocol), Presence of malignant tumoral disease, APACHE Score II. Moreover the presence of some relevant genetic polymorphisms will be studied in different genes such as IL-6, IL-10, TNF-alpha, and IL-1 cluster.

Two groups of patients suffering from ankylosing spondylitis were treated by total hip arthroplasty. Twenty-one patients (37 hips) were treated with cemented metal-polyethylene prosthesis, whereas 18 patients (36 hips) had cemented ceramic coupling implants. The two groups had similar preoperative clinical data. The average follow-up period was seven to eight years for both. Each patient was graded clinically (pain, function, range of motion, deformities) and roentgenographically (radiolucent lines, etc.). Patients with metal-polyethylene implants showed important modifications of the bone around the implant. Clinical and roentgenographic results were relatively good in patients with ceramic implants. The results underline the importance of the friction coupling of the implant.

Il contributo esamina i costi dell'emigrazione intellettuale italiana all'estero formulando ipotesi sulla base di stime del costo medio di percorrenza del curriculum scolastico e universitrio e di altre variabili