Comparison between the high-definition 3D exoscope and the operating microscope in head and neck reconstruction.

The purpose of this study was to compare the three-dimensional (3D) operating exoscope (OE) with the conventional operating microscope (OM) in head and neck reconstruction. A retrospective cohort study was performed including 50 consecutive patients with no history of previous surgery or irradiation (32 male, 18 female; mean age 59.2 ± 13.3 years), who underwent free flap head and neck reconstruction using a 3D OE (n = 25; OE group) or conventional OM (n = 25; OM group). The mean total operative time was 8.0 ± 1.53 h in the OE group and 7.6 ± 1.52 h in the OM group (P = 0.86). The median (interquartile range) anastomosis time was 78.0 (63.0-91.5) minutes in the OE group and 90.0 (75.5-115.0) minutes in the OM group (P = 0.06). The final free flap survival rate was 100%. Only seven patients experienced a free flap reconstruction-related complication, and they were similarly distributed between the two groups (four in the OE group, three in the OM group; P = 0.68). Secondary outcomes (length of hospital stay, tracheostomy dependence, feeding tube dependence) were comparable in the two groups (P > 0.05). The 3D OE is a viable alternative to the conventional OM for performing standard head and neck free flap reconstructive procedures.

Epidemiological and molecular characterization of HBV and HCV infections in HIV-1-infected inmate population in Italy: a 2017-2019 multicenter cross-sectional study.

HBV/HCV co-infection is common in HIV-1-infected prisoners. To investigate the characteristics of HIV co-infections, and to evaluate the molecular heterogeneity of HIV, HBV and HCV in prisoners, we carried-out a multicenter cross-sectional study, including 65 HIV-1-infected inmates enrolled in 5 Italian detention centers during the period 2017-2019. HIV-1 subtyping showed that 77.1% of inmates were infected with B subtype and 22.9% with non-B subtypes. Italian nationals were all infected with subtype B (93.1%), except two individuals, one infected with the recombinant form CRF72_BF1, and the other with the HIV-1 sub-subtype A6, both previously not identified in inmates of Italian nationality. Non-Italian nationals were infected with subtype B (52.6%), CRFs (36.8%) and sub-subtypes A1 and A3 (5.2%). HIV variants carrying resistance mutations to NRTI, NNRTI, PI and InSTI were found in 7 inmates, 4 of which were never exposed to the relevant classes of drugs associated with these mutations. HBV and/or HCV co-infections markers were found in 49/65 (75.4%) inmates, while 27/65 (41.5%) showed markers of both HBV and HCV coinfection. Further, Italian nationals showed a significant higher presence of HCV markers as compared to non-Italian nationals (p = 0.0001). Finally, HCV phylogenetic analysis performed in 18 inmates revealed the presence of HCV subtypes 1a, 3a, 4d (66.6%, 16.7% and 16.7%, respectively). Our data suggest the need to monitor HIV, HBV and HCV infections in prisons in order to prevent spreading of these viruses both in jails and in the general population, and to implement effective public health programs that limit the circulation of different genetic forms as well as of viral variants with mutations conferring resistance to treatment.

Sudden death after fatal percussion of the cervical neurovascular bundle.

Background: Atypical compression of the neck may be classified as asphyxia in which the external compression on the cervical anatomical structures occurs in a peculiar manner. In such cases, death occurs due to the combination of several pathophysiological phenomena, such as respiratory, vascular, and nervous. When the mechanical action on the neck is violent and rapid, it is more correct to use the word percussion rather than compression. Usually there are no skin lesions of special significance in this type of neck percussion, unlike the cases of choking, strangulation, and hanging, and the diagnosis is challenging. It is important to carefully evaluate the body during the autopsy to identify which pathophysiological mechanism caused the death. Case report: A young woman died immediately after being struck by a concrete beam at the level of her neck. The woman was on vacation with her boyfriend and decided to hang from a concrete beam suspended between two columns to take a souvenir photo when the beam suddenly broke and fell on her. The autopsy revealed multiple abrasions, swelling, and lacerations to the face, neck, and chest. Internal examination revealed primarily the presence of hemorrhagic infiltration in the anterior cervical compartments and lacerations of various organs, including the trachea. Conclusion: Based on all the obtained data, including toxicological and histological, the cause of death was atypical ab extrinsic percussion of the neck, directed particularly at the right cervical neurovascular bundle.

3D printing and 3D bioprinting technology in medicine: ethical and legal issues.

Abstract: There has been a surge of interest in new technologies in medicine because of their promising clinical applications. Extensive research on additive manufacturing and its applications in the medical field has been carried out with good results and very high expectations. Due to their disruptive nature and potential, 3D printing and even more 3D bioprinting raise many ethical and safety concerns that need to be adequately addressed to provide good regulation before entering clinical practice. This article aims to highlight the general ethical concerns associated with the use of additive manufacturing in medicine and the lack of current international regulatory directives to guide these experiments. Transparency about how these new medical devices are regulated and approved is a fundamental requirement to promote and improve public trust, efficiency, safety and quality.

Evaluation of factors associated with trust in telemedicine in patients with inflammatory bowel disease during COVID-19 pandemic: a multicenter cross-sectional survey.

OBJECTIVE: Telemedicine (TM) has had a powerful impact in recent years, particularly on managing chronic diseases such as inflammatory bowel disease (IBD). Knowing patients' expectations and concerns is essential to increase their confidence in this mode of medical care. PATIENTS AND METHODS: We interviewed a large cohort of IBD patients enrolled at two Italian tertiary referral centers to investigate their trust in TM. RESULTS: A total of 376 patients completed the survey and were included in the study: 293 (77.9%) considered TM valuable for managing their disease, and 307 (85%) wanted to have TM service at their center. However, only 99 patients (26.3%) believed that TM guarantees the same level of care as the in-person visit. Among the socio-demographic variables, those independently associated with trust in TM were the higher education qualification (p=0.02) and the level of competence in information and communication technologies (ICT) (p=0.03). CONCLUSIONS: Our findings highlighted the importance of equipping IBD patients with basic ICT skills to utilize TM services and increase their confidence in ICT with the help of caregivers. Additionally, to improve the perceived value of TM, it will be helpful to use additional tools such as telemonitoring of disease activity using patients' reported outcomes or remote measurement of fecal calprotectin.

Use of a proline-specific endopeptidase to reintroduce gluten in patients with non-coeliac gluten sensitivity: A randomized trial.

BACKGROUND: A gluten-free diet (GFD) is the main therapy for non-coeliac gluten sensitivity (NCGS). However, the availability of novel enzymes with the ability to digest gluten could represent a therapeutic opportunity for NCGS patients to avoid a GFD. AIMS: To evaluate the controlled reintroduction of gluten with or without the endopeptidase P1016 in NCGS patients. METHODS: This is a randomized, double-blind, placebo-controlled monocentric study, Registered under ClinicalTrials.gov Identifier no. NCT01864993. Gluten was reintroduced incrementally over a 3-week period under nutritional control. NCGS patients were randomized into two groups and administered P1016 or placebo during gluten reintroduction. We evaluated symptoms (visual analogue scale, VAS), quality of life (SF-36) and mental health symptoms (SCL-90) on a weekly basis. RESULTS: We enrolled a total 23 patients who were allocated to a placebo group (n = 11, age 38.4 ± 2.9) or an intervention group (n = 12, age 39.5 ± 3.1). No effect of P1016 on symptoms was found. During gluten reintroduction, patients reported a significant increase in abdominal pain and a worsening of stool consistency. Furthermore, no differences were found between the groups regarding SCL-90 and SF-36 scores. CONCLUSIONS: Our results demonstrate a lack of effect of P1016 in the management of NCGS patients and the possible reintroduction of gluten.

Abuse and misuse of prescription opioids: is it only an Ameri- can problem? An observational study on an Italian casuistry.

ABSTRACT: Medical use of prescription opioids has steadily increased since the 1990s, particularly in the U.S.A. and Canada, along with abuse of these substances and significant increases in rates of addiction and death related to prescription opioids. The American authorities speak of an "addiction epidemic" and are launching a series of countermeasures to better address the problem. In Europe, there is an increasing use of prescription opioids and related problems, but the European context is much less dramatic than the American and Canadian ones. Never-theless, based on the data, it cannot be ruled out that a similar crisis will occur on the Old Continent. The aim of this study is to analyze the Italian context to better understand whether there is a possibility of an addiction epidemic. Twenty-four cases of death of people under treatment with pre-scription opioids have been retrospectively analyzed. Toxicological samples were collected with routine methods during the autopsy, followed by systematic screening for substances by diverse methods. Volatile compounds were identified using gas chromatography-flame ionization detection (GC-FID). Medical drugs and drugs of abuse were identified via the use of gas chromatography-mass spectrome-try (GC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS-MS). Of a total of 24 subjects, 14 died due to an overdose of Tramadol, while 7 died due to an overdose of Buprenorphine and 3 dues to a Fentanyl overdose. The most used drug was Tramadol. Histological examination was performed with hematoxylin/eosin staining, though no significant findings emerged apart from widespread edema and focal sclerosis of the myocardium, and interstitial and alveolar edema of the lungs. Our data show that attention must be paid to prescription opioids. European institutions, as soon as possible, must implement preventive measures that avoid the recurrence of the North American situation.

Bleeding varicose veins' ulcer as a cause of death: a case report and review of the current literature.

ABSTRACT: Chronic venous insufficiency (CVI) and varicose veins (VVs) of the lower limbs are very frequent vascular diseases in Western countri-es. One possible complication of these conditions is skin ulceration and its consequent rupture, which can be spontaneous or due to mild or trivial trauma. In some cases, the resulting hemorrhage is fatal. When the victim is found dead, a large amount of blood around the body might lead to the hypothesis of violent death. The Forensic Pa-thologist needs to be very careful in the corpse's examination, in order to exclude any alternative cause of death. Herein, an illustrative case is reported, as well as a literature review of the literature concerning sudden hemorrhages from VVs. We found 27 scientific papers, the total reported cases of VVs rupture with profuse hemorrhages were 36, 32 of which were fatal. The main characteristics of such forensic scenario have been collected. Corpse examination of the victims showed pallor of the skin and mucous membranes, as well as marked pallor of organs as a sign of hemorrhagic shock, but these pathological findings are unspecific. Usually, the skin near the ulcer presented color alteration (discoloration and atrophy or pigmentation and hyperemia). Besides, the histological examination of the skin could be a valid instrument to demonstrate the presence of the ulcer, even if it could be very difficult to sample, because of its small size. An important limit of our study is the small number of collected cases. More studies in this field are needed to improve evidence concerning death due to VVs rupture.

Comparative study between conventional and new methods in defining the cause of death from anaphylactic shock.

ABSTRACT: Anaphylaxis is defined as a rapid systemic reaction that develops in individuals previously exposed to specific allergens. The new exposure causes systemic cellular degranulation, which in turn leads to cardiovascular and respiratory changes that are fatal if not treated immediately. One of the main problems of this scenario in the forensic field is the determination of a correct post-mortem diagnosis. Traditional methods, such as histopathological examination of the respiratory tract and the use of specific antibodies used in immunohistochemistry, are sensitive but not always specific and therefore do not guarantee a high degree of probability in the diagnosis of anaphylaxis. For this reason, a new and promising research frontier in this field of forensic pathology could be represented by the application of miRNAs as biomarkers, as has been done in other areas of medicine.

Elective neck irradiation in the management of esthesioneuroblastoma: a systematic review and meta-analysis.

BACKGROUND: There is no consensus about the optimal management of the neck in clinically node negative esthesioneuroblastoma (ENB). The aim of this study is to assess the impact of elective neck irradiation (ENI) in terms of regional disease control and survival. METHODS: The study was performed according to the PRISMA guidelines searching on Scopus, PubMed/MEDLINE, and Google Scholar databases. The primary outcome was the regional recurrence rate (RRR), that was reported as odds ratio (OR) and 95% confidence interval (CI). Secondary outcomes were the overall survival (OS), and the distant-metastases free survival (DMFS), that were reported as logarithm of the hazard ratios (logHRs) and 95% confidence intervals (CIs). RESULTS: A total of 489 clinically node negative patients were included from 9 retrospective studies. ENI significantly reduced the risk of regional recurrence compared to no treatment. No difference was measured between ENI and observation, according to both OS and DMFS. No stratified analysis could be performed based on Kadish stage and Hyams grade. CONCLUSIONS: ENI should be recommended to improve the regional disease control. No advantage was measured in terms of survival or distant metastases with a low quality of evidence. Further prospective studies should be designed to understand if ENI could be avoided in early stage and low-grade tumors.

Estimation of the time of death: where we are now?

ABSTRACT: One of the increasingly discussed topics in forensic pathology is that concerning the quantification of the postmortem interval (PMI). The estimation of the time interval between the death of a person and the discovery of the body is extremely complicated, as it is affected by the influence of many factors, both endogenous and exogenous. With the advancement of knowledge in the field of molecular biology, several studies have been performed, for more than 30 years, on the degradation pattern of macromolecules, such as proteins, DNA, RNA, and the relationship with PMI. Despite initial enthusiasm, studies have shown different kind of limitations in determining PMI in the forensic field. In the last years, consequently, researchers focused their attention on the potential of microRNAs as housekeeping genes, due to their postmortem stability and resistance to degradation. MiRNAs are small, endogenous, single stranded, non-coding RNA molecules identified in plants, animals and DNA virus transcriptome. Various and growing are the fields of application: to establish time of death, to evaluate vitality of skin lesions, in cases of head trauma, and cases of acute myocardial infarction. Their use could also be particularly useful in determining late PMI (beyond 24 hours after death), as no additional markers are available in this scenario. At the moment, scientific research is still at an early stage as it is mainly based on animal models. However, the promising properties of miRNAs and their low cost may make this field of research very interesting for an increasingly precise determination of PMI in the future.

Post-mortem diagnosis of sepsis: when it's too late.

Post-mortem diagnosis of sepsis is often very difficult to make, especially in the elderly affected by multiple comorbidities. However, clinical evaluation following histology, immunohistochemistry, microbiological tests, immunoassays and proteomics can improve reliability of this post-mortem diagnosis.

Assisted reproduction and Coronavirus in Italy.

OBJECTIVE: A novel type of Coronavirus was identified in China in December 2019. The first cases of a form of pneumonia of unknown etiology were detected at the beginning of that month in Wuhan. The virus is believed to have emerged at the Wuhan Huanan Seafood Market, where transmission of a zoonotic pathogen to humans occurred. PATIENTS AND METHODS: Some studies conducted in China during the epidemic report small numbers of pregnant women infected with SARS-CoV-2 and some pregnancy complications in patients with COVID-19. However, they fail to document the transplacental passage of the virus from mother to fetus. RESULTS: Following the COVID-19 outbreak, guidelines for couples who are undergoing treatments of assisted reproduction have been issued by the International Federation for Fertility Societies (IFFS), the American Society for Reproductive Medicine (ASRM), the European Society of Human Reproduction and Embryology (ESHRE) and the Latin American Network of Assisted Reproduction (REDLARA). They recommend couples to discuss assisted reproduction with their doctors while those at risk or with SARS-CoV-2 should consider freezing oocytes or embryos and retransferring them later. CONCLUSIONS: Other than the US, Italy is the country with the highest number of cases (197675 positives, 26644 deaths) (updated on April 26). The Italian National Transplant Centre and the Higher Institute of Health advised on March 17 to complete the cycles already started and not to start new cycles. Phase 2 will begin on 4 May with an increase in freedom of action and fertilization treatments will start again. The Society that brings together embryologists (SIERR) has issued the guidelines to be followed when this happens.

Minimally invasive surgery under local anaesthesia for chronic rhinosinusitis with nasal polyps: our experience in older adults.

OBJECTIVE: This paper aims to report our experience with a minimally invasive surgical procedure for the treatment of chronic rhinosinusitis with nasal polyps, performed in a day-surgery setting under local anaesthesia. METHODS: A retrospective study of 30 patients with chronic rhinosinusitis with nasal polyps was conducted. Sino-Nasal Outcome Test 22 and modified Lund-Kennedy scores were collected. Intra- and post-operative pain was evaluated using a 10-point visual analogue scale. RESULTS: The mean Sino-Nasal Outcome Test 22 score decreased from 41.8 ± 15.8 pre-operatively to 13.3 ± 9.5 post-operatively (p < 0.001). Accordingly, the mean endoscopic score decreased from 6.8 ± 1.8 to 0.2 ± 0.7 (p < 0.001). The mean intra-operative pain score was 2.9 ± 3.2, and 29 patients (96.7 per cent) reported no pain in the post-operative period (visual analogue scale score = 0). CONCLUSION: Our study confirms that minimally invasive surgery represents a safe, repeatable procedure that results in remarkable subjective and objective improvement, without intra- and post-operative pain or discomfort.

Teaching parotid surgery to ENT residents in the era of new technologies: an ex-vivo ovine model.

Surgical training has recently assumed a central role in the otolaryngology field, and the necessity to train residents and fellows' skills in a progressive manner has led to an incredible widespread of ex-vivo animal models for several surgical procedures. To report our experience with an ex-vivo ovine model for parotid gland dissection in a training context. A junior resident (PGY-1) and a post-graduate student with no experience in parotid surgery were guided by a skilled surgeon in the parotid gland dissection for each step of the procedure. Three different adult lamb heads were used for this feasibility study. A specific preparation of the model was performed before the training session. Similarity between the ovine model and the human were recorded. The resident and the post-graduate student were able to carry out a complete parotid gland dissection under supervision. The correct identification of surgical landmarks has led to a proper surgical simulation. The facial nerve dissection was adequately performed, and all branches were isolated. Parotid surgery training on an ex-vivo ovine model is useful, easy repeatable, and low cost. The ovine model presented in this study has similarities in size, structure, and tissue consistence to the human parotid, making it an ideal model for residents to simulate parotid surgery.

Micronutrients in support to the one carbon cycle for the modulation of blood fasting homocysteine in PCOS women.

PURPOSE: Fasting blood homocysteine is increased in PCOS women and is involved in several of its co-morbidities including cardiovascular disease and infertility. Corrective interventions based on the administration of supra-physiologic doses of folic acid work to a low extent. We aimed to test an alternative approach. METHODS: This was a prospective, randomized, parallel group, open label, controlled versus no treatment clinical study. PCOS women aged > 18, free from systemic diseases and from pharmacological treatments were randomized with a 2:1 ratio for treatment with activated micronutrients in support to the carbon cycle (Impryl, Parthenogen, Switzerland-n = 22) or no treatment (n = 10) and followed-up for 3 months. Fasting blood homocysteine, AMH, testosterone, SHBGs, and the resulting FTI were tested before and at the end of the follow-up. RESULTS: The mean baseline fasting blood homocysteine was above the normal limit of 12 µMol/L and inversely correlated with SHBG. AMH was also increased, whereas testosterone, SHBG, and FTI were within the normal limit. The treatment achieved a significant reduction of homocysteine, that did not change in the control group, independently of the starting value. The treatment also caused an increase of AMH and a decrease of SHBGs only in the subgroup with a normal homocysteine at baseline. CONCLUSIONS: In PCOS ladies, blood homocysteine is increased and inversely correlated with the SHBGs. Physiologic amounts of activated micronutrients in support to the carbon cycle achieve a reduction virtually in all exposed patients. Whether this is of clinical benefit remains to be established.

Effect of quorum sensing molecules and natamycin on biofilms of Candida tropicalis and other yeasts isolated from industrial juice filtration membranes.

AIMS: Cells limit the cell number of dense biofilms by releasing self-inhibitory molecules. Here, we aim to assess the effectiveness of yeast quorum sensing (QS) molecules and the antifungal agent natamycin against yeast biofilms of strains commonly isolated from fruit juice ultrafiltration membranes. METHODS AND RESULTS: Yeast QS molecules, such as tyrosol, 2-phenylethanol and farnesol, were detected by solvent extraction and HS-SPME GC-MS in Candida tropicalis cultures. The effect of QS molecules on mono- and multispecies biofilms formed by Rhodotorula mucilaginosa, C. tropicalis, Candida krusei and Candida kefyr was evaluated by plate count and epifluorescence microscopy. Farnesol caused a decrease in cell number and disrupted mono- and multispecies yeast biofilms during adhesion (0·6 mmol l-1 ). 2-phenyl ethanol 1·2 mmol l-1 stimulated biofilm density and increased cell number in both mono- and multispecies biofilms, while tyrosol did not show effects when tested against C. tropicalis biofilms (0·05-1·2 mmol l-1 ). Natamycin caused a strong decrease in cell number and disruption of biofilm structure in C. tropicalis biofilms at high concentrations (0·3-1·2 mmol l-1 ). The combination of farnesol 0·6 mmol l-1 and natamycin at 0·01 mmol l-1 , the maximum concentration of natamycin accepted for direct addition into fruit juices, effectively reduced cell counts and disrupted the structure of C. tropicalis biofilms. CONCLUSION: Farnesol 0·6 mmol l-1 significantly increased the inhibition exerted by natamycin 0·01 mmol l-1 (~5 ppm) reducing biofilm development from juice on stainless steel surfaces. SIGNIFICANCE AND IMPACT OF THE STUDY: These results support the use of QS molecules as biofilm inhibitors in beverages and would certainly inspire the design of novel preservative and cleaning products for the food industry based on combinatory approaches.