Use of a Paper Checklist to Increase Clinician Adherence to Mammography Screening Guidelines.

OBJECTIVE: To increase clinician adherence to mammography screening guidelines. DESIGN: Quality improvement initiative. SETTING/LOCAL PROBLEM: At a nurse practitioner-led primary care practice, a chart audit of adherence to American Cancer Society mammography screening guidelines indicated a 12% adherence rate for clinicians writing mammography orders. PARTICIPANTS: Nurse practitioners providing care to women ages 40 years and older. INTERVENTION/MEASUREMENTS: The intervention was a screening checklist that was completed by the woman at registration and given to the clinician during the examination. The pre- and postintervention measurement was the percentage of mammogram orders. A Fisher exact test was used to examine changes from pre- to postintervention rates of adherence. RESULTS: After the intervention, the percentage of women for whom a mammogram was recommended and ordered was 69.6%, compared to 12% from the original chart audit. This change was statistically significant (p = .01). CONCLUSION: Clinicians must find efficient approaches to improve processes within their practice settings to ensure that preventive care recommendations are made during visits. Although the screening checklist was deemed useful, improvement in adherence rates is still needed, and a paperless system should be initiated.

Transoral video assisted thyroidectomy: a systematic review.

INTRODUCTION: The aim of this study is to perform a review of the English-language international literature concerning thyroid surgery performed through the transoral vestibular approach, to evaluate its flessibility and safety in terms of complications. MATERIALS AND METHOD: The review was carried out on 17 studies of 17 different Authors. The following variables were taken into consideration: first Author's name, nationality, year of publication, number of cases, hospital stay, conversion rate, type of surgical approach, total number of total thyroidectomies and loboisthmectomies, operative time range, intraoperative blood loss range, number and percentage of complications. RESULTS: 736 procedures were performed: 289 total thyroidectomies and 447 loboisthmectomies. Surgical approach was trivestibular in 15 cases and combined (oro-vestibular) in 2 cases. The operative time varies from 43 minutes for a loboisthmectomy to 345 for a total thyroidectomy. Intraoperative blood loss ranges from 3 to 300 ml. Ten cases were converted into open surgery. The hospital stay varies from 1 to 10 days. Complications were: transient recurrent laryngeal nerve palsy in 34 cases, permanent in 2 cases; transient hypoparathyroidism in 62 cases. One case of postoperative bleeding, 22 postoperative seroma, 20 cases of mental nerve injury, 8 cases of operative wound infection. CONCLUSIONS: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is a new surgical method, the use of which exclusively meets the aesthetic needs of some patients. Its specific complication is the injury of the mental nerves. Further studies, however, seem to be necessary, on numerically broader cases, to ascertain the real validity of the method.

Cold platelets for trauma-associated bleeding: regulatory approval, accreditation approval, and practice implementation-just the "tip of the iceberg".

BACKGROUND: Laboratory and clinical evidence suggest that cold-stored platelets (CS-PLTs) might be preferable to room temperature platelets (RT-PLTs) for active bleeding. Ease of prehospital use plus potential hemostatic superiority led our facility to pursue approval of CS-PLTs for actively bleeding trauma patients. STUDY DESIGN AND METHODS: From November 18, 2013, through October 8, 2015, correspondence was exchanged between our facility, the AABB, and the US Food and Drug Administration (FDA). An initial AABB variance request was for 5-day CS-PLTs without agitation. The AABB deferred its decision pending FDA approval to use our platelet (PLT) bags for CS-PLTs. On March 27, 2015, the FDA approved 3-day CS-PLTs without agitation. On October 8, 2015, the AABB approved 3-day CS-PLTs without agitation and without bacterial testing for actively bleeding trauma patients. Our facility's goal is to carry CS-PLTs on air ambulances. RESULTS: CS-PLTs have been used for trauma patients at our facility since October 2015. As of August 2016, a total of 21 (19.1%) of 119 CS-PLTs have been transfused. The short 3-day storage period combined with the formation of clots in plasma-rich CS-PLTs during storage have been the major causes of a high (80.9%) discard rate. CONCLUSION: In the future, pathogen-reduced (PR), PLT additive solution (PAS) CS-PLTs seem more practical due to low risks of bacterial contamination and storage-related clotting. This should make longer storage of CS-PLTs feasible (e.g., 10 days or more). With a longer shelf life, PR PAS CS-PLTs could potentially be used in a wider range of patient populations.

Incidental thyroid carcinomas. A retrospective study.

AIM: The aim of the present study is to report our series of incidental thyroid carcinomas in the last 15 years and their follow-up, discussing therapeutics indications and surgical choices. PATIENTS AND METHODS: We have considered 1793 patients operated on Surgical Sciences Department of "Sapienza" University of Rome from January 1, 2001 to December 31, 2015. The study was conducted on 83 totally thyroidectomized patients with a real incidental thyroid carcinoma, by clinical, laboratory and instrumental controls. Whole-body scan was the most important test in postoperative evaluation. RESULTS: In our series, the incidence of incidental carcinomas was 4.62%. Compared to the total number of cancer patients, the percentage is 21,9%. In 15.66% of cases there was multifocality and in 7.23% also bilaterality. Regarding the histological type, in all cases they were papillary carcinoma. The size of the neoplastic lesions ranged from a minimum of 3 to a maximum of 10 mm. Whole-body scan revealed lymph node metastasis in 57.69% of patients. DISCUSSION: Comparing these data with our previous studies we have seen a significant increase in incidence of incidental thyroid carcinomas over the years. Our therapeutical choice is total thyroidectomy and complection thyroidectomy after lobectomy, because of a relevant percentage of multifocality and/or bilaterality of these tumors. Many Authors on the contrary prefer a more conservative approach invoking the good prognosis of these tumors. The 57.69% of lymph node metastasis at postoperative whole-body scan comfort us in our setting. CONCLUSION: Incidental thyroid carcinomas are not uncommon. We consider only tumors until 1 cm in diameter. Multifocality and bilaterality are often present such as occult lymph node metastasis. Our therapeutical choice is total thyroidectomy in order to conduct a proper follow-up.

Fine needle aspiration cytology of 650 thyroid nodules operated for multinodular goiter: a cyto-histological correlation based on the new Italian cytological classification (siapec 2014).

The new Italian cytological classification (SIAPEC 2014) of thyroid nodules, in line with those of Bethesda and BTA-RCPath, replaces the previous TIR3 class with two new classes (TIR3A and TIR3B), which correspond to different risks of malignancy and clinical actions required. The present study was conducted to evaluate the diagnostic accuracy of the new SIAPEC classification as opposed to its previous version (SIAPEC 2007). Preoperative cytology was compared with the final histology obtained from 650 consecutive patients who underwent total thyroidectomy for multinodular goiter. Of this total, 434 patients (group A) had their cytological diagnosis based on the old SIAPEC 2007 classification and 216 patients (group B) had their cytological diagnosis based on the SIAPEC 2014 classification. In group A 111 patients (25.6%) had a TIR3 diagnosis, while in group B 52 patients (24.1%) received a TIR3 diagnosis, of whom 30 had TIR3A and 22 had TIR3B. In group A, 46 (41.4%) out of the 111 patients with TIR3 diagnosis had, based on histology, a thyroid carcinoma. In group B, only 2 (6.7%) out of 30 patients with TIR3A diagnosis had a thyroid carcinoma. This rate of malignancy was significantly lower (p less than 0.001) than that observed in patients with TIR3B diagnosis, in which 12 (54.5%) out of 22 patients had a carcinoma. The observations here reported show that, in respect to the previous version, the new Italian cytological classification provides greater diagnostic accuracy for detecting thyroid nodule malignancy.

Early discharge after total thyroidectomy: a retrospective feasibility study.

AIM: The continued hospitalization after total thyroidectomy is often due to the onset of hypocalcemic complications more than 24 hours after surgery. So it would be important to predict which patients will not develop the hypocalcemic complication to discharge them early. This was the aim of our study. PATIENTS AND METHODS: Our retrospective study was conducted on 327 consecutive thyroidectomized patients, operated on for benign and malignant diseases. We evaluated the values of preoperative serum calcium levels (Cal0) and of the first postoperative day (Cal1) and two new variables were calculated (dCal and dCaln). The same thing was made on a subgroup of 111 patients in whom also parathiroyd hormone (PTH) values were detected. Statistical analysis was performed with the goal of determining if we could establish a safe criterion for discharge at 24 hours after surgery and if there is a correlation between suitability for discharge and diagnosis. RESULTS: As to discharge, the predictive power of the discriminant function applied was significant both on the total of patients and in the subgroup of 111 patients, but it was clinically unacceptable because it would expose us to a 21% to 27% error rate. It is not possible to identify a threshold, below which to consider patients surely dischargeable. The diagnosis does not appear correlated with the suitability for discharge. CONCLUSION: On the basis of serum calcium and PTH levels in the first postoperative day, it is impossible to predict which patients can be discharged 24 hours after surgery without incurring in hypocalcemic complications.

p300 modulates nuclear morphology in prostate cancer.

Alterations in nuclear structure distinguish cancer cells from noncancer cells. These nuclear alterations can be translated into quantifiable features by digital image analysis in a process known as quantitative nuclear morphometry. Recently, quantitative nuclear morphometry has been shown to predict metastasis and biochemical recurrence of prostate cancer. However, little is known about the cellular mechanisms underlying these nuclear morphometric changes. Alterations of nuclear matrix proteins are frequently involved in changes of nuclear structure. A number of co-activators interact with these nuclear structure-related proteins, suggesting that they might be involved in quantitative nuclear morphometry changes. We have shown previously that the transcriptional co-activator p300 is involved in prostate cancer progression. However, the ability of a transcriptional regulator like p300 to modulate nuclear morphology has not been described previously. In the present study, we show that p300 expression in prostate cancer biopsy tissue from 95 patients correlates with quantifiable nuclear alterations. Moreover, we show that transfection of p300 into prostate cancer cells in culture induces quantifiable nuclear alterations, such as diameter, perimeter, and absorbance among others, as assessed by digital image analysis. These alterations correlate individually with aggressive features in prostate cancer, such as expression of the proliferation marker Ki-67 and extraprostatic extension of the tumor. Finally, we found that transfection of p300 into prostate cancer cells specifically increases mRNA and protein levels of nuclear matrix peptides lamins A and C, suggesting that these proteins mediate the p300-induced effects. These findings reveal a new insight into the transcriptional and structural regulation of prostate cancer.

p300 in prostate cancer proliferation and progression.

Although prostate cancer (PCa) is the most frequently diagnosed cancer in males, little is known about the mechanisms involved in its progression. Recent in vitro studies suggest that coactivators of the androgen receptor play an important role in PCa progression. We have shown previously that p300 is involved in androgen receptor transactivation. In the present work, we studied 95 patients with biopsy-proven PCa who underwent prostatectomy as treatment of their tumors between 1995 and 1998. We found that p300 correlated with in vivo proliferation (P = 0.009) as determined by MIB-I expression. Moreover, high levels of p300 in biopsies predicted larger tumor volumes (P < 0.001), extraprostatic extension (P = 0.003), and seminal vesicle involvement (P = 0.002) at prostatectomy, as well as PCa progression after surgery (P = 0.01). Furthermore, we found that the disruption of p300 transcripts through small interfering RNA inhibited PCa cell proliferation both at the basal level and on interleukin 6 stimulation. We conclude that p300 plays an important role in PCa cell proliferation, as well as PCa progression.

[Surgical rehabilitation of stomal disease]. / La riabilitazione chirurgica delle patologie stomali.

The Authors report their experience in the surgical rehabilitation of patients with complicated ileo- or colostomy. Mechanical and psychosocial implications as well as different rehabilitative methods are discussed. The results of a surgical protocol in the treatment of stomal diseases observed in 63 patients are herein reported. In 14 patients the surgical treatment was performed in general anaesthesia, while in 49 local anaesthesia was used. The latter was better tolerated by the patients. In conclusion, surgery should play a major role in this rehabilitation protocol, either in terms of prevention or definitive treatment.

[Results of the local excision of rectal cancer after high-dose radiotherapy associated or not to chemotherapy]. / Risultati dell'escissione locale del cancro del retto dopo radioterapia ad alte dosi associata o meno a chemioterapia.

Local excision of rectal cancer in low-risk patients is appealing but it provides limited control of the disease. Postoperative radiation therapy may improve results. The Authors report on their experience with preoperative high dose radiation therapy for rectal cancer patients; more recently, chemoradiation was used. Local excision is advised only for those patients with minimal or no residual disease. The results obtained in 34 cases are encouraging; moreover, a better control of the disease seems to be offered combining chemo- and radiotherapy.

[Gastric resection and subtotal gastrectomy. Principles and updated surgical technique]. / La resezione gastrica e la gastrectomia subtotale. Princìpi ed attualità di tecnica chirurgica.

The Authors describe their last 10 years experience in gastric surgery. They report the results obtained in 12 gastric resections performed for complications following gastric and/or duodenal peptic ulcers, in 33 cases of total gastrectomies (34%), and 48 cases of subtotal gastrectomies (49%) for early and advanced cancer. The results lead to interesting conclusions: first of all achieving a wide jejunojejunostomy between the afferent and the efferent loop the problems related to gastric resection (as postoperative sequelae, dumping syndrome, reflux esophagitis, alkaline gastritis, etc.) are avoided. Problems regarding lymphadenectomy in patients submitted to subtotal gastrectomy (D2-D3) are then reported. After a brief history of gastric reconstruction following gastric resection the evolution in surgical techniques and the results obtained during the last 10 years are described. The good long term results allow to conclude that our strategy in gastric surgery ensures a good quality of life of the patients as well as a radical operation in case of gastric cancer.

[Septic ascites: a rare post-operative complication]. / L'ascite settica: una rara complicanza post-operatoria.

Spontaneous bacterial peritonitis in patients with chronic hepatitis represents a very controversial matter in terms of frequency, pathology and treatment. This unusual complication mainly due to decreased immunological defences and ascitic fluid opsonic activity is not accepted by all the Authors as a rare event. However, there is agreement as far as management is concerned: cultural examination of the ascitic fluid and the relative antibiogram are the best tools in guiding the approach to an adequate antibiotic therapy.

[Anterograde laparoscopic cholecystectomy: when and why]. / La colecistectomia laparoscopica per via anterograda: quando e perché.

Today largely diffused is the concept that laparoscopic cholecystectomy (LC) represents the treatment of choice for symptomatic gallstones. Nonetheless some questions have been raised on the real safety of this new method in terms of procedure-related complications. On the basis of our experience with traditional open cholecystectomy, we have recently performed a prograde LC in those cases with difficulties in identifying the anatomical structures of the so called Calot's triangle. This alternative route can be easily performed laparoscopically and has been useful in reducing the time of the intervention in the most difficult setting and to increase the safety of the procedure. The technical details and the results are compared with those of the laparoscopic retrograde route.

[Malignant peritoneal mesothelioma: apropos a new case]. / Il mesotelioma peritoneale maligno: a proposito di una nuova osservazione.

Prognosis for patients with malignant peritoneal mesothelioma is very poor, and most patients are beyond cure by the time the diagnosis has been made. The pathogenesis of this uncommon neoplasm seems to be related to asbestos and radiation exposure. The authors report a case of diffuse peritoneal mesothelioma in a 33-year-old man. Since the patient complained of aspecific symptoms and both biochemical and "imaging" studies did not provide useful informations for a definitive diagnosis, an exploratory laparotomy was performed. Intraoperative histological findings demonstrated the presence of a malignant peritoneal mesothelioma which had spread all over the omentum; considering the inoperability assessment of this case, the operation was completed and the patient was dismissed with an adjuvant chemo-therapy. Five weeks later the patient died.

[Knight-Griffen ileo-proctostomy after total colectomy]. / L'ileo-rettostomia secondo Knight e Griffen dopo colectomia totale.

The double stapled colo-rectal anastomosis according to Knight e Griffen is currently used following an anterior resection of the rectum. The technical feasibility and the reduced risk of contamination represent the major advantages of the procedure. Accordingly, the Authors have adopted this technique to perform an ileo-rectal anastomosis following total colectomy. Furthermore, the use of a circular stapler with a small diameter allows to create a pseudo-valvular mechanism between the ileum and the rectum. Preliminary results obtained in 7 patients are presented.

[Integrated anastomosis using the Knight and Griffen technique]. / L'anastomosi integrata secondo Knight e Griffen.

The widespread use of mechanical staplers in gastrointestinal surgery has recently resulted in a simpler and faster operative technique. The double-stapled anastomosis (Knight and Griffen, 1980) seems to further simplify the technique of colo-rectal anastomosis, with reduced risks of pelvic contamination. Moreover, this technique can be used to reconstitute bowel continuity following an Hartmann's procedure or to perform an ileo-rectal anastomosis. The results obtained in 21 patients treated by this technique are presently reported.

Primary hyperparathyroidism. A case report.

A case of primary hyperparathyroidism due to diffuse parathyroid hyperplasia, with thyroid goiter, bilateral renal lithiasis and fibrocystic osteitis is reported. Precise identification of parathyroid glands was achieved by U.S. and U.S.-assisted fine-needle aspiration. The role of the different diagnostic procedures has been evaluated in order to assess preoperatively a correct surgical approach.