Laparoscopic transperitoneal hernia repair (TAPP) in emergency: long-term follow-up in a high volume centre.

PURPOSE: Aim of this study was to analyse feasibility, safety and effectiveness of laparoscopic transperitoneal hernia repair (TAPP) approach to inguinal hernias in the emergency setting, with a longer follow-up than the studies present in literature. METHODS: We retrospectively analysed all patients who underwent emergency TAPP hernia repair in San Marco Hospital (Zingonia, Italy), from September 2010 to June 2020. A prospectively collected database of 685 consecutive TAPP hernia repair was reviewed. Feasibility and safety were evaluated through operative time, conversion rate, perioperative mortality, morbidity and prosthesis infection rate. Effectiveness was assessed by recurrence and complication rate, acute (during admission) and chronic (during follow-up) pain by Visual Analogic Scale (VAS), and recovery to normal activity in a long-term follow-up (mean period 1718 days). RESULTS: The final study group included 47 patients. The mean age was 59.6 years (range 22-89), 29 patients were male and 18 were female. The mean operation time was 64 min. Two cases were converted to open approach (4%). In four cases bowel resection became necessary (8.5%). Appendicectomy and omentectomy occurred once and twice, respectively (2% and 4%), and orchiectomy was required in two patients (4%). Seroma was the only postoperative complication that we registered in four patients. During a mean follow-up period of 1718 days, there was no recurrence of the hernia or other complications. Five patients referred mild occasional groin pain (VAS < 3), with quick relief without taking any pain killers. CONCLUSION: TAPP approach is a safe, feasible and effective therapeutic option for groin hernias in emergency setting. No recurrence or severe complications were reported in over 4 years of follow-up.

Non-lactose-fermenting uropathogenic Escherichia coli from dogs: virulence profile characterization.

Non-lactose-fermenting Escherichia coli (NLFEC) has a few descriptive studies restricted to human infections. In the present study, isolates of NLFEC obtained from urine samples of dogs with hyperadrenocorticism were characterized regarding their virulence ability, biofilm formation capacity and antimicrobial susceptibility profile. Escherichia coli lactose-fermenting strains from urinary infection in dogs with the same conditions were analysed to provide comparisons. The non-lactose-fermenting E. coli strains were classified as belonging to clade I E. coli, whereas the lactose-fermenting strains were classified in phylogroup B2. All strains presented virulence markers to adhesion, iron acquisition, toxins, colicin and cytotoxin production, and biofilm regulation. Components of the extracellular matrix in addition to the in vitro biofilm formation ability were observed in the strains. Multidrug resistance (MDR) profiles were observed by in vitro susceptibility tests to all NLFEC strains. In summary, non-lactose-fermenting uropathogenic E. coli from dogs behaves similar to lactose-fermenting E. coli, exhibiting MDR profile, and pathogenic potential of promote animal infections.

Insights on the genetic features of endometrial pathogenic Escherichia coli strains from pyometra in companion animals: Improving the knowledge about pathogenesis.

Endometrial pathogenic E. coli (EnPEC) isolates are involved in endometrial infections in animals and humans. Besides the high aggressiveness of the endometrial infections, the EnPEC virulence profile and pathogenesis are still little known. In this study, we have sequenced and analyzed an EnPEC strain from canine pyometra (E. coli_LBV005/17), following a molecular characterization of the virulence profile and phylogenetic evolution of an EnPEC collection from canines and felines (45 strains). Most of the strains belonged to phylo-group B2, and display a high virulence profile. In particular we highlight the classification of the E. coli_LBV005/17 as sequence type 131 (ST131), in addition to other five strains, as observed by gyrB phylogenetic analysis. Also, the phylogenetic position of EnPEC strains from pyometra in companion animals suggests that their origins are from both extraintestinal and commensal E. coli strains. Accordingly to Principal Coordinates Analysis (PCoA) and phylogenetic analysis we can propose that EnPEC strains have neither the same genetic profile, nor a unique common ancestral. In summary, the present work characterize an EnPEC genome from bitch pyometra and the genetic profile of 45 EnPEC strains from companion animals pyometra, being the commonest virulence pattern: fimA, papC, hlyA, hlyE, cnf1, entB, iroN, irp1, bssS, bssR, and hmsP. These data improving the background knowledge of this E. coli pathotype related to pyometra in companion animals and may support new methods to prevent the disease evolution.

Molecular detection of Salmonella serovars Enteritidis, Heidelberg and Typhimurium directly from pre-enriched poultry samples.

1. Salmonella is one of the most important pathogens in public health and it is usually associated with food-borne diseases. Salmonella serovars Enteritidis and Typhimurium are widespread in the world with outbreaks frequently associated with consumption of poultry products; furthermore, there is an increasing public health concern with the wide dissemination of the serovar Heidelberg in poultry flocks. 2. The aim of the experiment was to develop and to validate rapid methods to detect Salmonella serovars Enteritidis, Typhimurium, and Heidelberg by real-time PCRs and test isolates from pre-enriched poultry samples. 3. Three real-time PCRs were developed and used in combination to detect the serovars Enteritidis, Typhimurium and Heidelberg. These assays were validated by the analysis of 126 Salmonella isolates, eight other enteric bacterial species and 34 naturally contaminated poultry samples after pre-enrichment with buffered peptone water (BPW). 4. Real-time PCRs detected the isolates of the most important poultry serovars (Enteritidis, Typhimurium and Heidelberg) with 100% inclusivity and exclusivity in each assay. The PCR identified monophasic variants of the serovars Typhimurium and Heidelberg. All PCRs were validated in detecting these specific serovars directly from pre-enriched poultry samples. The whole analytical procedure was performed in less than 24 h in a veterinary diagnostic laboratory.

Palatal obturators in patients after maxillectomy.

Prosthodontic management of palatal defects is fundamental to improve patient's life undergoing to a maxillary surgical treatment. A lot of maxillary defects are a direct consequence of surgical treatment of malformations, neoplasms or trauma. The obturators are prosthesis used to close palatal defects after maxillectomy, to restore masticatory function and to improve speech. The primary goals of the obturator prosthesis are to preserve the remaining teeth and tissue and to provide comfort, function, and aesthetics to the patients. Different materials and retention methods are a characteristic of new types of obturators.

Laparoscopic resection for rectal adenocarcinoma.

AIMS: Laparoscopic surgery for rectal cancer is still under discussion, but there is evidence that minimal access surgery can be feasible and safe also in this field. The aim of this study was to confirm that laparoscopic resection for rectal cancer can afford good results in terms of recurrence rate and survival. PATIENTS AND METHODS: Since June 1998 through December 2007 as many as 252 patients underwent laparoscopic resection for rectal cancer. Laparoscopic anterior resection (LAR) was performed in 209 and laparoscopic abdominoperineal resection (LAPR) in 43. Neoadjuvant radiochemotherapy (nCRT) was administered in 48 patients with mid-low rectal cancer stage II and III with evidence of nodal involvement in preoperative work up. RESULTS: Patients who received nCRT showed a significant longer duration of surgery compared to patients who did not (p=0.004). Conversion to laparotomy was needed in 24 cases, (21 LAR and three LAPR) but no patient receiving nCRT needed conversion. Postoperative surgical complications occurred in 38 patients, 20 of which were represented by anastomotic leak after LAR. Six patients died postoperatively, in half the cases for surgery related causes. Downstaging after nCRT was seen in 40 patients, and complete histological response was observed in six cases. The mean number of lymph nodes harvested was 12, also in patients receiving nCRT. The mean follow-up was 48+/-33 months (range 0.1-120.4), and 10 patients experienced local recurrence. Cumulative 5 year survival was 73.7%. CONCLUSION: Laparoscopic resection for rectal cancer is feasible and safe, with morbidity and long-term results quite acceptable also in patients receiving neoadjuvant treatment.

Asthma induced by inhalation of flour in adults with food allergy to wheat.

BACKGROUND: Wheat is one of the major food allergens and it is also an inhalant allergen in workers exposed to flour dusts. Food allergy to wheat in adulthood seems to be rare and has never been reported to be associated with asthma induced by flour inhalation. OBJECTIVE: The study aimed at detecting adults with food allergy to wheat and screening them for the presence of specific bronchial reactivity to inhaled wheat proteins. METHODS: Adults with a history of adverse reactions to ingestion of wheat underwent skin prick test with commercial wheat extract and were assessed for the presence of specific wheat IgE in the sera. Food sensitivity to wheat was confirmed by double-blind, placebo-controlled food challenge (DBPCFC). Specific bronchial reactivity was investigated through a specific bronchial challenge with wheat proteins. RESULTS: In nine patients with evidence of specific IgE response to wheat, a diagnosis of food allergy was made by DBPCFC. Only two subjects had asthma as disease induced by ingestion of wheat. Seven subjects reported a history of respiratory symptoms when exposed to flour dusts. A significant reduction of forced expiratory volume in 1 s (FEV(1)) was detected in these seven patients when a specific bronchial challenge with flour proteins was performed. Only three out of seven subjects with asthma induced by flour could be considered occupationally exposed to flour dusts. CONCLUSION: For the first time, it has been shown that specific bronchial reactivity to wheat proteins can be detected in patients with different disorders associated with food allergy to wheat. The presence of asthma induced by inhaled flour is not strictly related to occupational exposure and it may also occur in subjects not displaying asthma among symptoms induced by wheat ingestion.

Stapled hemorrhoidopexy: day surgery or one day surgery?

Hemorrhoidal disease is one of the most common anorectal disorders, from 10% to 20% of all patients admitted at a clinical investigation need to undergo surgery, stapled haemorrhoidopexy is gaining wide acceptance as an interesting, safe and less painful technique, but hemorrhage is one of the most serious early complications and is a severe complication in day surgery. In our day surgery proctology, surgical procedures represent about 32%. Of these, 24% are for hemorrhoidal disease, we present our protocol and experience for early and safe discharge, 6h after stapled hemorrhoidopexy surgery.

Outcomes of laparoscopic Miles' operation in very low rectal adenocarcinoma. Analysis of 32 cases.

AIMS: Minivasive techniques for excision of low rectal tumours have spread worldwide with good results, but their employment is still under discussion. The purpose of this study is to assess short term results and survival of laparoscopic abdominoperineal resection (LAPR) in very low rectal cancers. METHODS: The charts of 32 patients undergoing LAPR for very low rectal adenocarcinoma (0-2cm from dentata line) were reviewed retrospectively. Outcomes were evaluated considering surgical procedure, short and long-term results and survival. RESULTS: A thorough LAPR was performed in 31 patients and conversion to laparotomy was required in 1 patient. Mean operating time was 244min. The length of hospital stay (LOS) was 13,3days. The mean number of nodes collected was 12 and the distal margin was 3,6cm on average. There was 1 post-operative death. In the follow up no pelvic recurrence was observed, while metachronous metastases were observed in 5 patients and peritoneal carcinosis in 2 patients. No port site metastasis was registered. Cumulative 5year survival probability was 0,50. CONCLUSIONS: The outcomes of this study suggest that LAPR in very low rectal cancer is a reliable procedure, operating time and LOS were acceptable. Oncologic principles were respected: length of specimen, distal margin and number of nodes retrieved were quite acceptable. Pelvic recurrence frequency was nil. Long term results were comparable with those of other series.

Forced swimming evokes a biphasic response in CREB phosphorylation in extrahypothalamic limbic and neocortical brain structures in the rat.

The transcription factor cAMP response element-binding protein (CREB) plays a critical role in plasticity processes underlying learning and memory. We investigated the phosphorylation of CREB in rat brain after forced swimming, a stressor known to impact on higher limbic and neocortical brain areas. As shown by immunohistochemistry, forced swimming increased phosphorylated CREB (P-CREB) levels in the dentate gyrus, all neocortical areas, the medial, lateral and basolateral nuclei of the amygdala, cerebellum but not in the hypothalamic paraventricular nucleus. Distinct differences in the P-CREB pattern were observed in the deeper vs. superficial layers of the neocortex. The response in P-CREB was stressor type-specific because exposure to either ether or a cold environment was ineffective. The forced swimming-induced changes in P-CREB levels showed a biphasic time-course: an early peak detected at 15 min was followed by a marked drop at 60 min; a second rise starting after 1-2 h, reached maximal values between 6 and 8 h, and remained elevated for at least 48 h. Examination of the neuroanatomical induction pattern of the CRE-inducible immediate early gene product c-fos revealed that it was only partly overlapping with that of P-CREB. Western analyses showed that only the 43-kDa CREB protein (an enhancer of CRE-containing promotors) was phosphorylated after forced swimming, while other members of the CREB/ATF family (CREM, ATF-1 and ATF-2) remained unaffected. The NF-kappaB pathway was not activated, indicating that forced swimming does not unspecifically evoke transcription factor activation. Thus, in contrast to physical stressors, such as ether or cold exposure, forced swimming, a stressor with a strong psychological component, elicits the recruitment of the CREB pathway in a widespread manner in the limbic system and neocortex; brain regions known to be implicated in various forms of (stress-related) learning and memory.

Increased serum lipoprotein(a) levels in patients with early renal failure.

BACKGROUND: Elevated serum lipoprotein(a) levels have been found in patients with end-stage renal disease and in patients undergoing dialysis, suggesting that this lipoprotein contributes to the increased cardiovascular risk seen in these patients. It is not known whether lipoprotein(a) levels are elevated in the early phases of renal disease. OBJECTIVE: To evaluate levels of lipoprotein(a) and other lipids and the prevalence of atherosclerotic disease in patients with early renal failure. DESIGN: Cross-sectional study. SETTING: Hypertension clinic of a university medical center. PATIENTS: 257 patients with normal renal function and 160 patients with early impairment of renal function (creatinine clearance, 30 to 89 mL/min per 1.73 m2 of body surface area). MEASUREMENTS: Renal function was assessed by 24-hour creatinine clearance, proteinuria, and microalbuminuria. Cardiovascular disease status was also assessed. Serum lipoprotein(a), lipids, apolipoproteins, and apolipoprotein(a) isoforms were measured. RESULTS: Age, blood pressure, and serum lipoprotein(a) levels were greater in patients with early renal failure than in those with normal renal function and were independently associated with the presence of decreased creatinine clearance. Serum lipoprotein(a) and creatinine clearance were inversely correlated. The prevalence of coronary artery, cerebrovascular, and peripheral vascular disease was greater in patients with early renal failure than in those with normal renal function. The frequency distribution of apolipoprotein(a) isoforms was similar in patients with normal and those with impaired renal function. CONCLUSIONS: Serum lipoprotein(a) levels are elevated in patients with early impairment of renal function and are associated with greater prevalence of cardiovascular disease. An inverse correlation between serum lipoprotein(a) level and creatinine clearance and a frequency distribution of apolipoprotein(a) isoforms similar to that of normal patients point to decreased renal catabolism as a probable mechanism of lipoprotein(a) elevation in patients with early renal failure.

Glucose metabolism and insulin receptor binding and mRNA levels in tissues of Dahl hypertensive rats.

Increased insulinemic response to an oral glucose load has been demonstrated in Dahl salt-sensitive hypertensive rats. To determine whether this abnormality is mediated at the level of the insulin receptor, we compared insulin receptor binding and mRNA levels in tissues of Dahl salt-sensitive rats (DS) and in their normotensive controls, Dahl salt-resistant rats (DR). To evaluate possible influences of dietary sodium intake, rats were fed either low (0.07% NaCl) or high salt (7.5% NaCl) chow until the DS became hypertensive, and then were killed by decapitation. Fasting plasma glucose and plasma insulin levels did not differ between DR and DS rats and were not affected by salt intake. In response to an oral glucose load, plasma glucose had a similar increase in DR and DS rats, but the increase in plasma insulin was significantly greater in DS rats. Scatchard analysis of binding was obtained from in situ autoradiographic studies performed in frozen skeletal muscle and kidney sections, and insulin receptor mRNA levels were measured by slot-blot hybridization. Number and affinity of insulin receptors were comparable in skeletal muscle and kidney of DR and DS rats and, in both groups, binding parameters were not affected by dietary sodium chloride. Hepatic and renal insulin receptor mRNA levels were also comparable in DR and DS rats fed either low or high salt chow. Thus, increased plasma insulin response to oral glucose load is associated with normal insulin receptor binding and gene expression in peripheral tissues in rats with Dahl hypertension. A postreceptor defect is likely responsible for the decreased sensitivity to insulin in this model of genetic hypertension.

Association of serum lipoprotein(a) levels and apolipoprotein(a) size polymorphism with target-organ damage in arterial hypertension.

OBJECTIVE: To investigate the association between lipoprotein(a) [Lp(a)] and other plasma lipids and apolipoproteins and target-organ damage (TOD) in patients with arterial hypertension. DESIGN: Cross-sectional study of a case series. SETTING: University medical center. PARTICIPANTS: Lipoprotein(a) and apolipoproteins were analyzed in 277 untreated patients with mild to moderate essential hypertension and in 102 healthy controls. Apolipoprotein(a) [apo(a)] phenotypes were additionally analyzed in an independent sample set of 106 hypertensive and 105 control subjects. MAIN OUTCOME MEASURES: Staging of TOD obtained according to World Health Organization guidelines by clinical evaluation, and laboratory tests including measurments of creatinine clearance, proteinuria, ophthalmoscopy, electrocardiography, echocardiography, and ultrasound examination of major arteries; levels of lipids, apolipoproteins, Lp(a), fibrinogen, and apo(a) phenotypes. RESULTS: Blood pressure, duration of hypertension, and levels of total cholesterol, low-density lipoprotein cholesterol, apolipoprotein B, Lp(a), and fibrinogen were significantly related to the presence and severity of TOD in univariate analysis. Stepwise multivariate analysis showed Lp(a) levels (P<.001) to be the best discriminator of the presence of TOD, followed by systolic blood pressure (P<.001), duration of hypertension (P=.01), and low-density lipoprotein cholesterol (P=.04). The Lp(a) levels were related to TOD independent of the level of blood pressure. We confirmed this association between Lp(a) concentrations and severity of TOD in a second independent sample set and observed a significantly higher frequency of low-molecular-weight apo(a) isoforms with increasing severity of TOD (P=.02). CONCLUSIONS: Lipoprotein(a) and apo(a) phenotype are sensitive indicators of the severity of TOD in patients with essential hypertension, and their evaluation might permit identification of hypertensive subjects liable to the development of organ damage. The higher frequency of low-molecular-weight apo(a) isoforms in patients with TOD demonstrates a genetically determined risk for the development of TOD in hypertensive patients.

Hypertension and abnormalities of carbohydrate metabolism possible role of the sympathetic nervous system.

To investigate the relationships between the sympathetic nervous system (SNS) and parameters of glucose metabolism in arterial hypertension, daily urinary excretion of catecholamines and plasma glucose, insulin, and C-peptide response to an oral glucose load (OGL) have been evaluated in 77 untreated patients with mild-to-moderate essential hypertension and in 31 normotensive controls. Urinary excretion of norepinephrine (UNE) was positively correlated with body mass index and with plasma glucose levels both at fast and after OGL. No correlations were found between urinary excretion of catecholamines and plasma insulin and C-peptide levels both at fast and in response to OGL. Because the frequency distribution of UNE was bimodal, hypertensive subjects were separated into two subgroups using an arbitrary cutoff, and the parameters of glucose metabolism were compared. Subjects with UNE > 205 microg/day had greater levels of fasting glucose and greater glycemic response to OGL than subjects with UNE < 205 microg/day, whereas no significant differences between the groups were found in fasting and stimulated plasma insulin and C-peptide. Thus, activation of SNS is related to glucose tolerance but not hyperinsulinemia and insulin hypersecretion in essential hypertension. Plasma glucose levels, independent of insulin, may contribute to the relationship between SNS activity and blood pressure in essential hypertension.

Benign familial macrocytosis.

We have identified a 52-year-old woman and her 27-year-old daughter with macrocytosis, normal haemoglobin and mean corpuscular haemoglobin concentration. Macrocytosis could be demonstrated from the age of 40 and 25 respectively. All blood tests were normal including vitamin B12 and folic acid. Bone marrow investigation showed rare macroblasts without other abnormalities. Endoscopy of the upper gastrointestinal tract and ultrasonography of the abdomen were normal. Thus, persistent macrocytosis was present without evidence of diseases that might account for it. In these subjects, macrocytosis is likely to be related to the presence of a genetic defect.

Abnormalities of autonomic nervous system in hyperadrenergic orthostatic hypotension: description of a case.

Hyperadrenergic orthostatic hypotension was diagnosed in a 27-year-old man because of recurrent episodes of hypotension associated with high plasma noradrenaline levels. In this patient, laboratory tests were performed to evaluate autonomic nervous system function. Decreased response to Valsalva maneuver and carotid sinus massage indicated decreased baroreflex and vagal responsiveness, respectively. Cardiovascular response to the handgrip was reduced in comparison to controls. Passive leg raise showed normal reduction of plasma norepinephrine, indicating normal responsiveness of cardiopulmonary receptors. 'Non-dipper' profile in the ambulatory blood pressure monitoring provided further evidence for an impaired autonomic control of cardiovascular function in this patient. This report suggests the presence of autonomic dysfunction in hyperadrenergic orthostatic hypotension.