The dangers of reused personal protective equipment: healthcare workers and workstation contamination.

BACKGROUND: Personal protective equipment (PPE) is essential to protect healthcare workers (HCWs). The practice of reusing PPE poses high levels of risk for accidental contamination by HCWs. Scarce medical literature compares practical means or methods for safe reuse of PPE while actively caring for patients. METHODS: In this study, observations were made of 28 experienced clinical participants performing five donning and doffing encounters while performing simulated full evaluations of patients with coronavirus disease 2019. Participants' N95 respirators were coated with a fluorescent dye to evaluate any accidental fomite transfer that occurred during PPE donning and doffing. Participants were evaluated using blacklight after each doffing encounter to evaluate new contamination sites, and were assessed for the cumulative surface area that occurred due to PPE doffing. Additionally, participants' workstations were evaluated for contamination. RESULTS: All participants experienced some contamination on their upper extremities, neck and face. The highest cumulative area of fomite transfer risk was associated with the hook and paper bag storage methods, and the least contamination occurred with the tabletop storage method. Storing a reused N95 respirator on a tabletop was found to be a safer alternative than the current recommendation of the US Centers for Disease Control and Prevention to use a paper bag for storage. All participants donning and doffing PPE were contaminated. CONCLUSION: PPE reusage practices pose an unacceptably high level of risk of accidental cross-infection contamination to healthcare workers. The current design of PPE requires complete redesign with improved engineering and usability to protect healthcare workers.

Impact of cardiovascular/diabetic comorbidity on conversion rate during laparoscopic cholecystectomy for acute cholecystitis: a multi-center study on early versus very delayed approach.

BACKGROUND: The impact of diabetes and cardiovascular comorbidity on laparoscopic cholecystectomy has been long debated, evaluating them as risk factors for conversion to an open procedure especially in patients with acute cholecystitis: an "early" procedure, as suggested by 2013 Tokyo guidelines, has been compared to a "very delayed" one in patients under anticoagulant/antiplatelet therapy or treated for diabetes and referred by medical wards to surgery after the acute period. METHODS: We selected 240 patients operated for acute cholecystitis by laparoscopy over the last 4 years at St. Orsola University Hospital-Bologna and Umberto I University Hospital-Rome, comparing 98 diabetic/cardiovascular patients versus 142 subjects as control group: the selection was based on operative timing, "early" (73 patients treated within 3 days) and "very delayed" (167 patients operated after 6 weeks). RESULTS: In the "early" subgroup there was no difference comparing diabetic/cardiovascular patients (31 pts) versus control group (42 pts) while in the "very delayed" subgroup among diabetic/cardiovascular patients (67 pts) there was significantly male predominance, ASA III/IV prevalence and less positive imaging findings versus control group (100 pts). In both subgroups, the conversion rate was significantly higher for diabetic/cardiovascular patients ("early"=25.8% and "very delayed"=8.95%) compared to control groups ("early"=4.76% and "very delayed"=1%), showing a trend (p=0.058) towards an increased conversion rate in the early approach among diabetic/cardiovascular group. CONCLUSIONS: Our study showed a significantly increased conversion rate to an open cholecystectomy for diabetic/cardiovascular patients affected by cholecystitis, especially within 3 days by the acute episode.

The surgical management of acute bowel ischemia in octogenarian patients to avoid Short Bowel Syndrome: a multicenter study.

BACKGROUND: This is a multicenter study performed in two Italian tertiary care centers: General Emergency Surgery Unit at St. Orsola University Teaching Hospital - Bologna and Department of Surgical Sciences at Umberto I University Teaching Hospital - Rome. The aim was to compare the results of different approaches among elderly patients with acute bowel ischemia. METHODS: Sixty-three patients were divided in two groups: 1) DSgroup- 28 patients treated in Vascular Unit and 2) GEgroup- 35 patients treated in Emergency Surgery Unit. RESULTS: Mean age was 80 years, significantly higher for the GEgroup (p<0.001). Gender was predominantly female in both groups, without statistical difference. Pre-operatively, laboratory tests didn't show any difference in white blood cell count, serum lactate levels or serum creatinine among patients, while increase of c-reactive protein was observed in DSgroup with significant difference (p<0.001). The Romamain cause of acute bowel ischemia was embolism in DSgroup (p=0.03) and vascular spasm in GEgroup (p<0.001). On CT scan, bowel loop dilation was present in 58.7% of patients without statistical difference in both groups. The time lapse from diagnosis to operation didn't show significant differences between two groups (mean 349.4 min). Pre-operative heparin therapy was administered in DSgroup more frequently (p< 0.001). Among DS patients, thrombectomy was the most frequent procedure (19 patients) associated with bowel resection in 9 cases. In GEgroup, 22 patients had an explorative laparotomy (p<0.001), 8 had a bowel resection with anastomosis and 5 a bowel resection plus stoma. A second look was required more significantly in DSgroup (p<0.002). Post-operative morbidity affected significantly GEgroup (p=0.02). The 3-day survival was significantly higher in the DSgroup (p< 0.001). At discharge 32 patients (50.8%) were alive, 21 in DSgroup (p< 0.001). Only one patient among both groups (1.6%) developed a short bowel syndrome. CONCLUSIONS: In octogenarian patients with acute bowel ischemia, surgery should be always pursued whenever the interventional radiology is not assessed as a viable option. Both groups of patients showed an excellent outcome in terms of avoiding a short bowel syndrome. A multidisciplinary management by a dedicated team could offer the best results to prevent large intestinal resections.

Agenesis of the internal carotid artery: a family pathology?

The internal carotid artery agenesis is a rare malformation disorder. We report the case of a 12-year-old boy suffering migraine, who had presented an episode featuring amaurosis fugax, spontaneously regressed. CT angiography images show hypoplasia of the left common carotid artery with loss of opacification of the left internal carotid artery consistent to agenesis. Moreover CT scans through the skull base demonstrate absence of left petrous carotid canal and an hypertrophic left middle cerebral artery originating from an aberrant artery arising from the right cavernous carotid. All diagnostic examinations confirmed the presence of the internal carotid artery agenesis, as Lie's type IV. We started an annual follow up that over the next 7 years did not reveal any change in magnetic resonance angiography images.

Analysis of prognostic factors for the indication of central lymphadenectomy in papillary thyroid carcinomas.

BACKGROUND: In this study we examined whether it was possible following preoperative parameters statistically significant correlation with the presence of metastatic lymph nodes in the papillary thyroid carcinoma. We conducted a retrospective study in a group of patients with a preoperative diagnosis of papillary carcinoma who underwent total thyroidectomy associated with routine lymphadenectomy of the central compartment (level VI). PATIENTS AND METHODS: The study group consisted of patients whose definitive histological lymph node examination was positive for metastasis (N1), and the control group comprised patients found negative for metastasis (N0). RESULTS: Tumour diameter had a significance at 10% level [Pr(>|z|): 0.056], thus indicating that increased tumour size results in a higher probability of being in group N1. The logistic regression revealed that variables with a significance at 5% level for the presence of metastatic lymph nodes in the central compartment (N1) were: sex [Pr(>|z|): 0.019], overall patient age [Pr(>|z|): 0.012] and age >45 [Pr(>|z|): 0.022]. We performed a statistical analysis with the association of three preoperative variables (presence of ultrasound-revealed microcalcifications, presence of solid hypoechogenic nodule and type III vascularisation on echocolour-Doppler); this was found to result in a highly significant probability of entering into group N1. CONCLUSIONS: We found variables statistically significant for the presence of metastatic central compartment lymph nodes, including female sex, age >45 yrs and tumour diameter >1.5 cm. The association of papillary carcinoma with microcalcifications, solid hypoechogenic nodule structure and type III vascularisation on echocolour-Doppler also resulted in a statistically significant increase in the probability of positive level VI lymph nodes.

Randomized study on the effects of different strategies of intermittent pneumatic compression for lower limb claudication.

BACKGROUND: The aim of the present study was to evaluate the efficacy of different strategies of intermittent pneumatic compression (IPC) for the treatment of lower limb claudication. METHODS: Five study groups were prospectively studied. Group 1: 9 patients not undergoing IPC; Group 2; six patients undergoing IPC 1 hour/thrice-a-day/4 months; Group 3: six patients undergoing IPC 2 hours/once-a-day/4 months; Group 4; six patients undergoing IPC 1 hour/thrice-a-day/2 months; Group 5: six patients undergoing IPC 2 hours/once-a-day/2 months. RESULTS: All patients completed the planned treatment schedule and stated a compliance of 33% in group 2, 83% in group 3, 66% in group 4 and 100% in group 5. Peak systolic velocity of the popliteal artery blood flow increased over baseline values particularly when IPC lasted 4 months (group 2: 85%, group 3: 81% vs. group 4: 76%, group 5: 73%). These beneficial effects lasted 10 months and vanished 14 months after the end of IPC treatment. The absolute claudication distance increased at the end of the treatment of 101% in group 2, 94% in group 3, 86% in group 4, and 83% in group 5, and it was still increased over the baseline values 14 months after the end of the treatment. No differences have been observed whether the treatment was performed once- or thrice-a-day. CONCLUSIONS: ICP treatment performed two hours once-a-day for four months provide excellent results with satisfactory treatment compliance. However, these effects are not durable and vanish about one year after the end of IPC treatment.

Treatment of "locally advanced" well-differentiated thyroid carcinomas.

PURPOSE: To analyse thyroid carcinomas having an extrathyroid extension in order to identify the principal prognostic factors and outline an effective therapeutic strategy. METHODS: We selected a sample of 160 patients suffering from locally advanced "well differentiated thyroid carcinoma (T4) who had undergone surgery at the Department of Surgery of University of Rome "La Sapienza". The sample was subdivided into three groups: T4, limited type I, and extensive type II, T4 microcarcinomas. RESULTS: We obtained excellent results with the T4 microcarcinomas, above all in patients under the age of 45, with a 94.5% survival rate, compared with 88% in patients aged over 45. In the extensive type II T4 carcinoma we obtained a survival rate of 29.4% in patients aged over 45 years. CONCLUSIONS: Age, combined with an aggressive histological variant (Sclerosing and tall-cell papillary carcinoma), is an important factor in prognosis. The radicality of surgical excision is considered an important prognostic factor, although the results reported in the literature are contradictory. Aggressive surgery can free from the disease a high percentage of patients over the age of 50 even with T4. We deem it fundamental to perform total thyroidectomy in all advanced cases of thyroid neoplasm and to extend neoplasm excision to the adjacent tissues, even involving justified surgical demolition.

[Postural vertigo and basilar artery flow increment]. / Surcroît du flux dans l'artère basilaire durant le vertige de position.

PURPOSE: Research was focused on cerebral arterial flow in normal individuals and in patients suffering from short-term vertigo when sitting up rapidly from a lying position. PATIENTS AND METHODS: The research was performed in normal subjects and 46 patients affected by short term vertigo who underwent transcranial Doppler 32. In normal subjects (16 with an average age of 25 and 16 with an average age of 61) cerebral artery flow was recorded in a sitting and lying position, in Trendelenburg position and during transition from one position to another. In subjects suffering from short-term vertigo, arterial flow was recorded at baseline and during short-term vertigo. RESULTS: In normal subjects the flow remained unchanged in all body positions as well as during transition from one position to another. In subjects with short-term vertigo basilar artery flow increased with the onset of dizziness and returned to normal when dizziness ceased. CONCLUSIONS: In normal subjects cerebral self-regulation maintains constant flow in any body position. Increased basilar artery flow during short term vertigo is probably either due to altered self-regulation or its reduction in the carotid area with compensatory basilar artery hyperflow, or else to over-response in vertebro-basilar territory.

Scintigraphy with 99mTc-MIBI and echography in the study of primitive hyperparathyroidism.

BACKGROUND: The authors analyse the value of the exams preoperative for the identification of the pathological parathyroid glands. METHODS: The authors examined 58 patients affected by primitive hyperparathyroidism (HPTp) who had undergone surgical treatment for primary hyperparathyroidism at the Third Surgical Department of University "La Sapienza" of Rome, in 175 patients affected by primitive hyperparathyroidism observed between January 1970 and June 2000; all patients had undergone echotomography of the neck and 99mTc-MIBI scintigraphy in the diagnostic phase. The histological valuation confirmed the diagnosis by I.P. RESULTS: 99mTc-MIBI scintigraphy demonstrated the pathological glands in 56 cases (96.6%), the echography in 57 cases (98.2%). The comparison of the two exams demonstrated the pathological glands in 100% of the cases. In 45 cases the scintigraphy localized the side (77.6%), and the echography in 41 cases (70.7%). In one case demonstrated I.P. persistent (1.7%) and never one case demonstrated relapsed. CONCLUSIONS: The authors think that the scintigraphy together with the echography show high sensibility to identification the pathological glands. Neck surgical exploration can still give the side good when the diameter of the parathyroids is inferior to 5 mm.

[Thyroid nodules: comparison of preoperative and intraoperative needle aspirate and definite histological study]. / Noduli tiroidei: confronto tra agoaspirato preoperatorio, intraoperatorio ed esame istologico definitivo.

The need to discover malignancy is the most challenging dilemma in the management of thyroid nodules, the most common endocrine disorders, affecting 4-5% of the general population. Malignancies account for only 2-3% of cases. The aim of our study was to evaluate the predictive value of preoperative fine-needle aspiration cytology (FNAC) in surgical decision making by evaluating the final pathologic diagnosis and comparing it to the preoperative and intraoperative diagnoses. We conducted a prospective study of 30 thyroid resections. The mean age was 49 years (range: 27 to 68 years). Preoperative physical and laboratory examinations, presenting symptoms, imaging studies and predictive values of preoperative and intraoperative FNAC were analyzed. The consistency of the lesion was strongly predictive of malignancy, when "hard". Single lesions were also predictive of malignancy. The diagnostic accuracy of preoperative FNAC vs intraoperative FNAC vs frozen section histopathology was 90% vs 100% vs 96.7%; sensitivity: 91.6% vs 100% vs 100%; specificity: 90.5% vs 100% vs 94.7%, while the positive predictive value was 84.6% vs 100% vs 91.7%, and the negative predictive value 95% vs 100% vs 100%. Ultrasound-guided preoperative FNAC showed high specificity, sensitivity and accuracy in diagnosing malignancy in thyroid nodules. Intraoperative FNAC was more accurate than intraoperative frozen sections in diagnosing malignancy in thyroid nodules.

Thymectomy and multiple sclerosis: ultrastructural study of an experimental model.

Transmission electron microscopy was performed on specimens of the thymus of rats induced for acute experimental allergic encephalomyelitis (EAE). The ultrastructural alterations of the thymus were progressive and correlated with EAE development. The thymic disorganization was due to a progressive degeneration of both epithelial cells and thymocytes. These data suggest a direct involvement of the epithelial thymic cells and thymocytes in EAE pathogenesis and may suggest the intriguing therapeutic concept of thymectomy in the management of multiple sclerosis.

[Parathyroidectomy: our school experience]. / La paratiroidectomia: esperienza di Scuola.

The Authors evaluated the results obtained in 145 patients operated on for hyperparathyroidism: 109 patients had primary hyperparathyroidism and 36 patients had secondary hyperparathyroidism. Preoperative localization by ultrasonography was assured in all cases, while only few patients were preoperatively evaluated by arteriography and selected venous sampling of the parathyroid hormone concentration. After surgical resection for primary hyperparathyroidism, transient postoperative hypoparathyroidism occurred in 30 patients (27.5%), recurrent disease occurred in 3 patients (2.7%), while 1 patient experienced persistent hypoparathyroidism (1%). In 3 patients (3%), resection of a solitary adenoma and biopsy of all parathyroid glands resulted in a permanent hypoparathyroidism which required long-term administration of vitamin D and oral calcium. Neither recurrent nor persistent hyperparathyroidism occurred in patients surgically treated for secondary hyperparathyroidism, and no postoperative hypoparathyroidism was registered. The Authors emphasize the importance of an adequate surgical strategy and accurate initial cervical exploration of the parathyroid glands as a necessary step for the correct treatment of this challenging disease.

[Surgery of differentiated cancer of the thyroid]. / La chirurgia del cancro differenziato della tiroide.

A retrospective study on patients with differentiated thyroid carcinoma operated on at the 3rd Department of General Surgery of the University "La Sapienza" of Rome from 1970 to 1996 was performed. In 709 patients total thyroidectomy was performed as the minimal procedure acceptable, while 19 patients had subtotal thyroidectomy out of necessity. A functional ipsilateral or bilateral lymphnectomy of the neck was performed in 256 cases. This wider operation is indicated in the presence of metastatic lymph nodes and on principle in patients older than forty-five years in which at least another risk factor is present. Long term follow-up (12 years) was assured in 302 patients and the survival rate was 92% independently from the histotype (papillary or follicular). The survival rate of a group of 120 patients (80 with papillary and 40 with follicular carcinoma) was analyzed in relation to the risk factors. This group analysis demonstrated a very low mortality rate in patients with low risk index and an increased rate in patients with a high risk index.

The immunolocalization of PGP 9.5 in normal human kidney and renal cell carcinoma.

The Authors studied the localization of protein gene product (PGP) 9.5-like immunoreactivity in normal human kidney tissue and compared the results with the same immunostaining in renal cell carcinoma. PGP 9.5-like immunoreactivity was found in cells of distal convoluted tubules and in some glomerular capillaries. The cells of proximal convoluted tubules did not show any immunostaining. Sections from renal cell carcinoma showed a very low immunostaining or were negative for PGP 9.5. As PGP 9.5 is a marker of the diffuse endocrine system, the Authors believe that the stained cells of distal tubules should be considered as neuroendocrine cells. The negative reaction to PGP 9.5 antibodies in renal cell carcinoma is rather surprising since not only tumours of neuroectodermal origin, but also tumours of other origin and tissues from some chronic degenerative diseases show a positive reaction. The explication of a negative reaction in renal cell carcinoma remains open: one of the possible explanations could be the specific histogenesis of this tumour.

Vascular anastomoses among abdominal organs in laboratory animals.

Vascular anastomoses among abdominal organs were studied in 289 laboratory mammals. Arterial anastomoses joining the wall or the parenchyma of the abdominal organs were studied in 108 animals and were found among the stomach, the spleen and the pancreas. In the cat, such anastomoses occur in 86.7% of cases, in the guinea pig in 73.3%, in the hedgehog in 61.1%, in the rabbit in 3.3%. The highest mean value was found in the cat: 3.1 anastomoses. Venous anastomoses were studied in 181 animals and were found among the stomach, the spleen and the pancreas, too. With the exception of the guinea pig (found in 89.1% of cases), these anastomoses were found almost in all cases of other five examined species. They mostly occur between the stomach and the spleen, and between the spleen and the pancreas with some differences in the guinea pig and the cat. The highest mean value was found in the rat: 6.1 anastomoses. For the present, it is not possible to state any significant differences among orders and species examined. As these vascular anastomoses occur also in man, we believe that they should be preserved during surgical procedures.

[The treatment of benign lesions of the liver. Indications and surgical approach]. / Il trattamento delle formazioni benigne del fegato. Indicazioni e strategia chirurgica.

Benign formations in the liver constitute a heterogeneous group of pathology lesions that are rarely found clinically. In the period between January 1985 and June 1992, 81 patients, affected by benign formations of the liver, were observed at the Institute of the III Surgical Clinic of Rome "La Sapienza". Most of these lesions are asymptomatic and their diagnosis is mostly casual. Among these we found 48 cases of echinococcus cystis, 13 cases of congenital cystic formations, 2 amoebiasis cases, and 1 case the ecografic exam, which shows an hepatic formation to the fifth segment, was not in conformity with the cytologic exam which proved negative because of cellular abnormalities of any nature, therefore it's constituted by normal parenchyma. Consequently the patient was discharged. We operated on 65 patients. The complications found in the patient operated on were not important and we had the death of only 1 patient affected by hepatic abscess on the 3rd day after surgery because of septicemia and cardio-circulatory problems. The follow-up made after a certain time has resulted negative because of relapses if we exclude 1 case of echinococcus cystis wherein we found a serological relapsing. In our experience and according to most of the authors, the operation must take place always in cases such as: adenoma, cystoadenoma, hemangiomas having a diameter higher than 3 cm, echinococcus cysts, syntomatic formations and when we have complications. For all other cases we must limit ourselves to observation over a certain period both the dimensions and morphological modification of the lesions.

[Preoperative diagnosis of thyroid nodule. Ultrasonography-guided fine-needle aspiration]. / In tema di diagnosi di natura preoperatoria del nodulo tiroideo. L'FNA ecoguidata.

Nodular thyroid pathology weighs heavily for 4-5% of the general population, being the most common among the endocrinopathies. Because of this these diagnostic methods have gained more and more importance as FNA able to select already in the pre-operation phase the malignant nodules from the benign ones and to decide on the most suitable surgical intervention. In the period of time between January 1989 and June 1992 in the Institute of the III Surgical Clinic in Rome there have been performed 403 FNA. From the whole total we have extrapolated 221 patients. In this study we stressed how the FNA method has a sensibility of 80%, a specificity of 93% and afterwards an accurate diagnosis of 92%. Besides we have verified that sonography and radionuclide scanning have a truth worthiness respectively of 64% and 52%. The FNA in our opinion allows us to have in the pre-operation phase a much more accurate diagnosis as regards that obtained with only sonography and radionuclide scanning therefore the latter methods must be considered complementary to FNA.

[Autotransfusion in general surgery]. / L'autotrasfusione in chirurgia generale.

Self-transfusion represents a clinical method used for the restoration of haematic losses that, in recent years has been employed more and more widely in the surgical ambit. The utilisation of this method has become increasingly frequent because of the high diffusion of haemotransmitted diseases, and of the incidences, not negligible, of complications relative to the transfusions of homologous blood. The techniques that are currently used are: self-donation with predeposit; inter-surgery recovery; hemodilution normal blood volume. From 1989 until now 260 patients have been performed, in the Institute of III Surgical Clinic of University of Rome, to self-transfusional method with predeposit and intersurgery recovery. In practice this technique did not present any complications.