[How to manage disasters: learning from recent experiences in the Emergency Department of a University Teaching Hospital, Italy]. / Come gestire i disastri: proposta di gestione economica degli eventi catastrofici.

The medical approach to disasters has been always a problematic issue for emergency departments. The authors of this paper reflect on possible efficient solutions for managing a massive influx of casualties in an Emergency Department, by analysing the responses to previous local catastrophic events, such as the collision of 'Segesta Jet', the great fire of Patti, the floods of Giampilieri/Scaletta and Saponara. The authors' point to a need for providing more extensive training of medical students in clinical aspects of disaster medicine.

[Management of maxillofacial injuries in an emergency unit: our experience]. / I traumi maxillo-facciali in Pronto Soccorso: casistica di un dipartimento d'emergenza e d'accettazione del Sud Italia.

Maxillofacial injuries are relatively frequent. These may be complicated by cranioencephalic injuries or large facial wounds. We report our experience with the initial management of these lesions in an emergency unit setting. In 2007, we observed 105 patients with maxillofacial injuries. Maxillofacial injuries were associated with cranio-encephalic injuries in 69 patients (65.7%) and with polytrauma in 31(29.5%), while in 5 cases (4.8%) they were isolated. The main causes of trauma were motorcycle accidents (60%). All patients were treated in accordance with the Advanced Trauma Life Support guidelines and assessed by computed tomography. No mortality was observed after diagnosis in the emergency unit or in the month following the trauma. Seventy-seven patients (73.3%) were admitted and 28 (26.7%) were treated and discharged. Accurate diagnosis and appropriate initial management yield good clinical outcomes with functional restoration and fewer aesthetic complications.

[Major emergency management in ship collusion]. / Gestione della maxi-emergenza nella collisione tra navi. Nostra esperienza.

AIM OF THE STUDY: To prove that a correct management of a major emergency allowed a quick triage, trauma team, appropriate treatment, discharge and treatment of many patients injured patients when, in January 2007, a crush between a merchant ship and an hydrofoil happened in the Messina strait, that separate Sicily and Calabria. MATERIALS AND METHOD: Four deaths and 105 injuries were observed. Our experience in the emergency care refers to 25 patients of them. All patients were investigated with routine blood tests, imaging techniques and classified according to AIS and ISS. Their classification in colour code was green for 14 of them (7 Males, 7 Females); yellow for 9 (5M, 4F) and red for 2, both males. RESULTS: Of the 105 injured patients, twenty five patients were referred to our Accident and Emergency Department. Ten were affected by cranial trauma, 6 by spinal injuries, 5 by thoracic injuries, 3 had bone fractures and 1 patient with severe wounds. Among all patients, 18 had an ISS <15; 7 had an ISS of 28 (range 17-45). Mean emergency room stay, discharge and transport of patients to wards was 103 minutes. Twelve patients were admitted to the hospital; 9 refused hospitalization, 4 were discharged. DISCUSSION: Twenty six ship-collisions occurred in the Messina Strait between 1950 and 2007, were documented 10 deaths, and other four death of Segesta Jet accident. The approach to Major Emergency was carried out in according to ATLS and P.E.I.M.A.F. This allowed specific and efficacious investigations.

[Breast abnormalities: a retrospective study of 208 patients]. / Anomalie mammarie. Studio retrospettivo su 208 casi.

Ectopic breast tissue occurs in 0.4-6% of the general population. Usually, these tissues develop along the embryonic milk line but other sites are reported in the literature. Accessory breasts are commonly axillary and may undergo hormonal changes. Some pathologies of normally positioned breasts can occur in ectopic breast tissue, including carcinoma, and therefore require traditional senological flow-charts and imaging strategies. Supernumerary nipples are generally asymptomatic but may sometimes be associated with urological malformations. In our 10-year experience, 208 patients were observed (138 polythelia and 70 polymastia) and 159 surgical procedures were performed, 97 for supernumerary nipple excision and 67 for accessory breast ablation. Five neoplastic lesions and 25 fibrocystic mastopathies were detected in specimens; normal nipple or breast tissue was found in 129. In view of the potentially malignant transformation of accessory breasts, thorough physician evaluation is needed. Surgery is currently suggested in cases of suspected malignancy, in symptomatic cases and for cosmetic problems.

[Personal experience using radioimmunoguided surgery (RIGS)]. / L'utilizzo della chirurgia radioimmunoguidata nella nostra esperienza.

Radio Immuno Guided Surgery (RIGS) is a technique that has numerous uses in oncology. It is characterised by a multidisciplinary approach by nuclear physician and surgeon for diagnosis and treatment; it uses colloid radiotracers, monoclonal antibodies or non-immunological tracers. We adopted this technique in 281 patients: 256 (91.9%) (range 26-82) with breast disease (breast cancer or occult breast lesions) and 25 (8.9%) (range 42-84) with colorectal cancer localized or recurrent. We used monoclonal antibodies (ArcitumoMab 99mTc-labelled) for colorectal carcinomas and aggregates of human serum albumin 99mTc-labelled for Radioguided Occult Lesion Localization (ROLL) and Sentinel Lymph-Node Biopsy (SLNB). All patients were studied preoperatively by routine blood tests, instrumental exams and tumoral markers. Amongst patients with breast disease, 142 breast cancers and 114 occult breast lesions were found. Among patients with colorectal disease, 8 cases had localized colorectal cancer and 17 cases had locoregional recurrence and/or metastasis. In all cases pathologic sites were detected by probe during surgery. The RIGS is indicated for ROLL and SLNB; nevertheless it is also suggested for pre- and intraoperatively staging of primary and recurrent colorectal cancers. This method gives a chance for a radical surgical and oncologic treatment in localized and recurrent cancer. Prospective studies are needed in order to estimate survival and usefulness of this methodology.

[Gunshot wounds. Our experience]. / Ferite d'arma da fuoco. Nostra esperienza.

Abdominal gunshot wounds may result in elevated morbidity and mortality. The optimal management is still controversial. The authors report on their experience with treatment of 49 patients. In all patients the PATI score was used to identify trauma and all were treated surgically. Laparoscopy was employed only in one patient. The mortality was 2% and the morbidity 6%. The authors conclude that the PATI score correlated well with morbidity and mortality. Resuscitation with immediate surgical treatment may reduce the morbidity and mortality rates.

[Non-lactational mastitis: our experience]. / Le lesioni infiammatorie non puerperali della mammella.

The most frequent breast inflammatory diseases are lactational and non-lactational mastitis. The diagnosis of these lesions is always difficult, as they often mimic breast cancer. The Authors report on their experience about 830 clinical cases of non-lactational mastitis, 804 were superficial abscesses and 24 were phlegmons. In 379 cases an infectious cause was found: in 249 by Streptococcus/Pseudomonas and in 30 by Staphylococcus Aureus. All patients underwent surgical treatment. Diagnosis was obtained by clinical examination, routine investigations (ultrasound, mammography and cytology) and post-operatively by histological evaluation. The non-lactational mastitis are more frequent in the postmenopausal and the menopausal period, but MDAIDS (Mammary Ducts Associated Inflammatory Diseases Sequence) are particularly interesting. MDAIDS was observed in 178 cases, these are very peculiar lesions characterized by ducts ectasia, squamous metaplasia, lymphoid infiltration and strictly correlated with heavy smoking. Sometimes, only surgical treatment clarifies the nature of these lesions. Patients with inflammatory diseases of the breast present with mastalgia and secretions, symptoms which alert patients to consult quickly a specialist. Instrumental investigations often don't clarify the diagnosis and surgical treatment by incision and drainage or excision is definitive.

Quality of life and predictors of long-term outcome in patients undergoing open Nissen fundoplication for chronic gastroesophageal reflux.

BACKGROUND: Long-term outcome of antireflux operations as well as pre- and postoperative parameters able to predict their clinical results are still controversial. The aim of the present study was to evaluate long-term quality of life of patients undergoing open fundoplication for chronic GERD and to investigate pre- and early postoperative functional parameters possibly related to persistence or recurrence of symptoms. METHODS: A cohort of 25 patients who underwent open Nissen fundoplications was reviewed for an evaluation of long-term residual symptoms and quality of life at an average follow-up of more than 10 years. Clinical evaluation was performed by using a symptom-specific score (DeMeester's score), 3 health-related quality of life scores, a GERD-specific (GERD-HRQL score) score, and 2 generic scores (SF-36) evaluating physical and psychological well-being. Subjective satisfaction grade of the patients was also investigated. In addition, a univariate analysis is provided, according to the long-term presence or absence of residual symptoms (120.6-month follow-up), taking into account pre- and postoperative (6-month follow-up) data of endoscopy, 24-hour pH monitoring, stationary manometry, and gastric-emptying test. RESULTS: Persistence or recurrence of GERD-specific symptoms (heartburn and regurgitation) were reported by 8 patients (32%); 2 patients (8%) were reoperated on for persistent dysphagia, whereas 17 patients (68%) were asymptomatic. GERD-HRQL and SF-36 scores displayed significant postoperative improvement, which continued in long-term follow-up. Twenty patients (80%) had repeat fundoplication. Among tested parameters, only postoperative mean supine esophageal clearance and gastric emptying half-time, although on average improved significantly after the antireflux procedure, differed significantly in long-term asymptomatic and symptomatic subgroups. In long-term asymptomatic patients, postoperative (6 month) mean supine esophageal clearance was 0.8 +/- 0.3 minutes (P = .011) and 2.4 +/- 0.2 minutes in symptomatic patients. Postoperative (6 month) mean gastric emptying half-time of long-term asymptomatic patients was 93.3 +/- 8.9 minutes, whereas in symptomatic patients it was 127.5 +/- 14.3 minutes (P = .047). CONCLUSIONS: Patients undergoing Nissen fundoplication had a satisfactory long-term quality of life. Clinical results did not deteriorate over time and showed to be related to postoperative esophageal clearance and gastric emptying, which could be regarded as early postoperative predictors of long-term clinical outcome.

Breast vasculitis presenting as a tumor-like lesion. A case report.

Breast vasculitis presenting as a tumor-like lesion is rare. The differential diagnosis in these cases can be extremely difficult but is very important for treatment and follow-up. We report the case of a 80-year-old woman who was admitted to our service with a lesion resembling an inflammatory carcinoma of the breast. We discuss the pathological and clinical characteristics, the presentation, assessment and treatment of this case and its resolution. Few reports in the literature have addressed the possible occurrence of systemic vasculitis mimicking cancerous lesions. The most common location of such lesions was shown to be the breast in one review. Although rare, such manifestations can be effectively recognized and treated.

[Sentinel lymph-node biopsy in breast cancer: five years' experience]. / Il linfonodo sentinella nel carcinoma mammario. 5 anni di esperienza.

The authors report on their experience with sentinel lymph-node biopsy in breast cancer. Sentinel lymph-node biopsy was performed in 91 patients with T1-T2 N0 M0 breast cancer using radiocolloid (99mTC radiolabelled colloidal human albumin microaggregate) injected perilesionally in 56 cases and by Blu Patent V alone in 35 cases. The sentinel lymph nodes identified were located in the axilla in 88 cases, in the internal mammary nodes in 2 cases and in a subclavicular site in 1 case. The histological examination was negative in 62 cases and positive in 29; Axillary lymph-node dissection was carried out in node-positive cases. No recurrences were observed in any of the cases treated. Lymphatic mapping and sentinel lymphadenectomy in primary breast cancer is now a feasible and useful method of avoiding routine axillary lymphadenectomy. However, the role of micro- or macrometastases in sentinel lymph nodes and the significance of identification of tumour mRNA have yet to be defined.

[Evaluation of complications and long-term results after surgery for gynaecomastia]. / Complicanze e risultati a distanza dei pazienti operati per ginecomastia.

In an attempt to evaluate ten years of surgical treatment of gynaecomastia, we analysed the incidence of complications and the quality of the results in a group of patients classified according to Simon. Over the decade 1992-2002, 107 patients with gynaecomastia aged from 17 to 79 years were treated. The prevalent surgical approach was subcutaneous mastectomy. In 71 patients the surgical approach was via a periareolar inferior incision, superior in 15, inferior with bilateral extensions in 10; using a complete circumareolar approach (according to Padron) in 8 patients and a subcutaneous transareolar mastectomy in 3. No immediate complications were observed. Ten patients presented a modest postoperative haematoma. Only in one diabetic patient with chronic bronchitis and grade III gynaecomastia did partial dehiscence of the surgical wound occur. Most patients achieved good results. We judged the results excellent in 94 patients, good in 11, and unsatisfactory in 2. On the basis of our experience and in agreement with the literature data, we can affirm that the best results were obtained by subcutaneous mastectomy with a periareolar incision.

Laparoscopic palliative gastrojejunostomy for advanced recurrent gastric cancer after Billroth I resection.

Palliative surgery for advanced gastric cancer has equivocal results. Laparoscopy is likely to provide some advantage compared to open procedures. We present a case of laparoscopic gastrojejunostomy for advanced gastric cancer, which recurred after Billroth I resection. Reproducing the results of the early experiences so far reported in the literature, laparoscopy provided us with the accurate staging of the disease along with the opportunity, at the same time, to perform a palliative procedure, avoiding laparotomy. Operative results were good, vomiting was relieved, and the patient was able to cope with his disease until death eventually occurred after 6 months.

[Nipple discharge: personal experience with 2,818 cases]. / La mammella secernente: esperienza personale su 2.818 casi.

After mastodynia, nipple discharge is the second most frequent condition that brings women to the attention of breast clinics. Seven types of nipple discharge exist: milky, multicolored, purulent, clear-watery, serous, pink or serosanguineous, brown or reddish-brown. From January 1982 to January 2003 we observed 2818 patients with nipple discharge (range: 16-83 years). Amongst these, 805 patients with nipple discharge were submitted to cytological examination of the secretions. One hundred and seventy-six had bilateral discharge, and 629 unilateral discharge. All patients with positive C3, C4 or C5 cytology and with unilateral discharge (227) were referred for surgical treatment. In 92 of these 227 cases (41%) the secretion was serous, in 59 cases (26%) bloody, in 45 cases (20%) purulent and in 31 cases (13%) multicolored. We performed duct galactophorectomy in 89 cases (39%), resection with reconstruction of the nipple-areola complex in 48 cases (21%), microdochectomy in 42 cases (18.5%), segmentectomy or quadrantectomy in 41 cases (18%), and mastectomy in 6 cases (3%); we also removed a papilloma from the ductal orifice in 1 case (0.44%). Histological specimens showed papilloma in 98 cases (43%), breast cancer in 39 cases (17%), galactophoritis in 36 cases (16%), fibrocystic disease in 46 cases (20%), including 31 (14%) with florid adenosis, and papillomatosis in 8 cases (4%). An increased probability of cancer is therefore associated with serous, bloody, reddish brown and watery secretions. This is particularly true when the secretion is unilateral and originates from a single duct, when there are cytological alterations, whether mammographic or galactographic, and when the patient is aged over 50 years.

[Surgical treatment of breast cancer after neoadjuvant therapy]. / La chirurgia del cancro della mammella dopo terapia neoadiuvante.

Primary chemotherapy represents a new therapeutic strategy that allows the implementation of conservative surgical treatment in locally advanced breast cancer or in cancers measuring > 3 cm. Of 127 patients with breast cancers measuring > 2.5 cm, 86 were treated with primary chemotherapy. This consisted in the administration of the ADM + TAX protocol in 28 cases and CNF in 58 cases. Three complete responses, 8 cases of stable disease and 75 partial responses were observed. Eleven radical mastectomies and 74 conservative treatments were performed. The chemotherapy protocol enabled us to convert 87% of the patients treated to conservative treatment, thus affording a treatment that offers a better quality of life despite the existence of a voluminous cancer and is of considerable psychological help in patients suffering from cancer of the breast.

[Radioimmunoguided surgery (R.I.G.S.) in colorectal cancer. Preliminary results]. / La chirurgia radioimmunoguidata (R.I.G.S.) nel carcinoma del colon-retto. Risultati preliminari.

The authors describe their experience in utilizing 'ArcitumoMab' and radioimmunoguided surgery in a group of patients with localized and advanced colorectal cancer. Twenty-one patients were studied who were found to be positive to 'ArcitumoMab'. Immunoscintigraphy was obtained in 95% of cases. Radioimmunoguided surgery was performed in all cases. One case, which was negative at immunoscintigraphy, was found to be positive intraoperatively when radioimmunoguided surgery was performed. Radioimmunoguided surgery, in the authors' view, is a useful technique but needs to be validated in larger samples, particularly in cases of relapse.