The management of chronic rhinosinusitis in clinical practice: An International Survey.

Chronic rhinosinusitis (CRS) is a common disease and is currently classified in two main phenotypes: CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). A panel of international experts conducted the present survey. A questionnaire, containing 25 questions, was completed by each member of the panel. About half of patients with suspected CRS had confirmed diagnosis. CRSwNP affected 31% of CRS patients. Endoscopy and CT were ever performed. Rhinitis and asthma were frequent comorbidities. Intranasal corticosteroids were prescribed on average in 86% of patients. Nonadrenergic compounds were prescribed by 71% of experts. Surgery for CRSwNP was performed in about half of patients; repeated intervention occurred in about one/third. In conclusion, the current survey demonstrated that CRS requires thorough diagnostic work-up, and the most common therapeutic approach is mainly based on intranasal corticosteroids, non-adrenergic decongestants, and surgery.

Emerging and re-emerging infectious disease in otorhinolaryngology.

SUMMARY: Emerging and re-emerging infectious disease in otorhinolaryngology (ENT) are an area of growing epidemiological and clinical interest. The aim of this section is to comprehensively report on the epidemiology of key infectious disease in otorhinolaryngology, reporting on their burden at the national and international level, expanding of the need of promoting and implementing preventive interventions, and the rationale of applying evidence-based, effective and cost- effective diagnostic, curative and preventive approaches. In particular, we focus on i) ENT viral infections (HIV, Epstein-Barr virus, Human Papilloma virus), retrieving the available evidence on their oncogenic potential; ii) typical and atypical mycobacteria infections; iii) non-specific granulomatous lymphadenopathy; iv) emerging paediatric ENT infectious diseases and the prevention of their complications; v) the growing burden of antimicrobial resistance in ENT and the strategies for its control in different clinical settings. We conclude by outlining knowledge gaps and action needed in ENT infectious diseases research and clinical practice and we make references to economic analysis in the field of ENT infectious diseases prevention and care.

Dicrocoelium dendriticum induces autophagic vacuoles accumulation in human hepatocarcinoma cells.

The relationship between Dicrocoelium dendriticum and cancer has been poorly investigated so far, but a large amount of findings suggest that other trematodes can favour cancer in both animals and humans. In this study, the effects of D. dendriticum on cell proliferation, cell death mechanisms and oxidative stress induction were evaluated in hepatocellular carcinoma (HCC) cell lines (HepG2 and HuH7). Results showed that short time exposure to low concentrations of somatic antigens from D. dendriticum caused slight proliferation in both HepG2 and HuH7 cells while high concentrations and long exposure time to extracts from D. dendriticum caused a significant growth inhibition. This effect was, however, not paralleled by apoptosis but it occurred with an about 40% increase of the formation of autophagic vacuoles. In the same experimental conditions, a strong oxidative stress was recorded with an about 100% increase of the intracellular O(2-). These data suggest the occurrence of an escape anti-apoptotic mechanism in HCC cells. In conclusion, these results suggest a role for D. dendriticum in the chronic oxidative stress and in the regulation of transformation processes in HCC warranting additional investigations in this specific area of research.

Intestinal parasites in immigrants in the city of Naples (southern Italy).

The present study was aimed at carrying out a cross-sectional copromicroscopic survey of helminths and intestinal protozoa in immigrants in Naples (southern Italy). Between October 2008 and November 2009, a total of 514 immigrants were tested comparing the FLOTAC dual technique and the ethyl acetate concentration technique. Combined results of the two techniques served as a diagnostic 'gold' standard and revealed an overall prevalence of parasitic infections of 61.9% (318/514). The ethyl acetate concentration technique detected a low number of positive results (49.0%) and this was confirmed for each helminth/protozoa species detected. Among helminths, Trichuris trichiura (3.9%), hookworms (3.7%) and Ascaris lumbricoides (1.4%) were the most prevalent. Strongyloides stercoralis (0.4%), Enterobius vermicularis (0.4%), Schistosoma mansoni (1.0%), Hymenolepis nana (1.6%) and Taenia spp. (0.2%) were also found, as well as zoonotic helminths, as Trichostrongylus spp. (0.8%) and Dicrocoelium dendriticum (0.8%). As regard to pathogenic protozoa, Blastocystis hominis was the most commonly detected (52.7%), followed by Entamoeba histolytica/Entamoeba dispar/Entamoeba moshkovskii (11.9%) and Giardia duodenalis (4.5%). Several issues concerning diagnosis, epidemiology and public health impact of parasitic infections in immigrants are offered for discussion. In conclusion, the present paper pointed out the need of better diagnosis and cure of the immigrant population in order to improve access to health care of this neglected and marginalised population group, for its own protection and care.

Surgical approach to retrosternal goitre: do we still need sternotomy?

Retrosternal goitre is defined as a goitre with a portion of its mass > or = 50% located in the mediastinum. Surgical removal is the treatment of choice and, in most cases, the goitre can be removed via a cervical approach. Aim of this retrospective study was to analyse personal experience in the surgical management of retrosternal goitres, defining, in particular, the features requiring sternotomy. Over a 5-year period (2004-2008), 986 patients underwent thyroidectomy in the ENT Department of the University Hospital of Udine, Italy; in 53 patients, 37 females, 16 males (mean age: 64 years, range: 35-85), thyroidectomy was performed for a retrosternal goitre, which extended, at computed tomography at least 3 cm below the cervico-thoracic isthmus. Retrosternal goitres were removed via a cervical approach in 49 patients; a sternotomy was necessary in 4 patients (7.5%), due to an ectopic intra-thoracic thyroid in one patient, and a very large thyroid reaching the main bronchial bifurcation in the other 3 (mean weight of goitres: 883 g, range: 520-1600). Histo-pathological studies revealed a benign lesion in 50 patients and a carcinoma in 2 (3.7%). The incidence of transient and permanent hypoparathyroidism was 13% and 3.7%, respectively. Transient recurrent laryngeal nerve palsy occurred in one patient (1.8%), post-operative bleeding in 3 patients (5.6%) and respiratory complications, requiring a tracheotomy in one case, in 2 patients (3.7%). Surgical removal of a retrosternal goitre is a challenging procedure; it can be performed safely, in most cases, via a cervical approach, with a complication rate slightly higher than the average rate for cervical goitre thyroidectomy, especially concerning hypoparathyroidism and post-operative bleeding. The most significant criteria for selecting patients requiring sternotomy are computed tomography features, in particular the presence of an ectopic goitre, the thyroid gland volume and the extent of the goitre to or below the tracheae carina. In conclusion, if retrosternal goitre thyroidectomy is performed by a skilled surgical team, familiar with its unique pitfalls, the assistance of a thoracic surgeon may be required only in a few selected cases.

[Rationale of the use of COX-2 inhibitors in ENT pathologies]. / Razionale d'uso dei cox-2 inibitori nelle affezioni ORL.

Upper airways inflammations (rhinitis, rhinosinusitis, polyposis, otitis, pharyngitis, etc) the pathologies most commonly encountered in the daily clinical practice and they represent, because of the high sanitary costs, an important social problem. The Literature suggests that almost all the symptoms, which characterize upper airways inflammations, are induced by the production of prostaglandins by cyclooxigenase (COX); it is obvious the need of a therapeutic action at this level. The non steroidal anti-inflammatory drugs (NSAID) block the activity of both COX-1 and COX-2, whereas the selective inhibitors of COX-2 (the coxibs) act only on this isoform. Actually, the therapeutic effects of both NSAIDs and coxibs are due to their actions on COX-2, while the system toxicity of NSAIDs (gastrointestinal perforation or ulcer, reduction of glomerular filtration rate, prolongation of bleeding time) is ascribable to the inference of these drugs with the COX-1. In conclusion, a correct approach to ENT inflammations must implies the use of drugs efficacious against the typical symptoms of the inflammatory process (and specifically the symptom: pain), eventually joined with an appropriate antibiotic treatment; in this context, a selective inhibitor of COX-2 short course treatment offers the double advantage of managing the inflammation and avoiding damages to the gastric mucosa.

Analysis of IL-2, IFN-gamma and TNF-alpha production, alpha5 beta1 integrins and actin filaments distribution in peritoneal mouse macrophages treated with homeopathic medicament.

The newer forms of immune modulatory therapy are aimed at specific cells or cytokines that contribute to the immune response. These forms of immunotherapy have been referred to as 'biological response modifiers'. Our lab was interested in investigating if a homeopathic medicament 'Metodo Canova' (MC), sold in homeopathic drugstores, does enhance immunological system responses acting through macrophages pathway. Mice peritoneal macrophages were cultivated with or without homeopathic medicament for 24 h for alpha5, beta1 and actin filaments distribution analyses through immunolabelling for confocal microscopy. To detect the IL-2, IFN-gamma and TNF-alpha production these cells were cultivated for 48 h with or without medicament, followed by analyses of these cytokines in supernatant culture with ELISA kits. It was observed differences in morphology and molecular distribution (alpha5 and beta1 integrins, actin filaments and Fc receptors) between the groups control and treated with MC. In control group macrophages had the morphology of resident cells and in MC treated group macrophages were more spread, had many cellular projections and a substantial increase in cytoplasmic volume. In addition, macrophages culture with two doses of MC showed that TNF-alpha production decreased when compared with control group.

[Selective parathyroidectomy with unilateral cervical exploration for primary hyperparathyroidism]. / La paratiroidectomia selettiva con esplorazione cervicale unilaterale nel trattamento chirurgico dell'iperparatiroidismo primitivo.

Primary hyperparathyroidism (pHPT), is caused in over 90% of the cases by a single parathyroid adenoma. Preoperative diagnostic imaging techniques, in particular dual phase scintigraphy with SestaMIBI/TC99 and high frequency probe ecography, are able to pinpoint it 90% of the time. These are the two cornerstones of modern pHPT surgery, which has witnessed the passage from cervical exploration of all the most common parathyroid glandular sites to a more carefully targeted, restricted approach in the side of the neck where the adenoma is suspected to be. This is how selective parathyroidectomy with unilateral cervical exploration and, recently, mini-invasive parathyroidectomy, came into being. Between 1996 and 2001, in the Otolaryngology Department of S. Maria della Misericordia Hospital in Udine, 39 patients affected by pHPT, half of whom (49%) were asymptomatic, underwent selective parathyroidectomy with unilateral cervical exploration. The object of this paper was to evaluate the efficacy of this surgical technique by comparing the pre- and post-operative calcaemia and parathormone levels. The normalization of these parameters, and particularly of the latter, was considered indicative of successful treatment. All the postoperative calcaemia levels were normal, while elevated parathormone levels persisted in only 2 cases (5%). Our statistics showed a 95% efficacy for selective parathyroidectomy, a result that is comparable to the percentages described in the literature. There were, furthermore, no significant peri- or postoperative complications in any of the cases. These observations, together with the brief operating times required for the procedure (20-25 minutes on average) and the low cost of the material employed, enable us to conclude that selective parathyroidectomy with unilateral cervical exploration continues to hold its own as a valid option in the present scenario of surgical pHPT treatment, also in consideration of the fact that it does not present the rigid inclusion criteria characteristics of mini-invasive techniques.

Parathyroid adenomas and malignant neoplasms: coincidence or etiological association?

OBJECTIVE: To evaluate the possible association between primary hyperparathyroidism and malignant neoplasms. DESIGN: An historical cohort study. SETTING: The only Regional General Hospital of the Province of Udine, Italy (population = 500.000). PARTICIPANTS: All the 101 patients with surgically treated parathyroid adenomas. MAIN OUTCOME MEASURE: The incidence rate of malignant tumor was calculated for this cohort based on the number of incidence cases and the person-years at risk. Standardized morbidity rate ratios (SMR) were calculated to infer the cancer relative risk of the study cohort as compared with the general population. RESULTS: A total of 13 cases of malignant neoplasms were ascertained among cohort members. The overall number of observed cases of malignancy did not exceed the number of expected cases (SMR = 1.0). However, strong and statistically significant direct associations were found with bladder cancer (SMR = 5.1) and polycythemia vera (SMR = 62.5). CONCLUSIONS: Due to the magnitude of the associations between parathyroid and bladder cancer and polycythemia vera, it is unlikely that they might be explained completely by bias or chance. Rather, biologically plausible explanations were identified. Particularly, non-paraneoplastic hypercalcemia due to primary hyperparathyroidism may increase the risk of these malignancies.

Refinement of a thyroid cultured cell system used in clinically relevant bioassays.

Thyroid cultured cells are now used worldwide in clinical bioassays of TSH and of thyroid autoantibodies. Having originally developed the thyroid cell cultures (Ambesi-Impiombato et al. 1980) from rat glands in our laboratory, we now aim to improve the system, moving in two directions: a) TSH-independent mutants have been produced and characterized, which can be used in clinical bioassays without "starvation" from the hormone. b) Human cultures have been attempted using our experience with rat cells, as well as innovative strategies. Preliminary results now indicate that human normal differentiated cells may be available for clinical studies in vitro, when species-specific differences may be critical.

Refinement of a thyroid cultured cell system used in clinically relevant bioassays.

Thyroid cultured cells are now used worldwide in clinical bioassays of TSH and of thyroid autoantibodies. Having originally developed the thyroid cell cultures (Ambesi-Impiombato et al. 1980) from rat glands in our laboratory, we now aim to improve the system, moving in two directions: a) TSH-independent mutants have been produced and characterized, which can be used in clinical bioassays without "starvation" from the hormone. b) Human cultures have been attempted using our experience with rat cells, as well as innovative strategies. Preliminary results now indicate that human normal differentiated cells may be available for clinical studies in vitro, when species-specific differences may be critical.

[Intraoperative extemporaneous examination of the parathyroid gland: what is the role of the pathologist in parathyroid pathology?]. / L'esame estemporaneo intraoperatorio delle paratiroidi: qual'è il ruolo del patologo nella patologia paratiroidea?

Hyperparathyroidism (HPT), once considered a rare disease, is nowadays observed and diagnosed more frequently. Consequently, surgical treatment of HPT is often performed with good therapeutic results. The success of parathyroid surgery depends mainly on the accuracy of histopathologic diagnosis through intraoperative examination of frozen tissue specimens. Yet, parathyroid gland pathology is very complex and some of its topics even controversial. Terminology and clinico-pathological concepts in this field are constantly changing and even basic characteristics such as weight, stromal fat content and "normal " histologic patterns of these glands are still actively discussed. The pathologist must often determine, merely by studying a small bioptic specimen, not only the parathyroidal (or non-parathyroidal) origin of the examined tissue, but also the histological "normal" or "abnormality" of the tissue. In carrying out his work the experienced pathologist takes on an important task and responsibility in distinguishing between normal, early hyperplastic (asymmetric), hyperplastic or adenomatous parathyroid glands. New diagnostic technical approaches (such as Electron Microscopy, intracellular fat morphometric evaluation, parenchymal cell mass study by density gradient, etc.) enhance the possibility of reaching a reliable pathologic diagnosis, but they do not solve all the present problems and sometimes can even lead the pathologist astray. Presently the diagnosis and treatment of primary HPT should be considered an open and current problem inasmuch as definite criteria to be followed in distinguishing between normal or single enlarged glands microscopically are still lacking. Neither the degree of accuracy of intraoperative frozen section examination during parathyroid surgery nor the possibility of misleading observations in such a study has been fully evaluated. A close cooperation between the pathologist and head and neck surgeon is of utmost importance to assure the best therapeutical results obtainable from parathyroid surgery in HPT.

Antibiotic prophylaxis in ear, nose and throat surgery: a comparison of a single preoperative dose with three peri-operative doses of ceftazidime.

An open prospective randomized trial was conducted in three Italian ear, nose and throat (ENT) surgery departments on 120 patients aged 10 to 84 years, to compare a single pre-operative dose vs. three peri-operative doses of ceftazidime in surgical prophylaxis. Sixty patients in group I received 1 g ceftazidime intramuscularly (im) or intravenously (iv) 1 h before surgery, and 60 in group II received three 1 g doses of ceftazidime, im or iv, 1 h before, and 6 and 12 h after surgery. Post-operative infections were observed in six group I patients (10.1%) and seven group II patients (11.6%). All infections arose in patients who had undergone 'moderate-risk' (6.7%) or 'high-risk' surgery (30.5%). We conclude that a single pre-operative 1 g dose of ceftazidime is as efficacious as multiple peri-operative doses in the prophylaxis of infectious complications following this type of surgery.

Surgical anatomy of the superior laryngeal nerve.

The authors report on their anatomic findings in 42 surgical dissections of the superior laryngeal nerve. Better knowledge of this anatomy should enable a more conservative cervical surgery and help in attempts at nervous rehabilitation of laryngeal paralysis.

Parathyroid surgery in primary hyperparathyroidism: an update.

The best approach to parathyroid removal in primary hyperparathyroidism (HPT) is still a major topic in neck surgery. The present report reviews our experiences with 71 patients operated by parathyroidectomy (PTX) between 1978 and 1987. Preoperative computed tomography, sonographic and double-tracer subtraction scanning examination allowed a precise assessment of the number and the topography of the diseased glands. Consequently, 65 patients underwent partial "selective" PTX, with removal of one or two glands, while 6 patients underwent subtotal PTX. The surgical results can be summarized as follows: full success in 67 cases (94.4%); persistent hypercalcemic syndrome in 3 cases (4.2%); recurrence of HPT in 1 case (1.4%). One case of persistent hypercalcemia was solved by reoperation. Thus, the total success rate was definitively assessed at 95.8%. As a complication of surgery a long-lasting postoperative hypocalcemic syndrome was observed in only 2 patients following subtotal parathyroidectomy. Our overall findings show that an attentive preoperative study by means of modern imaging techniques usually allows a "selective" partial PTX with good results and a low risk of complications.