Detection of carbapenemase- and ESBL-producing Klebsiella pneumoniae from bovine bulk milk and comparison with clinical human isolates in Italy.

Klebsiella pneumoniae is the most common Klebsiella species infecting animals and is one of the causing agents of mastitis in cows. The rise of antimicrobial resistance in K. pneumoniae, particularly in strains producing extended-spectrum ß-lactamases (ESBLs) and/or carbapenemases, is of concern worldwide. Recently (Regulation UE No 2022/1255), carbapenems and cephalosporins in combination with ß-lactamase inhibitors have been reserved only to human treatments in the European Union. The aim of this study was to investigate the role of cattle as carrier of human pathogenic carbapenem-resistant (CR) and ESBL-producing K. pneumoniae. On this purpose, a study involving 150 dairy farms in Parma province (Northern Italy) and 14 non replicate K. pneumoniae isolates from patients admitted at Parma University-Hospital was planned. Four multidrug resistant (MDR) K. pneumoniae strains were detected from 258 milk filters collected between 2019 and 2021. One carbapenemase KPC-3-positive K. pneumoniae ST307 (0.4 %; 95 % CI - 0.07 - 2.2) was detected in milk filters. The isolate also harboured OXA-9, CTX-M-15 and SHV-106 determinants, together with genes conferring resistance to aminoglycosides (aac(3')-IIa, aph (3″)-Ib, aph (6)-Id), fluoroquinolones (oqxA, oqxB, qnrB1), phosphonic acids (fosA6), sulphonamides (sul2), tetracyclines (tet(A)6) and trimethoprim (dfrA14). One KPC-3-producing K. pneumoniae ST307 was identified also among the human isolates, thus suggesting a possible circulation of pathogens out of the clinical settings. The remaining three bovine isolates were MDR ESBL-producing K. pneumoniae characterized by different genomic profiles: CTX-M-15, TEM-1B and SHV-187 genes (ST513); CTX-M-15 and SHV-145 (ST307); SHV-187 and DHA-1 (ST307). Occurrence of ESBL-producing K. pneumoniae in milk filters was 1.2 % (95 % CI 0.4-3.4). All the isolates showed resistance to aminoglycosides, 3rd-generation cephalosporins, and fluoroquinolones. Among the human isolates, two multidrug resistant ESBL-producing K. pneumoniae ST307 were found, thus confirming the circulation of this high-risk lineage between humans and cattle. Our findings suggest that food-producing animals can carry human pathogenic microorganisms harboring resistance genes against carbapenems and 3rd-generation cephalosporins, even if not treated with such antimicrobials. Moreover, on the MDR K. pneumoniae farms, the antimicrobial use was much higher than the Italian median value, thus highlighting the importance of a more prudent use of antibiotics in animal productions.

The association between patient activation and healthcare resources utilization: a systematic review and meta-analysis.

OBJECTIVES: To measure the association between patient activation and hospitalization or emergency department (ED) visits among adults with chronic diseases. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review of English articles was performed using the following databases: PubMed, Cochrane Library, Web of Science, PsycINFO, and Embase. Articles were searched from 2005 until July 2021. Observational studies that measured the association between patient activation, measured by the Patient Activation Measure (PAM), and hospitalization or ED visits among adults with chronic or multichronic diseases were included. Pairs of reviewers independently screened the studies and extracted data for qualitative and quantitative synthesis. The methodological quality was assessed using the Quality in Prognostic Studies (QUIPS) tool. RESULTS: A total of nine observational studies (153,121 participants) were included in the qualitative synthesis, whereas six were pooled in the quantitative synthesis (151,359 participants). High levels of patient activation were significantly associated with a reduced risk for both hospitalizations (RR [95% CI] = 0.69 [0.61; 0.77], I2 = 78%) and ED visits (RR [95% CI] = 0.76 [0.70; 0.84], I2 = 72%). CONCLUSIONS: Our findings suggest the existence of an inverse association between patient activation and healthcare resources utilization. Further observational studies are needed to fully comprehend the magnitude of this association.

Personas enfermas al final de la vida: vivencias en la accesibilidad a recursos sociosanitarios / Sick persons at the end of their lives: Experiences related to their accessibility to social-sanitary resources / Pessoas doentes no final da vida: vivencias na acessibilidade a recursos sociosanitários

Objetivo: Identificar cuáles han sido las principales limitaciones y dificultades en el acceso a los recursos sociosanitarios que han vivido las personas al final de la vida, a través de las vivencias y las percepciones de los cuidadores de estos enfermos. Método: Estudio cualitativo multicéntrico con enfoque fenomenológico, mediante 5 grupos de discusión y 41 entrevistas en profundidad, en Andalucía, España. La selección de los participantes se realizó intencionadamente entre los cuidadores que habían sufrido la muerte de su familiar, entre 2 meses y 2 años después del fallecimiento. Se optó por el método de Giorgi para el análisis de la información, y como soporte informático utilizamos Atlas ti 6.0. Resultados: Se han obtenido una serie de categorías relacionadas con distintos niveles de asistencia sanitaria: el sufrimiento en los servicios de urgencias, la necesidad de intimidad, la sensación de soledad y la vivencia en el domicilio. Conclusiones: Los cuidadores han descrito una serie de obstáculos de acceso a los distintos recursos sociosanitarios, entre los que destacan la existencia de protocolos muy generales de atención que no tenían en cuenta el proceso de enfermedad de su familiar y la necesidad de una habitación individualizada, durante el ingreso hospitalario. En el domicilio se sienten protegidos por los profesionales de atención primaria, pero presentan dificultades de acceso a apoyo psicológico y a las unidades de cuidados paliativos. Por tanto, es prioritario que desde el sistema sanitario se puedan fomentar los aspectos asistenciales esenciales en la atención a estos enfermos y favorecer una muerte con dignidad.

Objective: From the perspective of their health providers, to identify the main limitations and difficulties which persons at the end of their lives have experienced in relation to their accessibility to social-sanitary resources. Method: This is a phenomenological-focused qualitative and multi-centric study which conducted 5 discussion groups and 41 in-depth interviews in Andalucia, Spain. The participant selection was limited to those health providers who had suffered the death of a family member within the past two years. The Giorgi method was chosen to analyze and back-up the data. Atlas ti 6.0 was also used. Results: From the analysis, several sanitary-assistance-level categories arose including: the suffering at the urgency services, the need of intimacy, the feelings of loneliness, and the life at home. Conclusions: The care providers described a series of barriers to the access to social-sanitary resources highlighting the very general attention protocols which did not integrally consider the illness process of the beloved, and the need to an individualized room while admission at the hospital. Although while at home, these persons feel protected under the attention of the primary care professionals, they have difficulties to having access to psychological support at the palliative care units. Therefore, it is a priority that, from the sanitary system, the essential assisting attention can be warranted, thus supporting these sick persons to go through death in dignity.

Objetivo: Identificar quais têm sido as principais limitações e dificuldades no acesso aos recursos sociosanitários que viveram as pessoas no final da vida, através das vivencias e as percepções dos cuidadores destes doentes. Método: Estudo qualitativo multicêntrico com abordagem fenomenológica, mediante 5 grupos de discussão e 41 entrevistas a profundidade, em Andaluzia, Espanha. A seleção dos participantes realizou-se intencionadamente entre aqueles cuidadores que sofreram a morte de seu familiar, entre dois meses e dois anos depois da morte. Optou-se pelo método de Giorgi par análise da informação e como suporte informático, utilizamos Atlas ti 6.0. Resultados: Obtiveram-se uma série de categorias relacionadas, com diferentes níveis de assistência sanitária: o sofrimento nos serviços de pronto socorro, a necessidade de intimidade, a sensação de solidão e a vivencia no domicílio. Conclusões: Os cuidadores, descreveram uma série de obstáculos de acesso aos diferentes recursos sociosanitários nos quais salienta, a existência de protocolos muito gerais de atenção que não tinham em conta o processo de doença de seu familiar e a necessidade de um quarto individualizado, durante o ingresso hospitalar. No domicilio sentem-se protegidos pelos profissionais de atenção primaria, mas, apresentam dificuldades de acesso ao apoio psicológico e às unidades de cuidados paliativos. Portanto, é prioritário que desde o sistema sanitário se possam promover aqueles aspectos assistenciais essenciais na atenção destes doentes e favorecer uma morte com dignidade.

Chyloperitoneum associated with idiopathic pancreatitis: case report and review of the literature.

Acute chylous peritonitis is defined as the onset of acute abdomen findings due to abrupt chylous fluid accumulation in the peritoneal space. A correct diagnosis of this condition is seldom made preoperatively. The optimal management of true chylous pancreatitis depends upon the underlying etiology. Thorough lavage of the abdomen and adequate drainage has proven to be an excellent treatment modality for acute chylous peritonitis, since resolution of chylous ascites usually occurs within the next few days. However, conservative treatment may be appropriate in selected cases. We present a case report and a brief review of the literature.

El significado de morir dignamente desde la perspectiva de las personas cuidadoras: estudio fenomenológico / The meaning of dying with dignity from caregivers perspective: a phenomenological study

OBJETIVO: Explorar el significado de morir con dignidad desde la experiencia vivida por los testigos directos que han acompañado este proceso en personas fallecidas en Andalucía. MÉTODO: Estudio fenomenológico multicéntrico en el que se han analizado los discursos obtenidos en los grupos de discusión de 5 provincias andaluzas con la participación de 40 personas. El análisis de los datos se ha realizado a través de la propuesta de Van Manem.como herramienta informática hemos utilizado el programa Atlas Ti 7.0. RESULTADOS: El acompañamiento de los seres queridos se erige como elemento clave en la percepción de una muerte digna. También se destaca según orden de prioridad: el alivio del sufrimiento, el buen trato profesional, la capacidad de decidir y la posibilidad de expresar la dimensión espiritual. La cumplimentación de voluntades vitales anticipadas apenas es mencionada. CONCLUSIÓN: Se confirman como elementos esenciales los definidos en la Ley 2/2010, de morir con dignidad (sin sufrimiento, en compañía, respetando deseos, y posibilitando la despedida y el sentido trascendente del proceso de morir). Las personas cuidadoras en el final de la vida priorizan los aspectos psicosociales, destacando la necesidad de acompañamiento, la despedida de los seres queridos y el buen trato profesional sobre los aspectos físicos. La promoción de la Ley de Muerte Digna y Voluntades Vitales Anticipadas se encuentra aún en desarrollo

OBJECTIVE: To explore the meaning of dying with dignity from the perspective of the direct witnesses who have accompanied this process in dying people from Andalusia. METHOD: Phenomenological study conducted in different centres, which including analysing the transcriptions of the dialogues from discussion groups with 40 participants in five provinces in Southern Spain. The data was analysed using the Van Manen proposal and Atlas Ti 7.0 program was applied as a software tool. RESULTS: Being in the company of loved ones is noted as a key element in the perception of a dignified death. The following elements, according to a priority order, were also pointed out: relief of suffering, a good professional care, decision making ability, and the opportunity to consider their spiritual dimension. Achievement of their Living Wills is hardly mentioned. CONCLUSIONS: The essential elements defined in the Death with Dignity Law, 2/2010 are confirmed as being true (without suffering, with company, respecting living wills, having possibilities of the farewell, and the transcendental meaning of the death process). Caregivers, at the end of life, give priority to psychological aspects, underlying the need of company, a farewell of the loved ones, and a good professional care on the physical aspects. The promotion of the dignified Death Law and Living Wills are still being developed

[The meaning of dying with dignity from caregivers perspective: a phenomenological study]. / El significado de morir dignamente desde la perspectiva de las personas cuidadoras: estudio fenomenológico.

OBJECTIVE: To explore the meaning of dying with dignity from the perspective of the direct witnesses who have accompanied this process in dying people from Andalusia. METHOD: Phenomenological study conducted in different centres, which including analysing the transcriptions of the dialogues from discussion groups with 40 participants in five provinces in Southern Spain. The data was analysed using the Van Manen proposal and Atlas Ti 7.0 program was applied as a software tool. RESULTS: Being in the company of loved ones is noted as a key element in the perception of a dignified death. The following elements, according to a priority order, were also pointed out: relief of suffering, a good professional care, decision making ability, and the opportunity to consider their spiritual dimension. Achievement of their Living Wills is hardly mentioned. CONCLUSION: The essential elements defined in the Death with Dignity Law, 2/2010 are confirmed as being true (without suffering, with company, respecting living wills, having possibilities of the farewell, and the transcendental meaning of the death process). Caregivers, at the end of life, give priority to psychological aspects, underlying the need of company, a farewell of the loved ones, and a good professional care on the physical aspects. The promotion of the dignified Death Law and Living Wills are still being developed.

In vivo imaging of tau pathology using multi-parametric quantitative MRI.

As the number of people diagnosed with Alzheimer's disease (AD) reaches epidemic proportions, there is an urgent need to develop effective treatment strategies to tackle the social and economic costs of this fatal condition. Dozens of candidate therapeutics are currently being tested in clinical trials, and compounds targeting the aberrant accumulation of tau proteins into neurofibrillary tangles (NFTs) are the focus of substantial current interest. Reliable, translatable biomarkers sensitive to both tau pathology and its modulation by treatment along with animal models that faithfully reflect aspects of the human disease are urgently required. Magnetic resonance imaging (MRI) is well established as a valuable tool for monitoring the structural brain changes that accompany AD progression. However the descent into dementia is not defined by macroscopic brain matter loss alone: non-invasive imaging measurements sensitive to protein accumulation, white matter integrity and cerebral haemodynamics probe distinct aspects of AD pathophysiology and may serve as superior biomarkers for assessing drug efficacy. Here we employ a multi-parametric array of five translatable MRI techniques to characterise the in vivo pathophysiological phenotype of the rTg4510 mouse model of tauopathy (structural imaging, diffusion tensor imaging (DTI), arterial spin labelling (ASL), chemical exchange saturation transfer (CEST) and glucose CEST). Tau-induced pathological changes included grey matter atrophy, increased radial diffusivity in the white matter, decreased amide proton transfer and hyperperfusion. We demonstrate that the above markers unambiguously discriminate between the transgenic group and age-matched controls and provide a comprehensive profile of the multifaceted neuropathological processes underlying the rTg4510 model. Furthermore, we show that ASL and DTI techniques offer heightened sensitivity to processes believed to precede detectable structural changes and, as such, provides a platform for the study of disease mechanisms and therapeutic intervention.

Transient bacteraemia due to Chryseobacterium indologenes in an immunocompetent patient: a case report and literature review.

A 51-year-old woman was admitted to the emergency unit with diffuse headache, visus reduction, and paraesthesias of the trigeminal area and the left hand. Three days after admission she showed shaking chills, vomiting, and sudden onset of fever (39·4°C). Blood cultures were performed soon after fever onset. Fever persisted for the whole day, decreasing slowly after 12 hours. No empirical antibiotic treatment was started in order to better define the diagnosis. Fever completely disappeared the day after. Two blood cultures for aerobes were positive for Chryseobacterium indologenes. The patient was discharged with the diagnosis of transient bacteraemia and transferred to the neurology unit for further investigations. C. indologenes infections are described in 31 studies with a total of 171 cases (pneumonia and bacteraemia being the most frequent). Our case is the first report of transient bacteraemia caused by C. indologenes in an immunocompetent, non-elderly patient without needing medical devices.

A NOTES approach for thoracic surgery: transgastric thoracoscopy via a diaphragmatic incision in a survival porcine model.

AIM: Recently the NOTES approach has been extended to mediastinum by a transesophageal access and to the thorax by a transvescical endoscopic approach. The aim of this study was to assess the feasibility and the safety of transgastric endoscopic approach to the thoracic cavity, with lung biopsy, in a survival porcine model. METHODS: The study was performed on four 20-30 kg female pigs (Sus scrofus domesticus). Following gastric wall incision, the muscular pars of the left diaphragmatic dome was incised along with the parietal pleura and the endoscope advanced into the thoracic cavity. In all animals, a thoracoscopy was performed as well as peripheral lung biopsy. At the end of the operation the endoscope was withdrawn from the thoracic cavity after pleural sac decompression and the diaphragmatic incision closed by endoscopic clips under maximal expansion of lungs. The gastric incision was finally closed by endoscopic clips. Chest-tube placement was not utilized. Animals were sacrificed by day 15 postoperatively. RESULTS: The gastroscope was easily introduced into the thoracic cavity that allowed to visualize the pleural cavity and to perform simple surgical procedures such as lung biopsies without complications. There were neither respiratory distress episodes nor surgical complications to report. No adverse event occurred during the survival period. The postmortem examination 15 days after surgery revealed a good closure of the diaphragmatic incision. At necropsy, the lung biopsies were completely healed. There were no signs of infection in both thoracic and peritoneal cavities. The length of follow-up and number of animals studied might have not been sufficient. CONCLUSION: This study demonstrates the feasibility of transgastric thoracoscopy in porcine model. Long-term follow-up of much larger series will be necessary for provision of more reliable answers if this approach should be adopted in the future and eventually translated for humans with advantages for patients.

Natural orifices transluminal endoscopic surgery (NOTES): an overview of technical challenges and complications of transgastric procedures in anesthetized pigs.

AIM: Natural orifice transluminal endoscopic surgery (NOTES) is a new reality that is progressively gaining popularity in the scientific community. The aim of this study was to report the authors' experience with various peroral transgastric procedures performed on the porcine model. The technical difficulties and challenges that arose were also analyzed. METHODS: Ten anesthetized pigs, divided into an acute (3) and a survival group (7) underwent the following procedures using a double channel endoscope: peritoneoscopy (10), cholecystectomy (6),splenectomy (3), and gastrojejunostomy (3). RESULTS: All the procedures were completed successfully. There was one complication related to the gastric wall incision. In the survival experiment group all pigs (4) submitted to biliare procedures made an uncomplicated recovery after a follow-up period of 2 weeks. Gastrojejunostomies (3) were instead graved by one technical failure (anastomosis disruption at post-mortem examination) and one case of mortality (premature euthanasia for evidences of sepsis). Complete gastric cleansing was impossible to achieve and overinflation was a common problem. The creation of gastro-enteric anastomoses was technically difficult with the current available devices. CONCLUSION: Transgastric endoscopic surgery is technically feasible in a porcine model. A new instrumentation is needed and could strongly help to overcome the technical difficulties highlighted. More extensive animal studies are mandatory in order to evaluate the benefits and the limitations of this new technique.

Acute gastrointestinal bleeding following aortic valve replacement in a patient with Heyde's sindrome. Case report.

A 58-year old man was admitted to the hospital because of melena. He had a 1-year history of mechanical aortic valve replacement and coronary stent placement because of myocardial infarction and he was taking warfarin and clopidogrel. Esophagogastroduodenoscopy and colonoscopy were negative for bleeding. Capsule endoscopy showed bleeding diffuse angiodysplasia of the small bowel. The patient was treated with octreotide 20 mg, at monthly interval. After 25 months there had been no recurrence of gastrointestinal bleeding. The case suggests that mechanical valve replacement may not prevent gastrointestinal bleeding in Heyde syndrome and that octreotide treatment should be considered in these cases.

Mean and long-term results of the surgical treatment of early gastric cancer.

AIM: Interest in the diagnosis and treatment of early gastric cancer (EGC) has been steadily increasing due to the high 5-year survival rate which can reach 85-100% after curative resection. The aim of this retrospective study was to analyze the clinical and histologic characteristics as well as the results of 45 patients undergoing surgical resection for EGC. METHODS: Between 1998 and 2004, 45 patients, 14 females and 31 males with a mean age of 60.2+/-15 years (range: 31-85) were recruited. Subtotal gastrectomy was performed in 28 (62.2%) patients and total gastrectomy in 17 (37.3%). D1 and D2 resections were performed in 36 and 9 patients, respectively. The carcinoma was limited to the mucosa in 26 (57.8%) patients and extended into the submucosa in 19 (42.2%). Lymph node invasion occurred in 4 (8.8%) patients. Mean follow-up was 36 months (range: 3-63). Survival was calculated using the Kaplan-Meier method. Multivariate analysis of clinic and histologic factors was performed to identify predictive factors for survival. RESULTS: The 5-year actuarial survival rate was 85% and there was no postoperative mortality. Statistical analysis did not demonstrate any significant statistical relationship between survival and parietal penetration (P = 0.67) or superficial extension (P = 0.38) of the tumor. Survival was clearly influenced (P < 0.001) by lymph node involvement. CONCLUSIONS: Prognosis of EGC is usually excellent but can be influenced by the presence of lymph node metastases.

[Ultrasound-guided endoscopic drainage, without radiological examination, in patients with neoplastic biliary obstruction. Preliminary results]. / Sulla possibilità di drenaggio endoscopico, sotto guida ecografica, senza controllo radiologico, in pazienti con stenosi neoplastiche della via biliare principale. Risultati preliminari.

AIM: Endoscopic stent insertion has become the preferred method for palliation of malignant biliary obstruction. Currently, endoscopic stent placement involves the use of contrast media and radiological equipment to achieve direct opacification of the biliary duct systems, and to determine the location and the extension of biliary obstruction. This report proposes a new combination of ultrasonography and biliary endoscopy, with endoscopic stent placement entirely performed under US-guidance. METHODS: US-guided stent placement was carried out in 8 patients. A guide-wire and a guiding-catheter were endoscopically introduced and identified, by US, the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10F) were finally inserted over the guide-wire/guiding-catheter by a pusher tube system. RESULTS: Successful stent insertion was achieved in all patients. There were no complications. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2+/-9.5 vs 4.2+/-2.9 mg/dl at 1 week). CONCLUSION: Endoscopic stent placement performed under US-guidance, is safe and effective. Further studies in a larger series, including more proximal strictures are suggested.

[Endoscopic palliation of inoperable hilar biliary carcinoma with self-expanding metal stents]. / Trattamento palliativo endoscopico con protesi metalliche autoespandibili nelle neoplasie non operabili dell'ilo epatico.

AIM: Prosthetic palliation of patients with malignant hilar stenoses shows particular difficulties, especially in advanced lesions. This is a prospective report of the efficacy of endoscopically inserted single metal stent for complex malignant biliary hilar obstruction. METHODS: Sixty-one consecutive patients were recruited. Contrast injection was deliberately limited to the distal end of the malignant tumor stenosis. A single metal stent was inserted across the stricture into the duct that was technically easiest for the drainage. RESULTS: Successful stent insertion was achieved in 59 of 61 (96.7%) patients. In 3 (4.9%) cases stent malfunction occurred. Successful drainage was achieved in 59 (96.7%) patients and complete resolution of jaundice was achieved in 86% of cases. Early complications included 3 (4.9%) cases of cholangitis and 2 (3.2%) cases of stent occlusion. Late occlusion of the stent occurred in 14 patients (22.9%), including 10 (16.3%) cases of cholangitis and 1 case of liver abscess. Median stent patency was 169 days. Median patient survival was 140 days. CONCLUSION: Metal stent insertion is safe, feasible, and achieves adequate drainage in the great majority of patients with non-resectable hilar cholangiocarcinoma.

Ultrasonography-guided endoscopic stent placement for malignant biliary obstruction: a preliminary report of four cases.

We present a new combination of transabdominal ultrasound (US) and biliary endoscopy, with endoscopic stent placement carried out under US guidance. Four patients (two men, two women; average age 66.2 years) underwent US-guided stent placement for palliation of ampullary carcinoma (n = 3) or pancreatic cancer (n = 1). A guide wire and a guiding catheter were endoscopically introduced and identified, by US in the common bile duct across the stricture. Hydromer-coated polyurethane angled stents (10 Fr) were finally inserted over the guide wire/guiding catheter by a pusher tube system. Successful drainage, with substantial reduction in bilirubin level, was achieved in all patients (14.2 +/- 9.5 vs. 4.2 +/- 2.9 mg/dl at 1 week). The present case series shows that endoscopic stent placement performed under US guidance is safe and effective. Further studies of larger series, including more proximal strictures, are warranted.

[Videolaparoscopic adrenalectomy in an unusual case of adrenal mycetoma]. / La surrenectomia video-laparoscopica in un raro caso di micetoma del surrene.

The authors report a rare case of mycetoma of the adrenal gland. Mycetoma is a chronic, localized, non-contagious infection of cutaneous and subcutaneous tissue characterized by tumefaction, aggregates of aetiological agents (Actinomyces or true fungi). Sometimes an unusual site (other tissues or organs) is described in the literature, but to date no cases of adrenal gland mycetoma have been reported. The treatment of choice is surgical with associated penicillin and/or antifungal drugs. In the case reported surgical treatment is performed with a laparoscopic approach. This technique constitutes the gold standard in cases of benign neoplasms of the adrenal gland and incidentalomas. This therapeutic choice is open to criticism if a malignant neoplasm is suspected.

[Laparoscopic surgical treatment of cholecysto-choledochal calculi. A single step solution]. / Trattamento chirurgico laparoscopico della calcolosi colecisto-coledocica. La soluzione in un unico atto.

The laparoscopic era has created a new basis for the management of choledocholithiasis. Many surgeons now regard laparoscopic cholecystectomy and exploration of the common bile duct as the "gold standard". The main advantages of single-stage treatment consist in a significantly shorter hospital stay, very low complication rates and a reduction of average hospital costs. Among 601 cases of cholelithiasis treated over the period from 1994 to 1999, we report 73 cases of common-bile-duct stones. Surgical sphincterotomy was performed in 20 cases and endoscopic sphincterotomy in 24; only in 7 cases was choledochotomy and/or hepaticojejunostomy (3 cases) performed for critical situations. Twenty-two cases of cholelithiasis were treated by laparoscopic cholecystectomy and exploration of the common bile duct. Stone extraction was obtained with a balloon catheter or Dormia basket via a choledochotomy. Surgery was completed by suturing, cholangiography and the placement of sub-hepatic drainages. No mortality or long-term complications were recorded with the laparoscopic procedure; only two immediate complications were reported, both of which were biliary leakages (9%) that resolved spontaneously. With the other procedures, high rates of mortality, morbidity, hospital admissions and technical failure were registered. We regard laparoscopic exploration of the common bile duct as the treatment of choice for bile-duct stones when combined with cholecystectomy. We reserve ERCP plus endoscopic sphincterotomy only for common-bile-duct stones alone, without a gallbladder or gallstones. Open surgery is performed in particular situations such as Mirizzi's syndrome or when other procedures have failed to yield satisfactory results.

Clonidine-mepivacaine mixture vs plain mepivacaine in paediatric surgery.

In a double-blind study, 42 children, aged 1-10, undergoing general subumbilical surgery, were randomly allocated to two groups; they received, via caudal extradural, 1% mepivacaine 7 mg.kg-1 and normal saline 1 ml (Group 1) and a mixture of 1% mepivacaine 7 mg.kg-1 plus clonidine 2 micrograms.kg-1 and normal saline up to 1 ml (Group 2) respectively. No significant difference was noticed in age, weight, duration of surgery and onset time of anaesthesia, blood pressure, heart rate and oxygen saturation. Mean duration of analgesia (evaluated with 'Broadman objective pain scale') was 143 min for Group 1 and 218 min for Group 2 (P < 0.05); the time of sedation (evaluated with a sedation score) was statistically longer in Group 2 (172 min vs 89 min in Group 1). This longer sedation is due both to the longer analgesia and partially to a side effect of clonidine. In conclusion the addition of 2 micrograms.kg-1 of clonidine to mepivacaine prolongs the duration of caudal analgesia in children.