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.

Perceived parenting behavior in the childhood of cocaine users: relationship with genotype and personality traits.

Low parental care during childhood, a pattern characteristic of an "affectionless control" rearing style was frequently reported in the history of addicted individuals. Parents' childrearing regimes and children's genetic predispositions, with their own behavioral characteristics, have been seen to be closely interwoven, probably affecting children's development and addictive behavior susceptibility. In the present study, parents care perception, aggressive personality traits, and genotype (serotonin transporter promoter gene--5-HTTLPR) have been investigated in cocaine users and healthy control subjects. PBI scores (maternal and paternal care) were lower and BDHI scores (aggressiveness) higher in cocaine users in comparison with controls and significant differences in the perception of either paternal or maternal care were observed between cocaine users and non-users. The short-short (SS) genotype frequency was significantly higher among cocaine users compared with control subjects (P = 0.04). Logistic regression proves that persons bearing the SS genotype have a risk of becoming cocaine user almost three times higher than those having the LL genotype. Estimations of the effects of other factors potentially affecting the risk of being cocaine addicted clearly prove the significant impact of aggressiveness: the highest the score, the highest the risk of becoming cocaine user. Moreover, paternal and maternal care perception significantly improve the fit of the model (the log likelihood decreases passing from -105.9 to -89.8, LR test = 32.17, P-value = 0.0000). Each unit increase in the PBI score yields a significant 12% and 10% decrease of the risk of becoming cocaine user, respectively for paternal and maternal care. Interestingly, once controlled for the PBI score, the relative risk associated to the SS genotype drops strikingly and becomes no longer statistically significant. On the whole, our preliminary data suggest that the association between 5-HT transporter polymorphism and psycho-stimulant use may be mediated by mother-child relationship and parental attachment perception, both being environmental and genetic factors involved in the proneness to substance use disorders, particularly in aggressive-antisocial individuals.

[Benign thyroid disease: 20-year experience in surgical therapy]. / Malattia tiroidea benigna: esperienza ventennale di terapia chirurgica.

This retrospective study compares recurrence and postoperative complication rates after isthmo-lobectomy and subtotal thyroidectomy (group I) vs near-total and total thyroidectomy (group II) for benign thyroid disease. Seven hundred and forty-three patients were operated on for thyroid diseases over the period from 1977 to 1998. We considered 202 patients operated on for benign thyroid disease from 1988 to 1998. The follow-up ranged from 1 to 10 years (mean: 3.4 yrs). One hundred and thirty-two patients (65.3%) were operated on for bilateral nodular goitre, 35 (17.3%) for unilateral nodular goitre, 14 (6.9%) for toxic goitre and 21 (10.4%) for thyroiditis. Over the period 1988-1992, 19 patients underwent isthmo-lobectomy and 71 subtotal thyroidectomy (group I). From 1993 to 1998, 39 patients underwent near-total thyroidectomy and 61 total thyroidectomy (group II). The relapse rate was 14.4% in group I, while there were no recurrences in group II (p = 0.000064). Temporary hypocalcaemia was significantly higher (p = 0.000001) in group II (29%) than in group I (2.2%). Within group II, the rate was significantly higher (p = 0.0013) after total thyroidectomy (37.7%) than after near-total thyroidectomy (15.4%). In our experience, near-total and total thyroidectomy are an appropriate approach for preventing recurrence in patients with benign thyroid disease despite the fact that the risk of temporary hypocalcaemia is higher than after less radical surgery. Near-total thyroidectomy and the exercise of all due care in the surgical technique may help to reduce its incidence.

Neurotransmitters, neuroendocrine correlates of sensation-seeking temperament in normal humans.

Correlations between sensation-seeking (SS) personality dimension and plasma concentrations of norepinephrine (NE), epinephrine, and NE-dependent testosterone (T), cortisol and prolactin (PRL) were studied in 74 physically and psychologically healthy male volunteers, in order to see whether or not the noradrenergic system is involved in the modulation of this personality trait. Novelty-seeking scores by the Temperament and Character Inventory and SS scores on a Visual Analog Scale were positively correlated with plasma NE, T and PRL levels, suggesting that NE and the downstream cascade of NE-dependent hormones, together with other monoaminergic changes, might be responsible for the development and the degree of this temperamental character.

[Acute biliary pancreatitis. Role of laparoscopy after 30 years of traditional surgery experience]. / Pancreatite acuta biliare. Ruolo della laparoscopia dopo un'esperienza di chirurgia tradizionale di oltre trenta anni.

The authors herein show their own experience in the treatment of acute biliary pancreatitis. Aim of this study is to evaluate the effectiveness and the safety of the "early" laparoscopic approach to the mild to moderate acute biliary pancreatitis. The authors studied sixty cases of laparoscopic cholecystectomy with intraoperative colangiography for acute biliary pancreatitis (M/F 1:1.2; mean age 59.6 yrs, range 29.79). The patients were divided in two groups on the basis of the severity of the pancreatitis, defined through Ranson's score and Balthazar classification. The mortality rate was nil. Intraoperative morbidity rate was 6.6% in the group I (3/45), and 13.3% in the group II (2/15). Postoperative morbidity rate was 6.7% (3/45) in the group I and 40% in the group II (6/15). The authors show an original diagnostic and therapeutic algorithm for the treatment of acute biliary pancreatitis. Early laparoscopic cholecystectomy with I.O.C. is proposed as the gold standard treatment for mild to moderate acute biliary pancreatitis. This approach appears to be effective and safe in their experience. In case of severe acute biliary pancreatitis, further investigations are mandatory to evaluate the role of laparoscopic approach.

The use of radioimmune western blotting to evaluate indeterminate western blotting results in blood donor HIV serodiagnosis.

The serodiagnosis of HIV infection is sometimes puzzling due to questionable "indeterminate" results obtained by western blotting (wb), the confirmatory test used world-wide after a positive or borderline ELISA result. These situations cause anxiety in the person being tested and determine additional laboratory costs. We showed that radioimmune western blottting (riwb) an improved and sensitive modification of conventional wb, was able to resolve most "indeterminate" results in individuals who later fully seroconverted. We report in this paper the use of riwb in sera of 20 uninfected blood donors with an indeterminate wb continuing for at least 6 years, to verify the serological status in indeterminate not at risk individuals. Thirteen out of the 20 were indeterminate with conventional wb due to the presence of antibodies to p 24, two to p 17, two to p 55, two to p 51 and p 55 and one to p 24 and p 51 antibodies. The presence of all these bands was confirmed using riwb; moreover, in comparison with wb, the intensity of all bands was clearly enhanced. Despite the use of this highly sensitive method no new bands were found with riwb in indeterminate sera; negative results were obtained when sera borderline or positive with ELISA but negative with wb, were subjected to riwb.

Neurotransmitter and endocrine modulation of aggressive behavior and its components in normal humans.

Correlations between aggressiveness and its components and plasma concentrations of norepinephrine (NE), epinephrine (EPI), testosterone (T), cortisol (Cort) and prolactin (Prl) were studied in 158 physically and psychologically healthy male volunteers. Global aggressiveness, examined directly in the probands by the Buss-Durkee Hostility Inventory (BDHI), was not correlated with any of the biochemical parameters investigated, but reports by first-degree relatives and spouses showed positive correlations between global aggressiveness and NE and T levels. The BDHI scores for 'irritability' and 'resentment' were positively correlated with NE, T and Cort.

Severe hemorrhagic complications in pancreatitis.

Severe bleeding may complicate the course of either acute or chronic pancreatitis, the latter being more frequently involved. Pseudocysts, severe inflammation, regional necrosis and infection may cause major vessel erosion with or without pseudoaneurysm formation which eventually may result in severe bleeding into the gastrointestinal tract, retroperitoneum and peritoneal cavity. The AA report their experience on 8 cases and analyze the data of a comprehensive review of 389 cases of massive bleeding reported in the literature during the last 100 years until December 1993. Mortality rate seems to be related to the etiology of the bleeding along with its localization and the underlying anatomo-pathologic findings. In patients with chronic pancreatitis it is 22% while in patients with acute pancreatitis or chronic pancreatitis with acute exacerbation it is 60.4% and 57.1% respectively. Splenic, gastroduodenal and superior pancreaticoduodenal arteries are the most commonly involved vessels being associated respectively with a mortality rate of 20.5%, 27.9% and 46.1%. Massive haemorrhage complicating infected necrosis or abscesses implies a worse prognosis when compared to severe bleeding associated with pseudocyst with or without pseudoaneurysm. The increasing use of diagnostic and interventional radiology appears to be the way forward to improve survival rates. Awareness of high risk predisposing condition, activism in achieving an early identification of the bleeding sources, and eventually its angiographic control are essential guidelines for successful approach to the most unpredictable complication of pancreatitis. When embolization fails or is followed by recurrence of hemorrhage, definitive surgical procedures should be immediately instituted.

Is intraoperative ultrasonography useful in pancreatic cancer surgery?

Preoperative staging of pancreatic cancer represents a major challenge for a suitable surgical management of the disease. In a consistent number of patients laparotomy is still necessary in order to decide whether the tumor is resectable or not. In the present paper the Authors report their experience with intraoperative ultrasonography (IOU) in evaluating pancreatic cancer resectability. Very important data for intraoperative decision making were obtained in 37.9% of the patients, useful information in 31%, while in 31% IOU may be looked forward to as an important aid in decision making and for a safely guided dissection.

[Telescopic termino-terminal pancreatico-jejunostomy after duodenopancreatectomy]. / La pancreatico-digiunostomia termino-terminale telescopica dopo duodenocefalopancreatectomia.

The Authors report their experience in pancreatic stump management after pancreaticoduodenectomy. "Telescope" end-to-end pancreaticojejunostomy realized with some safe technical details represents a valid reconstructive procedure especially when the pancreatic remnant has a normal parenchyma without dilated duct.

[Transfusional hemolytic reactions of an alloantibody not determinable by standard methods of compatibility]. / Reazione emolitica trasfusionale da alloanticorpo non rilevabile con le metodiche standard di compatibilità.

Anti-e is rare as allontiboby, relatively frequent as autoantibody. A case of immediate haemolytic transfusion reaction (IHTR) in a patient with a high-titer alloantiboby of this specificity, not revealed in cross-match, is described.