Cognitive assessment to optimize prediction of functional outcome in subacute hip fracture: a short-term prospective study.

BACKGROUND: Cognitive impairment is a long-known negative prognostic factor after hip fracture. Cognition is usually screened by a single easy-to-administer bedside tool, but recent studies have shown that screening tests may be not enough to rule out cognitive impairment with an unfavorable prognostic role. Unfortunately, data on outcome prediction by further cognitive assessments is sparse. AIM: We focused on patients with subacute hip fracture defined cognitively intact or mildly impaired on the screening evaluation performed by the Short Portable Mental Status Questionnaire (SPMSQ). We hypothesized that each of 3 further cognitive tests could independently predict activities of daily living, with optimal prediction of function obtained by performing all three the tests. DESIGN: Short-term prospective study. SETTING: Rehabilitation ward. POPULATION: Inpatients with subacute hip-fracture. METHODS: Three cognitive tests were performed on admission to rehabilitation in the patients who made ≤4 errors on the SPMSQ: Montreal Cognitive Assessment (MoCA), Rey Auditory Verbal Learning Test (RAVLT, immediate and delayed recall) and Frontal Assessment Battery (FAB). We assessed activities of daily living by the Barthel index. Successful rehabilitation was defined with a Barthel Index Score ≥85. RESULTS: Each of the three cognitive tests assessed before rehabilitation significantly predicted the Barthel index scores measured at the end of the rehabilitation course in our sample of 280 inpatients. However, only the MoCA score retained its significant predictive role when the scores from the three tests were included together as independent variables in a multiple regression model, with adjustments for a panel of potential confounders (P=0.007). The adjusted odds ratio to achieve successful rehabilitation for a seven-point change in MoCA score was 1.98 (CI 95% from 1.02 to 3.83; P=0.042). CONCLUSIONS: Contrary to our hypothesis, MoCA but not RAVLT and FAB retained the prognostic role when the scores from the three tests were evaluated together as potential predictors of functional ability in activities of daily living. CLINICAL REHABILITATION IMPACT: In the presence of a normal (or mildly altered) score on the SPMSQ in subacute hip fracture, MoCA scores improve prediction of activities of daily living and should be routinely performed.

A screening test is not enough to define the prognostic role of cognitive impairment after hip fracture: a short-term prospective study.

BACKGROUND: Cognitive impairment assessed by easy-to-administer tests successfully predicts function after hip fracture, whereas the prognostic role of additional cognitive evaluations is largely unknown. AIMS: To investigate the capability of further assessments to discriminate cognitive impairment with prognostic relevance in hip-fracture women defined cognitively intact or mildly impaired on the Short Portable Mental Status Questionnaire (SPMSQ). METHODS: We prospectively investigated women with subacute hip fracture admitted to our rehabilitation facility. The women who made ≤4 errors on the SPMSQ were further assessed by 4 tests: Montreal Cognitive Assessment, Rey Auditory Verbal Learning Test (immediate and delayed recall) and Frontal Assessment Battery. Activities of daily living (ADL) were measured by the Barthel index. Successful rehabilitation was defined with a Barthel index score ≥85. RESULTS: Data from 127 women were available. Each of the 4 cognitive tests assessed at admission significantly predicted the Barthel index scores measured at discharge. The predictive role persisted after multiple adjustments. For a change in cognitive scores corresponding to the difference between 25° and 75° percentiles in their distribution in the sample, the adjusted odds ratio to achieve successful rehabilitation roughly ranged from 2 to 4, depending on which cognitive test was adopted. DISCUSSION: The women with subacute hip fracture defined cognitively intact or mildly impaired on the SPMSQ could have cognitive impairment revealed by further examination, with prognostic disadvantages in ADL. CONCLUSIONS: Assessing cognition by the SPMSQ seems not enough to exclude the presence of cognitive impairment with relevant prognostic disadvantage in hip-fracture women.

Metastatic retroperitoneal tumor from a non-functional neuroendocrine neoplasia of the left ethmoid-nose-orbitary region: Case report and short review of literature.

INTRODUCTION: NeuroEndocrine Neoplasms (NENs) are rare and can originate from any epithelial organ. We describe a very rare case of retroperitoneal metastasis from a non-functioning neuroendocrine tumor of the ethmoid region and focus on the various issues related to NENs, from their nosological classification up to the most recent acquisitions in the diagnostic and therapeutic field. PRESENTATION OF CASE: A woman presented with a mass in the right retroperitoneal area that infiltrated liver and kidney. The anamnestic data showed a previous undifferentiated small cell tumor of the left ethmoid-nasal-orbital region. The mass was removed surgically and the definitive histological examination revealed a non-functioning undifferentiated malignant small cell neoplasm. DISCUSSION: NENs represent a chapter of oncology whose systematization remains difficult. The lack of hormonal syndrome in Biologically Inactive Neuroendocrine Tumors (BINTs) may delay the diagnosis. Clinical manifestations relate to the size and location of the neoplasm. Small cell NeuroEndocrine Carcinoma (NEC) of the ethmoid-nose-orbital region is an extremely rare occurrence and generally the most frequent metastatic localization is represented by the larynx. CONCLUSION: This case highlights the contradictions typical of NENs and only new scientific acquisitions in the histopathological field can help us in the future. Surgery remains the only possibility of treatment and diagnosis of large masses of inactive NENs. This is the only case in the world of metastasis from NEC of the nose-orbital region in the retroperitoneum.

May predictors of difficulty in thyroid surgery increase the incidence of complications? Prospective study with the proposal of a preoperative score.

BACKGROUND: Although thyroidectomy is one of the most common surgical procedures performed worldwide, some permanent complications, despite the considerably reducing incidence, may affect dramatically the patients quality of life. The purpose of this study is to evaluate whether factors identified preoperatively and expressed in a score could be predictors of major surgical difficulty during total thyroidectomy and influence the incidence of complications. METHODS: A total of 164 patients who underwent total thyroidectomy were examined. For each patient we calculated a preoperative score, including seven parameters, which we evaluated to be predictors of difficulty in thyroid surgery, that is, sex, body mass index (BMI), neck length, neck extension, thyroid gland volume, thyroiditis, and increased parenchymal vascularization. The overall score was also compared with peri- and post-operative factors describing objectively the difficulty in thyroid surgery. These factors are the duration of the operation, the length of hospitalization, the incidence of complications such as hemorrhage, hypoparathyroidism, and recurrent laryngeal nerve injuries. RESULTS: There was no statistically significant association between our score and either the percentage of postoperative complications or the length of hospitalization. The operative time was the only variable remarkably associated with the score value (p < 0.00001). Comparing the duration of the operation with each of the preoperative predictive factors, we found that none of the factors reached the value of statistical significance, but a close association could be noted with the thyroid volume and the BMI. CONCLUSIONS: In our study, predictors of difficulty in thyroidectomy did not affect morbidity rates, as suggested by previous studies, but only operative times, which were significantly increased in patients with higher score. Although our results have limited statistical significance, they allow us to confirm the fundamental role of a systematic use of optical magnification and microsurgical technique in thyroidectomy. Further studies, with a larger cohort of patients, are needed to validate our results and to formulate a universally accepted predictive score of difficulty in thyroidectomy preoperatively.

Sclerosing angiomatoid nodular transformation (SANT) of spleen mimicking a splenic abscess: Case report and review of the literature.

INTRODUCTION: SANT of the spleen is a benign lesion that does not recur after splenectomy with unknown etiology. PRESENTATION OF THE CASE: We report a case of sclerosing angiomatoid nodular transformation (SANT) of the spleen mimicking a splenic abscess in a patient with imaging studies that failed to differentiate this lesion from other splenic lesions. DISCUSSION: SANT of the spleen is a rare condition, with only less than 100 cases reported in the literature. Clinically, SANT is only a kind of described pathological diagnostic conception. As in our case, these splenic lesions are often incidental findings on imaging studies performed for other reasons. CONCLUSION: The patient was treated with splenectomy, which has proved to be both diagnostic and therapeutic. Although histology can lead to the diagnosis of vascular tumor, immunohistochemistry is the only way to confirm the diagnosis.

Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report.

INTRODUCTION: True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. PRESENTATION OF CASE: A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. DISCUSSION: The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. CONCLUSION: The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.

Advancement of thyroid surgery video recording: A comparison between two full HD head mounted video cameras.

BACKGROUND: The aim of this study was to test two different video cameras and recording systems used in thyroid surgery in our Department. This is meant to be an attempt to record the real point of view of the magnified vision of surgeon, so as to make the viewer aware of the difference with the naked eye vision. MATERIALS AND METHODS: In this retrospective study, we recorded and compared twenty thyroidectomies performed using loupes magnification and microsurgical technique: ten were recorded with GoPro® 4 Session action cam (commercially available) and ten with our new prototype of head mounted video camera. RESULTS: Settings were selected before surgery for both cameras. The recording time is about from 1 to 2 h for GoPro® and from 3 to 5 h for our prototype. The average time of preparation to fit the camera on the surgeon's head and set the functionality is about 5 min for GoPro® and 7-8 min for the prototype, mostly due to HDMI wiring cable. Videos recorded with the prototype require no further editing, which is mandatory for videos recorded with GoPro® to highlight the surgical details. CONCLUSION: the present study showed that our prototype of video camera, compared with GoPro® 4 Session, guarantees best results in terms of surgical video recording quality, provides to the viewer the exact perspective of the microsurgeon and shows accurately his magnified view through the loupes in thyroid surgery. These recordings are surgical aids for teaching and education and might be a method of self-analysis of surgical technique.

THY3 cytology: What surgical treatment? Retrospective study and literature review.

INTRODUCTION: THY3 nodules collects 20% of cytological examinations, with a rate of malignancy by about 20-30%, and represent one of the most controversial topics of scientific debate. In fact, differential diagnosis of follicular lesions, is very difficult, due to the inability of cytology to differentiate between adenomas and carcinomas. Surgery represents the only possible diagnostic and therapeutic approach, but on the type of surgery there is still absolute discordance of opinions. METHODS: We retrospectively analyzed 230 patients undergoing total thyroidectomy for THY3 cytology between May 2007 and September 2013. Subsequently we re-evaluated our results assuming a conservative surgical approach in patients without preoperative contralateral pathological evidence. RESULTS AND DISCUSSION: Our results indicate an incidence of malignancy in THY3 cytology of 29.6% (n = 68/230), in line with literature data; multifocal bilateral carcinoma in 26.5% of patients; 37 incidental carcinomas (16.5%), 15 of which located contralateral at THY3 nodule; nodular hyperplasia in 52.2% of patients. So, according to a conservative surgery, among patients ideally underwent lobectomy (n = 110), we wouldn't recognize 10 of overall 105 malignancies (9.5%) (including bilateral tumors on THY3 and contralateral incidental carcinomas). Thus, these malignancies would be neither diagnosed nor removed during surgery. CONCLUSIONS: We believe these results allow to state that total thyroidectomy is oncologically the most appropriate intervention to make the patient "disease-free". Moreover, our study could serve as a motivation for further research, but maybe is needed a new Consensus Conference to define a surgical protocol universally recognized.

Standard laparoscopic versus single-incision laparoscopic colectomy for cancer: early results of a randomized prospective study.

BACKGROUND: Standard laparoscopic colectomy (SLC) for cancer is a safe, feasible, and oncologically effective procedure with better short-term and similar long-term results of open colectomy. Conversely, owing to technical difficulties in colonic resection and full mesenteric dissection, single-incision laparoscopic colectomy (SILC) has been considered unsuitable for oncologic purposes. We compared the technical feasibility and early clinical outcomes of SLC and SILC for cancer. METHODS: In this prospective randomized clinical trial, 16 (50%) patients underwent SLC (10 left and 6 right) and 16 (50%) patients underwent SILC (8 left and 8 right). RESULTS: Demographics, preoperative data, and characteristics of the tumor were similar. The mean number of resected lymph nodes was 16 ± 5 in the SLC and 18 ± 6 in the SILC group (P = NS). Surgical time was 124 ± 8 minutes and 147 ± 5 minutes, respectively (P = NS). Surgical mortality was nil and the major morbidity rate was 6.3% in both groups. CONCLUSIONS: SILC for cancer is a technically feasible and safe oncologic procedure with short-term results similar to those obtained with a traditional laparoscopic approach.