Wired and wireless network solution for the integrated management of data and images.

PURPOSE: This paper reports on the authors' experience with the implementation of an internal network with open structure model (extranet) inside a private healthcare institution. MATERIALS AND METHODS: An integrated clinical-administrative internal network was set up within a private orthopaedic hospital with about 90 beds. The system consists of a DICOM-based HIS-RIS network connected to the radiological department PACS, and is implemented through an internal web-server over a mixed wired-wireless network. The strengths of the system are: the use of an open-structure model allowing external access; the inclusion of a wireless component of the network, which extends access to mobile workstations; the possibility of conducting the quality assurance procedures directly from outside the hospital. RESULTS: The system allows the diagnostic images generated by the various equipment (Rx, CT, NMR, etc.) to be filed in compliance with the AIPA (Italian Authority for Information Technology in Public Administration) regulations; the images and electronic clinical records are made available to the departments by means of an internal web server. The use of the wireless component of the network has several additional advantages: for example, it enables healthcare personnel to view clinical records and diagnostic images on their laptop monitors from any department or hospital room, and it makes every change or addition readily available to the healthcare personnel. In this way the laptops represent an evolution of the traditional paper-based clinical record. Moreover, a direct connection was set up with the University Department of Image Processing with a view to increasing the hospital's efficiency and productivity. This connection allows adequate quality assurance procedures to be carried out on the radiological department equipment without requiring the physical presence of specialised staff, and therefore reducing costs and machine idle time. A second phase of the project is currently being tested. This consists in the collaboration of a pilot group of twenty family doctors to test system functionality during telebooking, teleconsulting and information exchange with specialists, as well as the possibility of keeping track of the patients' diagnostic work-up and clinical therapy. DISCUSSION AND CONCLUSIONS: In the context of the Italian healthcare system, the creation of adequate hospital information systems (HIS) and their integration with PACS was at first a prerogative of a few large hospitals. Recently, however, more and more patients have started to approach the healthcare world directly through the Internet, at first to request only information (leading to the diffusion of specialised web sites, or portals) and later also e-services. This new demand led us to create a Hospital Information System able to organise the internal activity of the hospital and offer several external services such as telebooking and teleconsulting, and therefore increase the hospital's efficiency and productivity. a method of choice for following patients after interventional procedures or as a mass-screening tool to select patients to be referred for coronary angiography.

Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: eighteen cases.

The classic treatment of generalized peritonitis due to perforation of sigmoid diverticula is based on the principle of a two-stage surgery with a temporary derivation of the colonic transit. This procedure is associated with a prohibitively high immediate and delayed morbidity, especially associated with the abdominal wound. The laparoscopic approach to this complication is less aggressive and allows a second-stage elective laparoscopic resection. Eighteen consecutive patients (ten women and eight men; average age, 53.7 years) underwent emergency laparoscopic treatment for generalized peritonitis due to perforated diverticula. Eight of these patients had previously had diverticulitis attacks. By peritoneal cavity exploration and full peritoneal lavage (average, 15 L), the infected sigmoid lesion was stuck with biologic glue. A drain was inserted at the site of the lesion and in some cases also in other abdominal zones. No colostomy was necessary. Antibiotic treatment was started at diagnosis and continued for a minimum of 7 days. There was no mortality. Morbidity was limited to three patients (two cases of lymphangitis and one of pulmonary disease). No patient had a wound abscess or residual deep collections. The mean hospitalization was 8 days. Fourteen patients underwent elective laparoscopic sigmoid resection with a delay of 3.5 months. One conversion to laparotomy was necessary. The laparoscopic treatment of generalized peritonitis due to perforated sigmoid diverticula is an interesting alternative to the traditional treatment. It is associated with a lower morbidity, a shorter postoperative hospital stay, and an improvement in the patient's quality of life, because colostomy is avoided. It is also associated with economic savings.

Original technique for small colorectal tumor localization during laparoscopic surgery.

INTRODUCTION: Small colonic tumor localization and correct extension of colonic resection is critical in laparoscopic surgery. Currently used techniques are sometimes inconclusive and may carry some morbidity. We describe an original method of small tumor localization during laparoscopic colorectal operations through the use of preoperative clip applications by colonoscopy and intraoperative ultrasound of the colon. METHODS: Eight patients with small colonic lesions necessitating preoperative marking were included into this study. A two-step technique was used. Before the operation two metal clips were endoscopically applied proximally and distally to the lesion site. At surgery an intraoperative ultrasound examination of the colon or rectum surface was performed to localize the clips. Subsequent laparoscopic colon resection was performed. RESULTS: Endoscopic metallic clips were easily applied around the lesion in all cases without complications. No dislodgement of clips was documented. At surgery laparoscopic ultrasound visualized the clips in all cases. The examination took between 5 and 17 minutes with no specific morbidity. The lesions with the surrounding clips were always found in the resected specimen. CONCLUSIONS: Endoscopic metal clipping and intraoperative laparoscopic ultrasound proved to be an easy, safe, and accurate technique in locating small colonic tumors.

[Laparoscopic treatment of generalized peritonitis with diverticular perforation of the sigmoid colon. Report of 10 cases]. / Traitement laparoscopique des péritonites généralisées par perforation diverticulaire du colon sigmoïde. A propos de dix cas.

BACKGROUND: The classical treatment of perforated sigmoid diverticulitis with generalised peritonitis is based on the principle of two-stage surgical procedures with a temporary initial defunctioning colostomy. This approach is associated with significant morbidity, concerning mainly the abdominal wall. PATIENTS AND METHODS: Ten consecutive patients, eight female and two male, with a mean age of 54.6 years, underwent an emergency laparoscopy for generalised peritonitis secondary to perforated diverticula. Six had had previous infectious episodes; six were obese; four were diabetic and two had chronic lung disease. After exploration of the abdominal cavity and discovery of a purulent peritonitis (n = 8) or faecal peritonitis (n = 2), an extensive peritoneal lavage was performed (average 15 litres), the contaminating sigmoid lesion was covered with biological glue and a drain inserted at the site of the lesion. In some cases, drainage of dependent zones was also performed. No colostomies were performed. Antibiotic therapy instituted as soon as the diagnosis had been made was continued, on average, for 7 days. RESULTS: There was no mortality. There was a low morbidity: one case of lymphangitis on catheter and one of broncho-pulmonary infection. No cases of abdominal wall sepsis or residual deep collections were observed. The mean duration of hospitalisation was 8 days. Nine patients underwent a sigmoid resection (laparoscopic in eight cases) 3 to 4 months later, with a mean duration of hospitalisation of 6 days. One conversion to laparotomy was necessary. CONCLUSIONS: Laparoscopic treatment of generalised peritonitis secondary to perforated sigmoid diverticulitis constitutes an alternative to classical surgery. It is associated with a decreased morbidity and a marked reduction in duration of the hospitalisation. Colostomy can be avoided and the patient's quality of life is improved during the period previous to secondary colectomy, performed by laparoscopy eight times out of nine. In addition, the cost of this approach is significantly lower.

[Port site metastasis. Prospective study of 131 cases]. / Metastasi sui siti dei trocars. Studio prospettico: 131 casi.

Laparoscopic staging and laparoscopic treatment of gastrointestinal malignancy is still controversial because some studies report port sites metastases. The aim of the study is to determine in 131 patients, with prospective follow-up, after laparoscopic staging or laparoscopic treatment, the incidence of port site metastases. 131 patients with localized a gastrointestinal malignancy or other advanced malignant tumors were included. In 57 cases only laparoscopic staging was performed, in 25 cases the laparoscopic staging was followed by a laparoscopic resection and in 49 cases after laparoscopic staging a traditional laparotomic treatment was performed. In 57 cases (43.5%) the tumor invaded the serosal layer. The median follow-up was 17.7 months (3 to 62 months). 502 port-sites were controlled. One patients (0.7%) presented one port site metastases after right colectomy for carcinoma with local carcinomatosis. This study confirm that port sites metastases are rare, and that are favorised by serosal invasion and support the laparoscopic staging of malignant abdominal tumors in order to recognize occult lesions which are not detected by conventional preoperative clinical, biological and radiological explorations (44.2% in this study). In addition, selected patients can be submitted to laparoscopic treatment of the disease (20%).

Curative radiotherapy (RT) using limited RT treatment fields in elderly patients with non-small cell lung cancer in clinical stage IIIA.

We report a prospective phase II study utilizing limited radiotherapy (RT) treatment fields in elderly (greater than or equal to 75 years) patients (pts) with non-small cell lung cancer (NSCLC) in clinical stage IIIA. Sixteen good risk pts with histologically confirmed NSCLC in clinical stage IIIA, age greater than or equal to 75 years (yr) (range 75-83; median age 77) were entered in the study. All pts were treated with Limited RT fields (including T and N1-2 usually with a 1.5 cm, radiographic margin) and received a minimum of 54 Gy (range 54-62 Gy, median 60 Gy, dose/fraction 2 Gy/5 dd a week). All pts have been followed-up for a median time of 3.5 years (range 1.75-6.58). Median survival (MS) was 18 months (range 7-52 months). No acute and/or late significant toxicity was recorded. Univariate analysis showed a better survival in pts receiving a radiation dose greater than or equal to 60 Gy, with an MS of 34 vs 14 months (p=0.017) and in pts with Karnofsky Performance Status greater than or equal to 80, with an MS of 34 vs 12 months (p=0.0O2). There are scarce data available on survival in elderly pts with NSCLC in clinical stage IIIA. Pts submitted to 'standard' RT in unresectable NSCLC have a poor median survival time and 5-year survival rates. The results obtained in our pts encourage us to use 'limited' RT in elderly but the results require a phase III study before definitive recommendations can be made.

Endoscopic management of inveterate esophageal perforations and leaks.

The endoscopic management of four selected patients with inveterate esophageal perforations or leaks is presented. One patient had a perforation of the cervical esophagus following endoscopic removal of a foreign body already treated with surgical drainage; two patients had a leak following diverticulectomy and esophagogastrostomy, respectively, persistent after multiple surgical repairs; the last patient had a spontaneous perforation of the thoracic esophagus persistent after two transthoracic repairs. The mean time elapsed between the diagnosis of perforation and the endoscopic treatment was 19 days. In one patient, transesophageal drainage of a mediastinal abscess was performed. In the other three patients, a stent was placed to seal the leak in combination with gastric and esophageal aspiration. Two of these patients underwent endoscopy in critical condition and could have not been candidates for major surgical procedures. All patients received enteral nutrition. No morbidity or mortality related to the endoscopic procedure was recorded; the treatment was effective in all patients who recovered and resumed oral feeding within 3 weeks. We conclude that endoscopic transesophageal drainage and stenting are effective procedures in the management of patients with inveterate esophageal perforations or leaks.

[Surgical treatment of esophageal stenosis caused by reflux]. / La terapia chirurgica delle stenosi esofagee da reflusso.

From 1976 to 1993, among 582 patients with reflux esophagitis seen at our Institution, 164 (28%) presented with an esophageal stricture, and 68 of these (41%) underwent surgical treatment. The male to female ratio was 1.6:1, and the median age 51 (range 15-78). Thirteen of the 68 patients (19%) had an associated Barrett's esophagus. Esophageal manometry revealed scleroderma in nine individuals (13%). In 11 patients (16%) observed before 1985 the stricture was not dilatable. Surgical therapy consisted of fundoplication (n = 39), Collis gastroplasty plus fundoplication (n = 10), total duodenal diversion (n = 4), and esophageal resection (n = 15). The mortality rate was 4.4%: two patients died of necrosis of the colon transplant and one of acute pancreatitis. The median follow-up was 27 months (6-129). Esophageal sparing procedures significantly reduced the need of further endoscopic dilatation (p < 0.001). Standard fundoplication was successful in 30 of 39 patients (77%). Regression of Barrett's epithelium was not recorded after any of the conservative surgical procedures.

[The partial parenteral nutrition of preterm infants with a body weight < 1000 g: the effects of an infusion of human albumin on plasma amino acid concentration]. / Nutrizione parenterale parziale di neonati pre-termine di peso corporeo < 1000 g: effetti della infusione di albumina umana sulla concentrazione plasmatica di aminoacidi.

This paper concerns with the changes of plasma amino acid (AA) concentrations of N. 10 ELBW infants receiving a regimen of partial parenteral nutrition including human serum albumin (HSA) as a protein supply. The plasma AA concentration has been compared with VLBW infants orally fed with human milk (HM) or human milk supplemented with human milk protein (HMP). As for the essential AA: in comparison to VLBW infants fed HM, the plasma concentration of VAL, PHE and LYS is significantly higher, that of THR, MET, LEU and HIS is similar, whereas that of ILE is significantly lower; in comparison to VLBW infants fed HMP, with the exception of PHE whose plasma concentration is higher, concentration of essential AA significantly lower; the percentage ratio between plasma concentration and intake is in the range of 1,4 to 3,3, except for LYS (= 0.83), indicating a good efficacy of the i.v. administered HSA as AA source, or a slow plasma clearance or a sustained flux of AA from body protein catabolism. Further researches are needed to investigate these aspects and the intermediate steps between i.v. infusion of HSA and the utilization of the component AA for body protein synthesis.

Evaluation of the efficacy of an instructional programme in the self-management of patients with asthma.

The restrictions imposed on patients with asthma is problematic to them, in that their physical disability interferes with personal, interpersonal and/or professional goals. Twenty-three patients under the care of general practitioners were surveyed by interview in their homes, doctors' surgery or at work to determine their current control of selected variables related to their asthma: exercise, use of drugs and related factors. An instructional programme was offered to interested participants to assist in complying with their prescribed medication regimens and to tailor exercise to their tolerance levels. Findings showed that 18 patients experienced moderate to severe restrictions when troubled with asthma. Although over one-half of the patients exercised regularly for fitness, including seven with aerobic exercise, some chose sports they thought could provoke an asthmatic attack. Half took precautionary measures when exercising. All patients used bronchodilators to relieve their asthma, yet one-third did not keep their inhalers accessible. None of the most troubled 18 lived in a smoke-free environment, and one-third kept furry animals as pets. Recommendations are made for further study of the effects of instructional programme to improve compliance to a healthy lifestyle.

Synovial osteochondromatosis of the ankle: MR findings.

The authors present a case of primary synovial osteochondromatosis of the ankle, as demonstrated by magnetic resonance (MR). Ankle involvement by osteochondromatosis is unusual. The characteristic MR findings are: target appearance of some loose bodies with a low intensity peripheral rim and a center isointense to the soft tissues on T1-weighted images, which remain unchanged on T2-weighted images. Conversely, other loose bodies were characterized by homogeneous hyperintensity close to the bone marrow on T1-weighted images, with loss of signal on T2-weighted images. The authors believe that these findings are quite pathognomonic of a long-standing synovial osteochondromatosis.

Perineural spread of nasopharyngeal carcinoma: radiological and CT demonstration.

Perineural spread is well known to be the most insidious form of tumour spread of a number of head and neck malignancies. However, perineural extension of nasopharyngeal carcinoma (NC) is a poorly recognized event. Four cases of perineural metastases from NC have been detected with pluridirectional tomography and CT. In 3 cases involvement of the Vidian nerve (nervus canalis pterygoidei) and pterygoid canal was observed. In a fourth patient, invasion of one pterygopalatine fossa and perineural spread along ipsilateral maxillary nerve with enlargement and erosion of the foramen rotundum was demonstrated. Radiological diagnosis of clinically unsuspected perineural tumour spread is important because it markedly influences treatment planning and prognosis of NC.

[X-ray computed tomography in pathology of the greater omentum]. / Rilievi tomodensitometrici nella patologia del grande omento.

CT examinations were reviewed in 19 patients with proved omental lesions (15 metastases, 1 lymphoma, 1 benign mesothelioma, 1 echinococcosis and 1 tuberculosis). Four distinct but aspecific patterns of omental pathology were identified with CT: omental caking; finely infiltrated fat with a "smudged" appearance; discrete nodules; cystic masses. CT is the most reliable radiographic technique to routinely evaluate omental lesions.