Sacral neuromodulation for the treatment of fecal incontinence: analysis of cost-effectiveness.

PURPOSE: The cost-effectiveness and budget impact of introducing sacral nerve modulation (SNM) as a treatment for fecal incontinence in Italy were evaluated in a simulation model. METHODS: A decision-analysis model with a Markov submodel was used to represent clinical pathways for treatment of patients with fecal incontinence in a scenario with SNM and a scenario without SNM. Data were obtained from published studies and from an expert panel. Evaluation of resource consumption was conducted from the perspective of the Italian National Health Service, and costs were retrieved from the Italian NHS procedures reimbursement list. The time horizon was 5 years, and a 3% discount rate was applied to costs and outcomes. Effectiveness was measured in symptom-free years and in quality-adjusted life-years (QALYs). Fecal incontinence prevalence data and SNM usage forecasts were used to estimate budget impact over the next 5 years. RESULTS: The incremental cost-effectiveness ratio for introducing SNM was €28,285 per QALY gained for patients with a structurally deficient anal sphincter and €38,662 per QALY gained for patients with intact anal sphincters. If a threshold of €40,000 per QALY gained is set as the level that a decision-maker would regard as cost-effective, the probability that the introduction of SNM will be cost-effective would be 99% for patients with a structurally deficient sphincter and 53% for patients with an intact sphincter. Budget impact analysis showed that introducing SNM would have an estimated budget impact of 0.56% over 5 years on the budget allocated for fecal incontinence treatment. CONCLUSION: Our data show SNM to be an efficient investment with an acceptable incremental cost-effectiveness ratio and a limited impact on the total allocated budget for fecal incontinence.

Intestinal anisakiasis in Italy: a case treated by emergency surgery.

Anisakiasis is a fish-borne zoonotic disease. A case of intestinal anisakiasis in a woman who had consumed raw marinated anchovies was reported. The intestinal localization resulted in occlusive acute abdomen which required an emergency surgical treatment. The histological examination of the eosinophilic granuloma removed from the resected colon revealed the presence of larval nematodes of the genus Anisakis as causative agents.

[Strangulated abdominal herniation by Ladd's band]. / Ernia intestinale strozzata su briglia di Ladd.

A case of a 64-year-old man with abdominal pain since three days, with vomiting and ileus and without previous surgery is reported. Faecal material was aspirated by a nasogastric tube; TC showed dilatation of the small bowel with the walls of the loops thickened. The patient was submitted to emergency surgery with diagnosis of intestinal infarction. At laparotomy an extensive necrosis (two meters) of small bowel was present, caused by visceral herniation by a Ladd's band. Intestinal resection was performed with latero-lateral stapled anastomosis. The postoperative course was uneventful and the patient was transferred in VII p.o. day to an hospital of his Country.

Intestinal anisakiasis in Italy: case report.

A case of intestinal anisakiasis caused by Anisakis sp. larva type I in a woman from Italy who consumed raw marinated anchovies, is reported. The diagnosis was based on the morphological features characteristic of anisakid larval stages, which were readily recognized in a large granuloma removed after emergency surgical treatment.

[Pneumatosis cystoides intestinalis in emergencies: clinical management and treatment. 2 case reports]. / La pneumatosi cistica intestinale in urgenza: gestione e trattamento dei pazienti. Due casi clinici.

Pneumatosis Cystoides Intestinalis gives many diagnostic and therapeutic troubles especially when it occurs in patient admitted in an emergency setting. The Authors report two cases of PCI related to patients admitted into the Emergency Department (DEA II) with diagnosis of intestinal perforation, mode according to the radiological findings of free subfrenic air, but not confirmed at physical examination. The Authors discuss the role that imaging and physical examination play in evaluating this kind of patients, considering the etiopathogenetic hypothesis about this rare disorder.

[Emergency treatment and diagnosis of appendix mucocele]. / Considerazioni su trattamento e diagnosi in urgenza di mucocele appendicolare.

The Authors report a case of appendicular mucocele admitted in an emergency setting in the Emergency Department (DEA II). The patient, 78 y-old man, went to attention complaining diffuse abdominal pain: physical examination revealed mild tenderness and right lower quadrant pain to palpation. Rx plain and CT scan demonstrated a right iliac fossa cystic lesion with mural calcification, adherent to the caecum. On basis of imaging, clinical and laboratory findings the patient underwent surgery postoperative diagnosis was mucocele of the appendix. The aim of this report is to discuss the role of imaging and clinical approach in treatment of appendicular mucocele, which is known to be so aspecific in presentation, especially when it occurs in an emergency setting.

Spontaneous rectus sheath haematoma in HCV mixed cryoglobulinemia requiring emergency treatment (case report).

Hepatitis C virus-related mixed cryoglobulinemia is a vasculitis, associated with a number of systemic manifestations and diseases. The Authors present a patient with mixed cryoglobulinemia, who developed acute abdominal pain and severe anemia, caused by spontaneous haematoma of rectus abdominis sheath. Prompt diagnosis of this unusual complication of cryoglobulinemia vasculitis may allow conservative treatment and avoid surgery, which is more expensive and invasive. To the best of Author's knowledge, spontaneous rectus sheath haematoma in a patient with cryoglobulinemia has not been previously reported.

Interaction between cyclosporine and Hypericum perforatum (St. John's wort) after organ transplantation.

The use of herbal medicine has become increasingly popular in the United States. Hypericum perforatum (St. John's wort) is an herbal extract that is used widely as a folk remedy for depression. In this case report, we describe a kidney transplant recipient who developed marked reduction of cyclosporine therapeutic activity after the self-initiation of St. John's wort. Postulated mechanisms for the ability of this herbal extract to interact with pharmaceutical medications are presented, and the existing literature is reviewed.

The mammalian homologue of the novel peptide Bv8 is expressed in the central nervous system and supports neuronal survival by activating the MAP kinase/PI-3-kinase pathways.

Previous studies have identified the mammalian homologue of Bv8 (mBv8), a small protein originally isolated from skin secretions of the frog, Bombina variegata. In situ hybridization showed that mBv8 RNA was widely expressed in the rodent CNS, with high levels being detected in layer II of the cerebral cortex, limbic regions, cerebellar Purkinje cells, and dorsal and ventral horns of the spinal cord. A similar pattern of distribution was found by examining the presence of mBv8 protein by immunocytochemistry. Addition of frog Bv8 to cultured cerebellar granule cells reduced the extent of apoptotic death induced by switching the growing medium from 25 to 5 mM K+. Bv8 could also protect cultured cortical neurons against excitotoxic death. Both effects were prevented by PD98059 and LY294002, which inhibit the mitogen-activated protein kinase (MAPK) and phosphatidylinositol-3-kinase (PI-3-K) pathways, respectively. In cultured cerebellar granule cells, Bv8 stimulated both the MAPK and the PI-3-K pathways, as revealed by Western blot analysis of phosphorylated p44/p42 MAPKs and phosphorylated Akt, respectively. We conclude that mBv8 acts as an endogenous neurotrophic factor and supports neuronal survival through the activation of the MAPK/PI-3-K pathways.

[Compartment syndrome or gas gangrene? A case report]. / Sindrome compartimentale o gangrena gassosa? Caso clinico.

A case of forearm compartment syndrome due to a minor trauma is reported. The severe clinical conditions due to a shock state lead to an initial misdiagnosis of clostridial myonecrosis. The patient, 68 y-old woman, was admitted to the intensive care unit of Authors' hospital for a traumatic injury of the right forearm. A diagnosis of gas gangrene due to clostridial myonecrosis was done and forearm amputation suggested. In spite of this indication a decompression fasciotomy of the forearm compartments was performed as well as a hyperbaric oxygene therapy. Since culture of necrotic tissue samples did not demonstrate any bacterial growth, the Authors decided to avoid amputation and perform a radial arteriovenous fistula to improve venous return and reduce distal edema and continuous bleeding, with a complete recovery within 40 days. Good evaluation of patient with suspected compartment syndrome means correct and not delayed treatment, avoiding invalidating outcome.

Prostaglandin E2 inhibits the interleukin-2 promoter activity through down-regulation of the Oct-dependent transcription of the octamer motif.

Prostaglandins, mainly those of the E series (PGE), are modulators of immune responses. Indeed PGE2 inhibits T cell activation and the transcription of the interleukin-2 (IL-2) gene, the major T cell growth factor. We observed that PGE2 inhibits IL-2 promoter transcription activity by interfering with signals activating the (-96 to -66 bp) octamer motif. This motif binds Oct-1 and Oct-2 as well as the phorbol ester and calcium ionophore-inducible jun and fos AP-1 factors. The PGE2-dependent down-modulation is observed in the presence of either the endogenous transacting factor Oct-1 or the exogenously expressed Oct-2. PGE2 does not regulate octamer function by influencing the jun and fos mRNA or Oct-1 protein levels or their DNA-binding abilities. Functional dissection of the octamer motif, through mutations of either the AP-1 or the octamer sites, revealed that the AP-1 site is dispensable for PGE2-dependent inhibition which instead may occur through the interference with the Oct-mediated transactivation of the octamer element. Our data suggest that the Oct-octamer interaction is a novel target of the PGE2-induced down-regulation of the IL-2 promoter.

Common complications of wound healing. Prevention and management.

The culmination of any operation is a healed wound. Failure of a wound to heal increases time spent in the hospital and the expense, and may start a cascade of progressive complications. Thus, it is important to optimize as many factors as possible before operation and to have the knowledge and resources to deal with wound problems should they occur. This approach involves understanding basic wound healing with its multiple factors, including nutrition, and knowing how to deal with potential adverse factors in wound healing, such as chemotherapy, corticosteroids, and radiation.