First Case of Medically Assisted Suicide in Italy Set New Legal Perspectives.

Abstract: The first act of assisted suicide in Italy was recently carried out. This event is an absolute novelty for the country, affected by recent legislative changes aimed only at introducing the right to interrupt health treatments and, therefore, carry out exclusively omissive end-of-life acts. These normative provisions lay their foundations in a cultural context centered on the protection of the right to life and health; however, the cases that have occurred over time, including the famous story of DJ Fabo, have led the Constitutional Court to re-evaluate these dictates, introducing in 2019 the right to resort to assisted suicide procedures within well-defined areas, including incurability of the condition, the serious suffering of the individual and the retained ability to stand trial. The case addressed concerns a quadriplegic subject who was the victim of a road accident. Following consultation with a specialized institution, the subject made the decision to undergo an assisted sui-cide procedure in Italy. Having obtained the authorization from the competent authorities, he started a fundraiser to finance the devices and drugs required and, finally, he died. The opening by Italy towards the assisted suicide procedure represents a great step towards a broad context, as well as a decisive act for the purpose of protecting the right to self-determination of the individual. However, the current legislative framework presents significant criticalities and shortcomings. In first place, the dissonance between the laws in force and the judicial sentences is likely to generate problems of uneven application of the rules in a country dominated by the principle of Civil Law. Furthermore, the need for the applicant to fully self-finance the procedure clearly clashes with the constitutional principle of free access to care. Then emerges the need for a guideline document regarding the completion of the procedure itself, the times, methods and drugs implied, in order to significantly reduce the decision-making process by the ethics committees that still weighs on each individual case. Finally, conside-ring what has been observed on the subject of voluntary termination of pregnancy, it is necessary to ask what will be the general orientation of the doctors called to perform the act and whether they will be given the opportunity to express their refusal. The case analyzed could represent the beginning of a new era for Italian culture, but the large-scale application of assisted suicide procedures requires the introduction of legislative provisions that definitively eliminate the critical issues that have emerged so far.

The potential impact of acute coronary syndromes on automatic sensing system in Subcutaneous-ICDs.

BACKGROUND: The Subcutaneous-ICD (S-ICD) is emerging as a suitable option for most ICD candidates, however some open issues regarding the sensing algorithm still remain. OBJECTIVES: We aimed to examine the performance of the S-ICD sensing algorithm in patients hospitalized for ST elevation myocardial infarction (STEMI), non ST elevation acute coronary syndrome (NSTE-ACS) or chronic coronary syndrome (CCS), before and after revascularization. METHODS: We performed a S-ICD automated screening on 75 patients, 21 hospitalized for STEMI, 23 for NSTE-ACS and 31 for CCS, before and after percutaneous revascularization, regardless their eligibility to ICD implantation. RESULTS: Patients did not differ in clinical, electrocardiographic and echocardiographic parameters. Rates of screening pass were significantly lower in STEMI patients compared to NSTE-ACS and CCS (5% vs 56.7% vs 81% respectively, p < .0001). The viability of the primary vector was lower in STEMI patients compared to NSTE-ACS and CCS (33% vs 56% vs 71%, p .027 respectively). After revascularization, there were no more significant differences between groups. Pairing subjects at baseline and after revascularization, STEMI subjects percentages of screening success were respectively 5% and 81% (p < .001) and the rates of primary vector viability were 33% and 81% (p .002). STEMI was the only independent predictor of screening failure at multivariate logistic regression analysis (odds ratio 10.68 confidence interval 2.77-41.38, p = .001). CONCLUSION: The performance of the S-ICD and possible malfunction detections in the context of an acute ischemic event deserve further evaluation. Adequate patient selection and the development of dynamic device programming are warranted.

The role of tibial nerve stimulation for enhanced postoperative recovery after colorectal surgery: a double-blind, parallel-group, randomized controlled trial.

BACKGROUND: Postoperative ileus (POI) is the most common cause of prolonged hospital stay following abdominal surgery, despite an optimized enhanced recovery after surgery (ERAS) program. The aim of the study was to evaluate the role of postoperative transcutaneous electrical tibial nerve stimulation (TTNS) in the recovery of bowel function and in shortening hospital stay after colonic resection. METHODS: Patients having elective laparoscopic colonic surgery within an ERAS program at our institution between June 2016 and June 2019 were enrolled and randomly assigned to a treatment protocol with TTNS or sham electrical stimulation. The primary endpoint was the time of recovery of gastrointestinal motility, measured as the first passage of stool. Secondary endpoints included: first passage of flatus, length of hospital stay, and complication rate related to the use of TTNS. RESULTS: One hundred and seventy patients who had right hemicolectomy (median age 71 years (range 43-89 years); 47.5% women) and 170 patients who had left colectomy (median age 67 years range (37-92 years); 41.5% women) were enrolled. The only factor significantly affected by TTNS was time to first passage of flatus after right hemicolectomy (reduced from 46 to 33 h, p = 0.04). However, if only patients with low compliance to early oral nutrition (63 of 340; 18.5%) were considered, a statistically significant difference in time until first flatus (p < 0.01) and first bowel movement (p < 0.0001) and a shorter time until discharge (median 5 vs 7 days) were found in both left and right colectomies groups, respectively. CONCLUSIONS: TTNS may have a positive effect on gastrointestinal tract motility and recovery from POI after colorectal surgery in a selected group, who has low compliance with an ERAS program, without increasing the risk of complications.

Total hip arthroplasty and sexual activity: a systematic review.

Hip discomfort due to degenerative pathologies causes limitations in the everyday activities of patients, including sexual activity. To address such limitations, patients are usually treated with total hip arthroplasty (THA). The aim of this systematic review was to investigate the success of this surgical procedure to ameliorate sexual activity of patients. We performed a comprehensive research of four electronic databases for articles pertaining to the benefits of THA on sexual activity. Exclusion criteria included articles not in English. The search initially yielded 34 articles. Two authors subsequently read all abstracts and excluded all studies unrelated to the topic, leaving 16 articles for further evaluation. Sixteen articles filtered by orthopaedic departments were included in this review. A total of 2391 patients were considered. Pre- and postoperative reports on sexual concerns have been evaluated and compared. The current literature suggests that sexual life is improved after THA. Patient education regarding postoperative expectations and resumption of sexual activity is severely lacking and the majority of surgeons offer little or no information on the subject. Specifically designed studies on the subject are required to evaluate the effects of surgery and approaches on postoperative restrictions.

Trends in surgical management of the infected total ankle arthroplasty.

OBJECTIVE: We performed a systematic review of surgical treatment of the infected total ankle arthroplasty. The purpose of this investigation was to describe the current trends and to perform a critical analysis of the evidence reported in the existing literature. MATERIALS AND METHODS: A comprehensive search for all relevant articles published in English was conducted. Scientific databases were accessed to identify papers dealing with the management of the infected total ankle arthroplasty. We identified and collected every patient that underwent a surgical management of infected ankle arthroplasty. Data extracted were summarized and reported. A descriptive analysis was performed; when possible, a statistical analysis was accomplished. RESULTS: Thirty-two papers (152 infected ankle arthroplasty) published in the last 20 years were identified. Twenty-seven patients (17.76%) were treated with irrigation and debridement, revision total ankle arthroplasty was performed in 72 cases (47.37%), arthrodesis was performed as a primary treatment in 30 patients (19.74%), 12 patients (7.89%) underwent a spacer arthroplasty while amputation was performed as a primary treatment in 9 patients (5.92%). CONCLUSIONS: Our study reveals the improvement of the surgical management of the infected total ankle arthroplasty through the last 20 years. Irrigation and debridement and two-stage revision represent the most viable treatment in acute postoperative and late chronic infections respectively. We noted a trend towards maintaining articularity through a two-stage revision. The quality of evidence is weak with biases both in reporting and selection process. High quality randomized controlled trials are required to compare different treatments in order to introduce an evidence-based treatment protocol.

Coexpression profile of leukemic stem cell markers for combinatorial targeted therapy in AML.

Targeted immunotherapy in acute myeloid leukemia (AML) is challenged by the lack of AML-specific target antigens and clonal heterogeneity, leading to unwanted on-target off-leukemia toxicity and risk of relapse from minor clones. We hypothesize that combinatorial targeting of AML cells can enhance therapeutic efficacy without increasing toxicity. To identify target antigen combinations specific for AML and leukemic stem cells, we generated a detailed protein expression profile based on flow cytometry of primary AML (n = 356) and normal bone marrow samples (n = 34), and a recently reported integrated normal tissue proteomic data set. We analyzed antigen expression levels of CD33, CD123, CLL1, TIM3, CD244 and CD7 on AML bulk and leukemic stem cells at initial diagnosis (n = 302) and relapse (n = 54). CD33, CD123, CLL1, TIM3 and CD244 were ubiquitously expressed on AML bulk cells at initial diagnosis and relapse, irrespective of genetic characteristics. For each analyzed target, we found additional expression in different populations of normal hematopoiesis. Analyzing the coexpression of our six targets in all dual combinations (n = 15), we found CD33/TIM3 and CLL1/TIM3 to be highly positive in AML compared with normal hematopoiesis and non-hematopoietic tissues. Our findings indicate that combinatorial targeting of CD33/TIM3 or CLL1/TIM3 may enhance therapeutic efficacy without aggravating toxicity in immunotherapy of AML.

How to prevent dislocation after revision total hip arthroplasty: a systematic review of the risk factors and a focus on treatment options.

BACKGROUND: Dislocation represents the most common complication after revision total hip arthroplasty (rTHA). Understanding risk factors for dislocation has a great clinical relevance for every hip surgeon in order to consider all surgical options for effective planning. The aim of this systematic review was to answer two main questions-(1) what are the risk factors for instability after rTHA? and (2) what are the best preoperative assessments and surgical options to avoid dislocation after rTHA? MATERIALS AND METHODS: Scientific databases were accessed to identify papers dealing with prevention and treatment of dislocation after rTHA. We performed a search using the keywords 'revision hip arthroplasty' and 'dislocation', 'instability', 'outcome', 'failure', 'treatment'. After removal of duplicates and exclusion of works published in different languages, 33 articles were reviewed completely. RESULTS: Risk factors were analysed in order to establish the most relevant and evidence-based treatments available in the current literature. CONCLUSIONS: The risk of dislocation after rTHA can be reduced using some precautions inferred from the literature. The use of a larger femoral and acetabular component, elevated rim liner and dual mobility implants can significantly reduce the risk of dislocation after rTHA. However, care must be taken regarding patient-related risk factors since these cannot be addressed and modified. Hence, a complete evaluation of risk factors should be performed for each patient and procedure before starting rTHA.

Bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot.

Flatfoot is a common condition in growing-age patients. Despite its common presentation, nowadays surgical indications and treatments are still debated. Arthroereisis is a widely used technique, and several implants designs have been proposed over time. Despite the good results shown in the literature, the main drawback of these techniques has always been the need for a second surgery for implant removal. Bioabsorbable devices have been introduced to overcome this necessity.Correct approach to the patient, indications and contraindications and available studies on bioabsorbable implants for subtalar arthroereisis in pediatric flatfoot were analyzed in this narrative review. Even if only a few studies have been published in the literature, bioabsorbable implants showed good clinical results comparable to non-absorbable implants and with a rare necessity for implant removal or revision. When correct indications and proper surgical technique are followed, arthroereisis with bioabsorbable implants appears to be an effective solution for the treatment of pediatric flexible flatfoot.

Modified minimally invasive direct anterior approach through a bikini incision for total hip arthroplasty: technique and results in young female patients.

Direct anterior approach for THA has gained popularity over the last years. However, concerns have been raised regarding the cosmetic, related to the incision that does not respect the Langer's skin tension line and may produce hypertrophic scars. The aim of this study was to analyze the preliminary results in 22 young female patients undergoing THA through a minimally invasive direct anterior approach using a modified oblique bikini incision. Clinical evaluations showed an improvement of WOMAC, UCLA and Harris Hip Score at 5-month follow-up. The technique ensured proper implant positioning and showed advantages in terms of complications, transfusion rates, hospital length of stay and functional recovery. From the aesthetic point of view, the expected cosmetic results were obtained. Minimally invasive direct anterior approach using a modified oblique bikini incision represent a viable option for THA, combining both the advantages of a minimal invasive procedure with a better aesthetic appearance.

Direct vertebral rotation and differently shaped dual rod translation technique in adolescent idiopathic scoliosis.

Direct vertebral rotation (DVR) is widely used to correct the axial deformity in adolescent idiopathic scoliosis (AIS). Indirect rotation techniques may help DVR in order to improve outcome. Vertebral translation technique combined with the use of two differently shaped rods resulted effective in reducing the rib hump deformity. The aim of this study is to describe the technique and evaluate the efficacy of combined DVR and vertebral translation technique on axial deformity correction. Mean follow-up was 2.7 years. Cobb angle, kyphosis angle, apical vertebrae axial rotation angle, SRS-22 questionnaire of 30 AIS patients treated with combined DVR and differently shaped dual rods translation technique were collected and compared preoperatively and postoperatively. At the last follow-up no screw pull-out, nonunion or loss of correction were recorded. The combination of DVR and differently shaped dual rods translation technique in AIS can provide good three-dimensional correction and improvement of patient's quality of life.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period.

Main surgical approaches to the hip have been modified during last decades, in an effort to reduce invasiveness of the surgical procedure and allow a faster rehabilitation. Direct anterior approach is the only approach, which does not require muscle detachment, thus theoretically leading to reduced post-operative pain and allows earlier recovery. The aim of this study was to report a comparison between patients operated with direct anterior approach and postero-lateral approach in terms of immediate post-operative and in-hospital records. Pain, operative time, intra- and post-operative complications, blood loss, hospitalization, motor component of the Functional Independence Measure (M-FIM), timed up and go (TUG) test were measured between the two groups and compared. Direct anterior approach showed better results in M-FIM, TUG, hospitalization and blood loss, without any significant difference for intra- and post-operative complications between the 2 groups. This study shows that early post-operative recovery is influenced by the chosen approach. Direct anterior approach showed better outcomes when compared to postero-lateral approach, limited to hospitalization, blood loss, and functional scores. Further comparisons are needed to evaluate direct anterior approach to maintain advantages over postero-lateral approach on longer follow-up period.

Surgical treatment of insertional Achilles tendinopathy: a systematic review.

Insertional Achilles tendinopathy is a frequent cause of pain and performance impairment of the ankle. It is more common in runners, but may also affect general population. Conservative treatment is the gold standard in the early phases but 10% to 30% of patients require surgery. The aim of this study is to review the current literature in order to evaluate current surgical strategies for Insertional Achilles tendinopathy and to analyze the effectiveness of the available techniques. We performed a systematic review of the literature, to identify studies reporting clinical outcome after surgical treatment for Insertional Achilles tendinopathy in any population group with at least 6 months follow-up. The quality of the articles included was evaluated by the Coleman Methodology Score and correlated with the reported outcome and year of publication. We identified 16 studies reporting on 465 surgically treated Insertional Achilles tendinopathy with a mean follow-up of 29.8 months. Average age at the time of surgery was 53 years. Two different categories of surgical treatment were distinct: debridement alone or debridement with augmentation in case of excessive tendon loss. Results were excellent or good in 89.6% of cases and fair or poor in 10.4%. Average complications rate was 18.3%, with 15.7% of minor and 2.6% of major complications with no difference in the two groups. Negative correlation was found between Coleman Methodology Score and the reported outcome and positive correlation was found between Coleman Methodology Score and year of publication. Good or excellent outcome can be expected after surgical treatment for Insertional Achilles tendinopathy whatever the adopted procedure, but there is no specific evidence regarding which surgical technique provides a better outcome or a lower rate of complications. Research with higher levels of evidence and methodology that is more rigorous are needed in order to evaluate the optimal surgical strategy for patients with IAT.

Isolate acetabular cup revision through the direct anterior hip approach: surgical technique, early experience and review of the literature.

Direct anterior approach to the hip allows perfect exposure of the acetabulum and an easy proximal and medial extension that makes it eligible for isolate acetabular cup revision although it is seldom used and there are only few published studies. On 23 consecutive acetabular revision (16 cases Paprosky grade 1 or 2, 5 cases 3A, 1 case 3B and 1 case 4) at an average 28-month follow up, we did not record failures or major complications. Early complications included prolonged wound healing in 4 cases and transient femoral cutaneous nerve palsy in 2 cases, the mean postoperative Harris Hip Score was 82.2 with 82.5% of excellent and good results. Our results are consistent with those reported in the literature with similar techniques. The direct anterior approach has shown excellent results for isolated cup revision, though is probably better suited for surgeons that have some experience with the same approach for primary cases.

Simultaneous double rod and en-bloc direct vertebral rotation technique for correction of main thoracic adolescent idiopathic scoliosis: retrospective analysis of 14 cases.

Adolescent idiopathic scoliosis (AIS) is a triplanar deformity associated with rib hump, especially when a principle thoracic curve is present. The aim of this study is to evaluate the results of AIS correction retrospectively, using simultaneous double rod derotation manoeuvre technique followed by en-bloc direct vertebral rotation (DVR). Fourteen patients were included in this study. Coronal and sagittal thoracic Cobb angle, global coronal balance, sagittal balance, rib hump prominence, Scoliosis Research Society outcome instrument score (SRS-22) and Walter Reed visual assessment scale (WR-VAS) values were recorded pre- and postoperatively and evaluated. Results were evaluated at a mean follow-up of 2 years. Good to excellent radiographic and clinical results were obtained in all patients. No major perioperative complications occurred. This technique has proved to be effective for surgical correction of the deformity in Lenke type 1 AIS with good clinical and radiological results and low rate of complications.

Is a minimally invasive anterior approach effective in old patients? A pilot study.

Minimally invasive approach to the hip is a blood preserving surgery, with rapid rehabilitation, and low dislocation rate. Intuitively, these characteristics render this approach extremely suitable in the elderly patient. The aim of this study was to analyze the early clinical and radiographic results in the first 30 consecutive patients above 70 years of age undergoing THR through a minimally invasive anterior approach. Clinical evaluations showed an improvement of the Harris Hip Score and WOMAC score after surgery. Radiographic assessment showed cup orientation averaging 47° (range 40°–59°) and no valgus stem aligned. Allogeneic blood transfusion was required in only 6 patients (19.8%). One patient experienced an intraoperative fracture of the greater trochanter. No early implant dislocation was observed in the study population. In conclusion we advise a minimally invasive anterior approach for THR in older patients when a careful patient selection has been done.

Pedicle screw insertion techniques: an update and review of the literature.

Pedicle screw construct have become one of the most practiced procedure in spinal surgery. Despite commonly used, questions remain about their safety especially for the thoracic spine and in deformity where difficulty in positioning can lead to pedicle breach and adjacent structures injury. Misplacement rates have been reported to be from 5 to 41% in the lumbar spine and from 3 to 55% in the thoracic spine. Hence, various procedures have been described in order to improve pedicle screw insertion accuracy. Aim of this study is to evaluate current concepts on pedicle screws placement techniques to better understand recent attitude and clarify some doubts when selecting the most proper method.

Exogenous lipoid pneumonia (ELP): when radiologist makes the difference.

Lipoid pneumonia is an uncommon disorder characterized by accumulation of lipid components into the interstitial and alveolar compartment. The usual classification distinguishes endogenous and exogenous and acute or chronic forms, related to the type of fats, the amount of damage and the time of exposure. We describe a case of exogenous lipoid pneumonia by inhalation of vaseline used for cleaning of the tracheostoma in a 63-year-old female, presenting as cough, worsening dyspnea in few weeks. The diagnosis was finally established with a re-evaluation of BAL with specific staining for lipids, revealing the presence of foamy macrophages lipids rich, according to HRCT findings.

Effects of hydrogen sulfide (H2S) on mesenteric perfusion in experimental induced intestinal ischemia in a porcine model.

INTRODUCTION: Insufficient mesenteric perfusion is a dramatic complication in critically ill patients. Hydrogen sulfide, a newly recognized endogenous gaseous mediator, acts as an intestinal vasoactive agent and seems to protect against mesenteric ischemic damage. We investigated whether sodium hydrogen sulfide, a hydrogen sulfide donor, can improve mesenteric perfusion in an experimental model of pigs, both in physiological and ischemic conditions. METHODS: The study was conducted at Careggi University Hospital (Florence, IT). Fourteen male domestic pigs (≈10 Kg) were anesthetized and mechanically ventilated. Animals were randomized in control and ischemia groups. Mesenteric ischemia was induced with a positive end-expiratory pressure of 15 cmH2O. After mini-laparotomy, each animal received incremental doses of sodium hydrogen sulfide every 20 minutes. Perfusion of both the jejunal mucosa and sternal skin were measured by laser Doppler flowmeter, and systemic hemodynamic parameters were monitored. RESULTS: In the control group, sodium hydrogen sulfide was able to significantly improve the mesenteric perfusion, showing a 50% increase from the baseline blood flow. In the ischemia group, NaHS-induced a two-fold increase of the mesenteric post-ischemic perfusion with a recovery up to 70% of pre- positive end-expiratory pressure mesenteric blood flow. Sodium hydrogen sulfide did not directly or indirectly (by blood flow redistribution) affect the sternal skin microcirculation, heart rates, or mean arterial pressure, suggesting a tissue-specific micro-vascular action. CONCLUSIONS: In a porcine model, we observed a mesenteric perfusion recovery mediated by administration of hydrogen sulfide donor without affecting general hemodynamic.

Challenges in robotic distal pancreatectomy: systematic review of current practice.

Over the last decade, robotics has gained popularity and is increasingly employed to accomplish several abdominal surgical procedures. Nevertheless, pancreatectomies are regarded as demanding procedures for which the application of minimally-invasive surgery is still limited and its effectiveness has not been conclusively established. We aimed to investigate the current role of robot-assisted surgery to perform distal pancreatectomy. A systematic review of the English-language literature was conducted for articles dealing with robotic-assisted distal pancreatectomies. All relevant papers were evaluated on surgical and oncological outcomes. A total of 10 articles reporting on robotic distal pancreatectomies were finally considered in the analysis, including 259 patients. Mean operative time was 271 minutes (range 181-398); mean blood loss was 210 mL (range 104-361), in 11.6% of cases conversion to laparotomy occurred, spleen preservation was accomplished in 51.4% of procedures, mean time of postoperative hospital stay was 7 days. Overall, postoperative mortality and morbidity were 0% and 23.4% respectively, the mean number of lymph nodes harvested was 12.7. In all included series, no case of R1 resection was reported. Despite its relatively recent introduction in clinical practice, robotic-assisted surgery has been widely employed to perform distal pancreatectomy worldwide and it should be considered a safe and effective procedure. Both surgical and pathologic data support its application in the management of pancreatic lesions of the body and tail.

Preservation of hamstring tibial insertion in anterior cruciate ligament reconstruction: a review of the current literature.

Hamstring graft (HG) used in anterior cruciate ligament (ACL) reconstruction undergoes a biological modification process called "ligamentization" in the early postoperative period that proceeds through three different phases: an early graft-healing phase with central graft necrosis, a phase of proliferation, and finally, a ligamentization phase toward the properties of the intact ACL. The fastening of this process could result in more aggressive rehabilitation protocols as well as faster sport resumption. A recent literature supports the preservation of HG tibial attachment in order to enhance "ligamentization" process. Aim of this literature review is to describe all the techniques described that spare HG tibial insertion and the obtained results in order to evaluate evidence that would substantiate the maintenance of HG tibial insertion in ACL reconstruction. A search was performed using the following keywords "ACL reconstruction" in combination with "hamstrings," "hamstrings insertion," "tibial insertion," "ligamentization," and "over the top"; 18 articles were found to be relevant. Among these, eight randomized clinical trials (RCTs) were found. The RCT analyzed presented a high number of biases regarding the analyzed topic, thus making impossible to draw definitive evidences to validate HG tibial insertion sparing in ACL reconstruction. Despite the satisfactory results in many clinical series and the promising results in anatomic and animal studies, well-designed prospective clinical trials with large cohort of patients associated with MRI evaluation are mandatory to assess the beneficial effects of HG attachment preservation in ACL reconstruction.