Italian guidelines for the surgical management of enteral stomas in adults.

BACKGROUND: Worldwide, stomas represent a medical and social problem. Data from the literature on stoma management are extensive but not homogeneous. In Italy, no guidelines exist for this topic. Thus, clear and comprehensive clinical guidelines based on evidence-based data and best practice are need. In 2018, the Multidisciplinary Italian Study group for STOmas, called MISSTO, was founded. The aim was to elaborate guidelines for practice management of enteral and urinary stomas in adults. METHODS: A systematic review of the literature was performed using PubMed, National Guideline Clearinghouse, and other databases. The research included guidelines, systematic reviews, meta-analyses, randomized clinical trials, cohort studies, and case reports. Five main topics were identified: "stoma preparation", "stoma creation", "stoma complications", "stoma care", and "stoma reversal". The systematic review was performed for each topic, and studies were evaluated according to the GRADE system, AGREE II tool. RESULTS: Recommendations were elaborated in the form of statements with an established grade of recommendation for each statement. For low levels of scientific evidence statements, a consensus conference composed of expert members of the major Italian scientific societies in the field of stoma management and care was held. After discussing, correcting, validating, or eliminating the statements by the experts, the final version of the guidelines was elaborated and prepared for publication. This manuscript is focused on statements on the surgical management of enteral stomas. CONCLUSIONS: These guidelines are the first Italian guidelines on multidisciplinary management of enteral stomas with the aim of assisting surgeons during stoma management and care.

Cement thickness at implant-supported single-tooth Lava assemblies: a scanning electron microscopic investigation.

OBJECTIVES: The fit of implant-supported single-tooth Lava zirconia assemblies was investigated in this study. The implant-abutment interface, the interface between the metallic and the zirconia portion of the abutment and the interface between Lava abutments and copings were evaluated. The adaptation of titanium abutments to implants and Lava copings was investigated as a control. MATERIAL AND METHODS: Twenty implants were randomly assigned and connected to Lava abutments (group 1) or titanium abutments (group 2). All specimens were subjected to scanning electron microscopy (SEM) analysis of the fixture/abutment fit. Afterwards, specimens were luted to Lava copings and subjected to a SEM evaluation of the marginal external adaptation of the abutments with the copings. Finally, the samples were embedded in resin, sectioned and subjected to SEM analysis of the following interfaces; group 1: titanium/zirconia interface (between the constitutive components of the Lava abutment) and the zirconia/zirconia interface (between the Lava abutment and the coping); group 2: the titanium/zirconia interface (between the titanium abutment and the Lava coping). Non-parametric analysis of variance and a post hoc test were used for statistical analysis. RESULTS: Significant differences emerged in the cement thickness between titanium and zirconia components of the Lava abutments as compared with the thickness measured at the interface between Lava copings and the abutments investigated. No differences were found in cement thickness between Lava copings and the two different abutments. CONCLUSIONS: When Lava abutments are used, the most critical cement thickness is the internal interface between its titanium and zirconia components. Lava coping adaptation for both Lava and titanium abutments is within the clinical acceptable range.

An eleven-year case report of an avulsed maxillary central incisor after delayed replantation.

A 12 year-old girl presented with an avulsed maxillary central incisor for a trauma occurred two days earlier. The avulsed tooth was endodontically treated and replanted. Regardless of the ankylosis and replacement root resorption the tooth was retained for a very favourable nine-year period after trauma. In addition no severe infraposition occurred. When the extraction was necessary, despite the slight atrophy, as a result of compromised alveolar bone development due to ankylosis, an implant-supported crown was placed as definitive rehabilitation without recourse to bone augmentation procedures. In conclusion, delayed replantation in children will require long-term therapeutic commitment. In favourable cases, tooth with delayed replantation might be retained for a very long time thus avoiding the bone atrophy that would have accompanied early tooth loss and, consequently, reducing grafting requirements when a definitive implant-supported restoration will be required.

The speed of sound correlates with implant insertion torque in rabbit bone: an in vitro experiment.

OBJECTIVES: This study investigated the correlation of quantitative ultrasound with bone quality as evaluable from implant final insertion torque. MATERIAL AND METHODS: Implants were planned at diaphyses (group 1) and epiphyses (group 2) of 16 rabbit femurs where amplitude-dependent speed of sound (Ad-SOS) was measured. The insertion torque from 7-mm-long implants placed at planned sites was recorded. The correlation between cutting torque and Ad-SOS was evaluated using Spearman's coefficient. RESULTS: Statistics were based on data from 15 diaphyses and 13 epiphyses. The mean insertion torque was 8.8 N cm while the mean Ad-SOS was 1710.9 m/s. A negative correlation resulted between insertion torque and Ad-SOS. CONCLUSIONS: In the rabbit bone model investigated, quantitative ultrasound correlates inversely with implant insertion torque. Although this correlation remains to be verified in humans because rabbit femur does not convincingly represents different human bone qualities, it seems that ultrasound could convey potentially useful, pre-surgical, site-specific, non-invasive information on bone mechanical characteristics therefore deserving further research efforts.

Stability values of titanium dioxide-blasted dental implants in edentulous maxillas: a 3-year pilot study.

The purpose of this follow-up study was to measure the resonance frequency of Astra Tech TiO(2) blasted implants at second surgery, at one and 3 years of loading. Secondly, it was investigated whether resonance frequency at second surgery could discriminate between successful implants and those that will fail over a 3-year period. Fifty titanium dioxide-blasted implants in eight consecutive patients with edentulous maxillas seeking fixed rehabilitations, were included in the study at abutment connection after 6 months of healing. Resonance frequency, clinical and radiographic records were obtained at abutment connection and after one and 3 years of loading. The cumulative survival rate after 3 years was 100%. The mean resonance frequencies were 65 +/- 4.8 implant stability quotient (ISQ) at second surgery (range 50-78 ISQ), 66 +/- 3.4 ISQ after 1 year of loading (range 53-76 ISQ) and 64 +/- 3.8 ISQ after 3 years of loading (range 53-77 ISQ). No significant differences resulted between these three time points. The marginal bone level decrease of 0.6 mm between the second surgery and the 3-year follow-up was observed. One limitation of the study is that no late failures were encountered in this relatively small sample. Consequently, it was not possible to establish a cut-off ISQ for implants that, after abutment connection, would maintain their stability over a 3-year period. Nevertheless, it might be concluded that following the first year of loading the range of 53-76 ISQ describes the stability of osseointegrated Astra Tech TiO(2) blasted implants.

One-year outcome of narrow diameter blasted implants for rehabilitation of maxillas with knife-edge resorption.

OBJECTIVES: This study aimed at assessing the clinical outcome of narrow diameter implants in the treatment of knife-edge edentulous maxillas of adequate bone height but inadequate width (class IV of Cawood and Howell). MATERIAL AND METHODS: Twelve consecutive patients (eight women and four men, mean age 58 years) with class IV atrophic edentulous maxillas were included in the study. Seventy-three microthreaded TiO(2)-blasted implants were placed and the resonance frequency measured. All the implants had a diameter of 3.5 mm. After 6 months of submerged healing, fixed implant-supported prostheses were delivered to the patients and resonance frequency and radiographic examinations performed. After the first year of loading, the implant outcome was again evaluated clinically, radiographically and with resonance frequency analysis. RESULTS: All the implants were followed up to 1 year of loading and their survival rate was 100%. Bone loss after 1 year of loading was (mean+/-SD) 0.30+/-0.13 mm. Stability values were (mean+/-SD) 63+/-5.8 ISQ at placement, 60+/-4.7 ISQ at the abutment connection and 61+/-5 ISQ after 1 year of loading. A significant difference resulted between placement and abutment connection values (P=0.03). CONCLUSIONS: According to the present study, narrow implants may be used to restore edentulous maxillas with atrophies of class IV of Cawood and Howell. When planning the treatment of edentulous maxillas with such a resorption pattern, this possibility has to be considered as an alternative to more demanding grafting techniques.

Sinus membrane elevation in combination with placement of blasted implants: a 3-year case report of sinus augmentation without grafting material.

Owing to the increasing use of dental implants to restore edentulous conditions, clinicians often face situations where available bone volumes are reduced and need to be augmented before implant placement. This is common in the posterior maxilla, where the presence of the maxillary sinus combined with severe atrophy of the bone crest, owing to long-standing edentulism or pathological conditions, might preclude implant placement. Techniques to augment the sinus floor in combination with several grafting materials are commonly used to restore adequate volumes for implantation. Recent studies have described bone reformation and integration of oxidized implants by simple elevation of the sinus membrane without any grafting material. The aim of this case report is to document the application of the sinus membrane elevation technique in combination with the placement of 3 blasted microthreaded implants in a patient who was clinically and radiographically followed up for 3 years. During the follow-up period, the blasted implants were all stable and intraoral radiographs showed that the bone reformed in contact with the implants and remained stable.

Postoperative chemotherapy in resected gastric cancer: results of a single center experience.

Gastric cancer remains a major health problem despite its decline in incidence in Western countries. Although radical surgery represents the primary curative option for gastric cancer patients, most of them relapse and die due to their disease despite an R0 resection. At present the routine use of postoperative adjuvant therapy to reduce disease recurrence is still considered an investigational approach. Out of a total of 275 patients (stage IB through IV M0 AJCC/UICC) who underwent surgery for gastric cancer at our Surgery Unit between 1993 and 2001, 156 were eligible for adjuvant chemotherapy, of whom only 52 accepted to undergo this treatment. This group of patients was retrospectively compared with a control group (1:2) and overall survival was assessed using hazard ratio and Kaplan-Meier estimates. Five-year survival was 40% in the chemotherapy group and 37.8% in the group which underwent surgery alone. Indeed, chemotherapy did not reduce the risk of death (HR 0.87, 95% CI = 0.57-1.34, p=0.54). Serosal involvement and the invasion of more than 6 lymph nodes were the main independent prognostic factors identified by multivariate analysis. The current study did not show a clear advantage of chemotherapy over surgery alone. However, our results can help to define strategies for future clinical trials with the use of new regimens based on more effective and less toxic drugs.

Use of short implants for functional restoration of the mandible after giant cell tumor removal. Case report.

The giant cell tumor of the jaws is a rare benign lesion, it has a slow and progressive evolution and it is locally aggressive. Its etiopathogenesis is unknown, it is most common in the mandible and it is often asymptomatic but pain arises from palpation of the area. Diagnosis is made by radiological and histological examination and surgical treatment is necessary. The clinical case of a 28-year-old man affected by a giant cell tumor of the mandible with an aggressive clinical and radiographical behaviour is reported. The patient showed a jaw swelling covered by hyperemic fibro-mucous tissue from tooth 4.6 to 3.4, absence of cortical bone and mobility of teeth. He also reported lip anesthesia. The giant cell tumor diagnosis was made with orthopantomography (OPT), computed tomography (CT) and needle biopsy. The lesion was surgically removed and histological examination confirmed the diagnosis. In spite of the wide loss of bony substance after surgery, the patient was provided with an implant supported fixed prosthesis without previous bone graft. In this case short implants allowed the prosthetic rehabilitation of a mandible with severe ''resorption'' due to surgical removal of a tumor. Implants were placed in the residual bone volume and successfully used to support a fixed prosthesis. The final result is optimal as is the quality of life of the young patient.

A comparative study of Endoflare-Hero Shaper and Mtwo NiTi instruments in the preparation of curved root canals.

AIM: To analyse the shaping ability of two new NiTi rotary systems in molar curved canals. METHODOLOGY: Thirty molar root canals with curvatures from 24 degrees to 69 degrees were divided into two groups that were balanced in terms of curvature. The canals in one group were shaped using the Mtwo (Sweden & Martina, Padova, Italy) and the canals in the other group using the Endoflare-Hero Shaper (Micro-Mega, Besançon, France) in a modified sequence. Pre- and post-instrumentation X-rays were taken using a radiographic platform, with a contrast medium being used to enhance canal opacity. The dentine removed at five positions along the canals, the symmetry of canal shaping and the presence of aberrations were analysed through computer-aided measurements. The instrument failures, the working time and the changes in working length were also recorded. The Mann-Whitney U-test was used for statistical analyses. RESULTS: Both systems produced uniform dentine removal and symmetrical canal shapes; there was no significant difference between the systems (P > 0.05). In the apical region, preparations were centred in the canal. A mean loss of working length of 0.55 mm for Mtwo and 0.58 mm for Endoflare-Hero Shaper was detected, with no significant differences between the instruments (P > 0.05). No aberrations were seen and no instruments separated. The mean working time was 124.4 s for the Mtwo system and 141.3 s for the Endoflare-Hero Shaper but this difference was not statistically significant (P > 0.05). CONCLUSION: The systems tested in this study were effective in shaping curved canals in extracted teeth.

[Massive hemoptysis from an aortobronchial fistula]. / Hemoptisis masiva por fístula aorto bronquial.

This is a report of a 61 year old man who was admitted at the Intensive Care Unit because of massive hemoptysis and respiratory failure. Four years before he had had an aortic dissection type A, and at that time an aortic valve, ascending aorta and aortic arch replacement, had been carried out. A thorax CT scan showed an aneurysm of the ascending aorta. A bronchoscopy was normal. In the angiography, a collateral of the left mammary artery was identified as the cause of bleeding and was subsequently embolized. After the procedure, the patient had a new episode of massive hemoptysis, and surgery was recommended. During surgery, the diagnosis of aortobronchial fistula was confirmed but the patient died during the intervention.

Hemoptisis masiva por fístula aorto bronquial. / [Massive hemoptysis from an aortobronchial fistula]

This is a report of a 61 year old man who was admitted at the Intensive Care Unit because of massive hemoptysis and respiratory failure. Four years before he had had an aortic dissection type A, and at that time an aortic valve, ascending aorta and aortic arch replacement, had been carried out. A thorax CT scan showed an aneurysm of the ascending aorta. A bronchoscopy was normal. In the angiography, a collateral of the left mammary artery was identified as the cause of bleeding and was subsequently embolized. After the procedure, the patient had a new episode of massive hemoptysis, and surgery was recommended. During surgery, the diagnosis of aortobronchial fistula was confirmed but the patient died during the intervention.

NGF treatment potentiates c-fos expression in the rat nucleus basalis upon excitotoxic lesion with quisqualic acid.

The induction of the c-fos gene in the rat brain by NGF was studied in a model of acute cholinergic hypofunction, i.e., the lesion of the nucleus basalis magnocellularis (NBM) with quisqualic acid. Choline acetyltransferase and Fos immunoreactivity (IR) in the NBM were analyzed at different times after the excitotoxic lesion. NGF treatment induced a potentiation of Fos expression 4 and 24 h after lesion. The possibility is discussed that c-fos induction is one of the early mechanisms of the neuroprotective action of NGF.

[Acute respiratory failure due to lipoid pneumonia]. / Insuficiencia respiratoria aguda por neumonía lipoidea.

We report a 63 year old white man admitted to our hospital because of fever, productive cough and a severe respiratory failure. Bronchoalveolar lavage revealed a positive microscopy for acid-fast bacilli and a four drug scheme for tuberculosis was initiated. There was no improvement in the patient's condition and mechanical ventilation was needed. A thorax CT scan disclosed images that suggested lipoid pneumonia (lower lobes involvement, hypodensity and negative sign in the angiogram). At this point the patient's relatives indicated that he was a long term user of paraffin oil for chronic constipation. Treatment with high doses of steroids was initiated and after whole lung lavage, mechanical respiratory assistance could be interrupted. We comment the association of this entity with lung infections produced by atypical mycobacteria.

Insuficiencia respiratoria aguda por neumonía lipoidea. / [Acute respiratory failure due to lipoid pneumonia]

We report a 63 year old white man admitted to our hospital because of fever, productive cough and a severe respiratory failure. Bronchoalveolar lavage revealed a positive microscopy for acid-fast bacilli and a four drug scheme for tuberculosis was initiated. There was no improvement in the patients condition and mechanical ventilation was needed. A thorax CT scan disclosed images that suggested lipoid pneumonia (lower lobes involvement, hypodensity and negative sign in the angiogram). At this point the patients relatives indicated that he was a long term user of paraffin oil for chronic constipation. Treatment with high doses of steroids was initiated and after whole lung lavage, mechanical respiratory assistance could be interrupted. We comment the association of this entity with lung infections produced by atypical mycobacteria.

Resucitación cardiopulmonar en pacientes hospitalizados / Cardiopulmonary resuscitation in hospitalized patients

Antecedentes: La introducción de la reanimación cardiopulmonar (RCP) en pacientes ambulatorios ha demostrado ser de utilidad, mientras que en pacientes hospitalizados los resultados han sido poco satisfactorios. El objetivo de nuestro trabajo fue identificar variables pronósticas que puedan afectar los resultados inmediato y final de la RCP para hacer un uso más racional de éste procedimiento. Materiales y métodos: Fueron estudiados prospectivamente todos los pacientes internados que tuvieron paro cardio-respiratorio (PCR) y recibieron RCP en un hospital de la comunidad y se analizaron 9 variables que pudieran influir en los resultados. Se hizo el análisis estadístico con el test de Chi-Cuadrado. Resultados: Se analizaron 127 casos de PCR, 54 (43 por ciento) fueron resucitados exitosamente; 20 (16 por ciento) sobrevivieron el alta de la Unidad de Cuidados Intensivos (UCI) y 14 (11 por ciento) permanecieron vivos a los 3 meses del PCR, sólo 12 (9 por ciento) fueron dados de alta del Hospital. Los factores pronósticos favorables que se identificaron fueon los siguientes: la localización del PCR, la corta duración de la RCP, un ritmo inicial diferente de la asistolia, la ausencia de falla orgánica previa y un tiempo breve de internación pre-RCP. Conclusiones: Nuestro trabajo confirma que el resultado de la RCP en pacientes hospitalizados es pobre. La identificación de los factores pronósticos permiten un uso más racional de la RCP. El mayor número de éxitos de este procedimiento fue obtenido fuera del área de cuidado crítico, con lo que se reafirma la necesidad de contar con un equipo entrenado en esta técnica que pueda operar las 24 horas en todas las áreas del hospital

Resucitación cardiopulmonar en pacientes hospitalizados / Cardiopulmonary resuscitation in hospitalized patients

Antecedentes: La introducción de la reanimación cardiopulmonar (RCP) en pacientes ambulatorios ha demostrado ser de utilidad, mientras que en pacientes hospitalizados los resultados han sido poco satisfactorios. El objetivo de nuestro trabajo fue identificar variables pronósticas que puedan afectar los resultados inmediato y final de la RCP para hacer un uso más racional de éste procedimiento. Materiales y métodos: Fueron estudiados prospectivamente todos los pacientes internados que tuvieron paro cardio-respiratorio (PCR) y recibieron RCP en un hospital de la comunidad y se analizaron 9 variables que pudieran influir en los resultados. Se hizo el análisis estadístico con el test de Chi-Cuadrado. Resultados: Se analizaron 127 casos de PCR, 54 (43 por ciento) fueron resucitados exitosamente; 20 (16 por ciento) sobrevivieron el alta de la Unidad de Cuidados Intensivos (UCI) y 14 (11 por ciento) permanecieron vivos a los 3 meses del PCR, sólo 12 (9 por ciento) fueron dados de alta del Hospital. Los factores pronósticos favorables que se identificaron fueon los siguientes: la localización del PCR, la corta duración de la RCP, un ritmo inicial diferente de la asistolia, la ausencia de falla orgánica previa y un tiempo breve de internación pre-RCP. Conclusiones: Nuestro trabajo confirma que el resultado de la RCP en pacientes hospitalizados es pobre. La identificación de los factores pronósticos permiten un uso más racional de la RCP. El mayor número de éxitos de este procedimiento fue obtenido fuera del área de cuidado crítico, con lo que se reafirma la necesidad de contar con un equipo entrenado en esta técnica que pueda operar las 24 horas en todas las áreas del hospital (AU)