Public health challenges and opportunities after COVID-19

With hindsight, the main weakness behind the ineffective response to the coronavirus disease 2019 (COVID-19) pandemic in some countries has been the failure to understand, and take account of, the multilayered systemic interdependencies that spread the effects of the pandemic across social, technological, economic and health-care dimensions. For example, to respond to the COVID-19 pandemic, all people were required to rapidly adjust to social distancing and travel restrictions. Such a complex behavioural response entails adaptation to achieve a full recovery from the systemic shock. To capitalize on the positive effects of disruption to the status quo, much more complex socioeconomic modelling needs to be considered when designing and evaluating possible public health interventions that have major behavioural implications. We provide a simple example of how this reasoning may highlight generally unacknowledged connections and interdependencies and guide the construction of scenarios that can inform policy decisions to enhance the resilience of society and tackle existing societal challenges.     

Gaps in coverage and access in the European Union

This study identifies gaps in universal health coverage in the European Union, using a questionnaire sent to the Health Systems and Policy Monitor network of the European Observatory on Health Systems and Policies. The questionnaire was based on a conceptual framework with four access dimensions: population coverage, service coverage, cost coverage, and service access. With respect to population coverage, groups often excluded from statutory coverage include asylum seekers and irregular residents. Some countries exclude certain social-professional groups (e.g. civil servants) from statutory coverage but cover these groups under alternative schemes. In terms of service coverage, excluded or restricted services include optical treatments, dental care, physiotherapy, reproductive health services, and psychotherapy. Early access to new and expensive pharmaceuticals is a concern, especially for rare diseases and cancers. As to cost coverage, some countries introduced protective measures for vulnerable patients in the form of exemptions or ceilings from user chargers, especially for deprived groups or patients with accumulation of out-of-pocket spending. For service access, common issues are low perceived quality and long waiting times, which are exacerbated for rural residents who also face barriers from physical distance. Some groups may lack physical or mental ability to properly formulate their request for care. Currently, available indicators fail to capture the underlying causes of gaps in coverage and access.     

Destructive spondyloarthropathy and radiographic follow-up in hemodialysis patients

Nine patients undergoing regular dialytic treatment for more than 60 months showed clinical and radiologic features of a noninfective and destructive spondyloarthropathy. The cervical spine was most affected (100%), followed by the dorsal (three patients, 33.3%) and the lumbar spine (two patients, 22.2%). Typically, radiographs and CT scans revealed narrowing of intervertebral spaces, with destruction or sclerosis of the subchondral bone of the vertebral plate.Autopsy was performed on three patients; histologic study demonstrated the presence of large amyloid deposits containing ₂-microglobulin ( ₂-m) in the discs and peridiscal ligaments.A radiographic follow-up of the cervical spine was performed in seven patients after a period of 12 months and showed that the bone destruction in DSA is very rapid and progressive. The lower biocompatibility of the cuprophan membranes of dialyzers is probably the factor most responsible for hyperproduction of ₂-m and subsequently osteoarticular deposition of a new type of amyloidosis.     

Thyroid carcinoma mimicking a toxic adenoma

A young woman with a thyroid papillary carcinoma behaving as an autonomously hyperfunctioning nodule is described. Only 17 similar patients have been seen in the past 25 years. It is emphasized that hyperthyroidism does not exclude malignant disease in hot nodules. This possibility suggests that all thyroid nodules, either cold or hot, require careful management. Therefore, in at risk cases, surgery could be the most useful treatment.     

Non-traumatic brain abscess

Between 1953 and 1989 eighty cases of non-traumatic brain abscess were treated in our department. We have re-examined the clinical and neuroradiological features of this pathological process and present our therapeutic approach and results. We believe that the optimal treatment for brain abscess consists of surgical removal.The prognosis for these lesions has undergone a marked improvement over the last two decades in response to neuroradiological, microbiological and surgical advances. The most influential prognostic factor seems to be preoperative clinical status.     

Involvement of cholecystokinin receptors in the control of striatal dopamine autoreceptors

Summary The interaction of locally perfused cholecystokinin-8 (sulphated) with systemically administered apomorphine was studied on the release of dopamine and its metabolites using microdialysis in the neostriatum of the halothane-anaesthetized male rat. Dialysate levels of dopamine, 3,4-dihydroxyphenylacetic acid and homovanillic acid were assayed by high performance liquid chromatography in combination with electrochemical detection. Perfusion with cholecystokinin-8 (100 M but not 1 M or 10 nM) increased the dialysate levels of dopamine without affecting those of DOPAC or HVA. At low concentrations (1 M and 10 nM but not 1 nM), cholecystokinin-8 counteracted the inhibitory effect of apomorphine (0.05 mg/kg, s. c.) on dopamine release. This counteraction was antagonized by perfusion with the cholecystokinin-8 antagonist proglumide (3 M). At this concentration, proglumide perfused alone was without effect on basal or apomorphine-reduced levels of dopamine. The results indicate a facilitatory effect of cholecystokinin-8 on dopamine release in rat neostriatum only at high concentrations. At lower concentrations, cholecystokinin-8 appears to modulate dopamine release by an inhibitory effect on dopamine autoreceptors possibly involving an intramembrane interaction between presynaptic cholecystokinin-8 receptors and dopamine autoreceptors. Send offprint requests to K. Fuxe at the above address     

Microscopic endoluminal tumorectomy

PURPOSE: We herein report our experience with transanal endoscopic microsurgery. The new technique combines an endoscopic view and access of the rectum under gas insufflationviaa stereoscopic telescope with all conventional surgical maneuvers such as tissue preparation, coagulation and control of bleeding, irrigation, suction, and, finally, suturing of the parietal defect. METHODS: The main indication for transanal endoscopic microsurgery is the removal of broad-based sessile polyps and excision of early rectal cancers. We performed local excision of pT2, G1-2 adenocarcinomas and excision of advanced rectal cancer in high-risk patients. The reported series includes 35 consecutive patients, who have been enrolled in a prospective clinical trial. Five patients were excluded for different reasons. The patients were submitted to 29 total wall excisions with or without perirectal fat and one mucosectomy. RESULTS: Postoperative histologic examination showed 9 adenomas and 21 adenocarcinomas. Morbidity included 2 (5.6 percent) perioperative and 2 (5.6 percent) late complications. There was no operative mortality and the mean postoperative hospital course was six days. All patients are in follow-up observation with a mean time of 10.3 months. In the group of adenomas and adenocarcinomas, we did not observe local recurrence. CONCLUSIONS: Considering our experience with the overall results reported by other authors, we believe that transanal endoscopic microsurgery is the procedure of choice for the treatment of rectal polyps and early rectal cancers provided strict patient selection criteria are met.     

Crossed aphasia. An update

The aim of this article is to present an update of a rare but interesting problem: crossed aphasia. This term indicates the presence of aphasia after unilateral cerebral lesion of the hemisphere ipsilateral to the patient's dominant hand. We report two cases, review the most relevant literature, and analyze clinical, neuroanatomical, and neurophysiological aspects, taking in consideration the various interpretations proposed to explain this unusual language disorder.     

Comparative biodistribution of indium- and yttrium-labeled B3 monoclonal antibody conjugated to either 2-(p-SCN-Bz)-6-methyl-DTPA (1 B4M-DTPA) or 2-(p-SCN-Bz)-1,4,7,10-tetraazacyclododecane tetraacetic acid (2B-DOTA)

The biodistribution of indium-111/yttrium-88-labeled B3 monoclonal antibody, a murine IgG1k, was evaluated in non-tumor-bearing mice. B3 was conjugated to either 2-(p-SCN-Bz)-6-methyl-DTPA (1B4M) or 2-(p-SCN-Bz)-1,4,7,10 tetraazacyclododecane tetra-acetic acid (2B-DOTA) and labeled with ¹¹¹In at 1.4–2.4 mCi/mg and ⁸⁸Y at 0.1–0.3 mCi/mg. Non-tumor-bearing nude mice were co-injected i.v. with 5–10 Ci/4–10 g of ¹¹¹In/⁸⁸Y-labeled B3 conjugates and sacrificed at 6 h and daily up to 168 h post-injection. Mice injected with ¹¹¹In/⁸⁸Y (IB4M)-B3 showed a similar biodistribution of the two radiolabels in all tissues except the bones, where significantly higher accretion of ⁸⁸Y than ¹¹¹In was observed, with 2.8% ± 0.2% vs 1.3% ± 0.16% ID/g in the femur at 168 h, respectively (P<0.0001). In contrast, mice receiving the ¹¹¹In/⁸⁸Y-(DOTA)-B3 conjugate showed significantly higher accumulation of ¹¹¹In than ⁸⁸Y in most tissues, including the bones, with 2.0% ± 0.1% vs 1.2% ± 0.09% ID/g in the femur at 168 h, respectively (P<0.0001). Whereas the ratios of the areas underneath the curve (%ID × h/g) in the blood, liver, kidney and bone were 0.96, 1.12, 1.13, and 0.74 for ¹¹¹In/⁸⁸Y-(IB4M)-B3 and 0.84, 1.23, 1.56, and 1.31 for ¹¹¹In/⁸⁸Y (DOTA)-B3, respectively, ratios 1 were observed between ¹¹¹In-(IB4M)-B3 and ⁸⁸Y-(DOTA)-B3. In summary, while neither IB4M nor DOTA was equally stable for ¹¹¹In and ⁸⁸Y, the fate of ⁸⁸Y- (DOTA)-B3 could be closely traced by that of ¹¹¹ In-(IB4M)-B3.     

Anastomosis

Esophageal anastomosis is still associated with a high rate of complications even though they have decreased considerably in recent years. Anastomotic leaks are more frequent in the neck than in the chest, and related mortality rate is not different. The leakage incidence does not depend on suture materials or on technical modalities used to perform the anastomosis. In fact, there is no difference between the leakage rate when comparing manual and mechanical anastomoses. The leak incidence after both mechanical and manual anastomoses is much higher in collective reviews than in reports coming from leading centers. Frequent esophageal surgeons can learn from their previous experience and therefore avoid technical errors, whereas casual esophageal surgeons do not have this opportunity. Performing an esophageal anastomosis is a technical matter, and suture healing is independent of the patient's biologic situation. Anastomotic fibrotic stricutures are frequent after both manual and mechanical anastomoses, and most can be avoided by meticulous suturing technique.

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Resumen La anastomosis esofágica todavía se asocia con una elevada incidencia de complicaciones, a pesar de que éstas han descendido en forma considerable en los últimos años. Las fugas anastomóticas son más frecuentes en el cuello que en el tórax y las tasas de mortalidad no son diferentes. La rata de fuga anastomótica no depende de los materiales de sutura o de las modalidades técnicas que se utilicen para realizar la anastomosis. De hecho no hay diferencia en cuanto a la rata de fugas entre las anastomosis manuales y las mecánicas. La incidencia de fuga, tanto en las manuales como en las mecánicas, es bastante más alta en las revisiones colectivas que en los reportes emanados de los centros médicos de mayor importancia. Los cirujanos especialistas en esófago tienen la posibilidad de aprender de sus experiencias previas y con ello evitar los errores técnicos, en tanto que aquellos cirujanos ocasionales no la poseen. La realización de una anastomosis esofágica es un asunto técnico y la cicatrización de la sutura es independiente de la condición biológica del paciente. Las estrecheces fibróticas de las anastomosis son frecuentes luego de las anastomosis manuales, al igual que luego de las anastomosis mecánicas y la mayoría puede ser evitada mediante una técnica meticulosa.

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Résumé Le taux de complications des anastomoses oesophagiennes, même s'il y en a moins ces dernières années, reste toujours élevé. La fréquence de fistules est plus grande quand l'anastomose est faite au cou par rapport au thorax, mais la mortalité n'en est pas très différente. L'incidence de fistules ne dépend ni du matériau de suture ni des modalités d'anastomoses utilisées. Il n'y a aucune différence lorsque les anastomoses manuelles sont comparées aux anastomoses méchaniques: L'incidence des fistules, que ce soit à la main ou à la machine est plus élevée dans les séries collectives par rapport à celle des centres spécialisés. Les chirurgiens qui font des anastomoses de façon régulière ont la possibilité de profiter de leur expérience et ainsi d'éviter les erreurs techniques, alors que le chirurgien occasionnel de l'oesophage n'a pas cette possibilité. L'anastomose oesophagienne est techniquement difficile et la cicatrisation est indépendante de l'état clinique et biologique du patient. Les sténoses fibreuses sont aussi fréquentes après les anastomoses manuelles qu'après les anastomoses méchaniques, mais la plupart peuvent être évitées par une technique méticuleuse.