Left sub costal minilaparotomy in aortic surgery

Aim of this work is to present our surgical technique, i.e. a left sub costal transperitoneal minilaparotomy, used in 40 patients operated on in the last year for atherosclerotic aorto-iliac occlusive disease (aortofemoral bypass) and aortic or aorto-iliac aneurysm (aorto-aortic graft or aorto-iliac bifurcated graft sutured on the common iliac arteries). The patients are placed in a dorsal decubitus. The cutaneous incision of 10 to 15 cm, depending on the abdominal size, is parallel to the condro-costal edge and spreads from the linea alba to the edge of the rectus muscle. The linea alba is usually incised; the oblique and the transverse muscles are not touched. The bowel is maintained within the abdominal cavity. Usually we do not use self-retaining retractors. The abdominal wall and the bowel are retracted with moistened towels maintained by blade intestinal retractors. When the abdominal cavity is gained, conventional dissection of the aorta and iliac arteries is carried out. These manoeuvres and the following surgical procedure are performed as usually with standard vascular instruments. Nasogastric suction and drains are not used routinely. In our series, this minilaparotomy technique, joined to , and to an intensive postoperative training, allows a better outcome of the patient and a discharge home from 3rd to 5th postoperative day. So we think that this technique, not so expensive as endovascular repair or laparoscopic and video-assisted surgery, nevertheless retains all the proven benefits of a minimally invasive surgery.     

Telecare for teenagers with type 1 diabetes: a trial

AIM: The aim of this paper was to test in teenagers with type 1 diabetes mellitus (T1DM) the Glucobeeb (Gb), a web based tool to support the diabetes care. METHODS: Gb transfers glucometer's data by phone and Internet to the PC of practitioner in files dedicated to each patient; the response returns to patient as 1-min vocal message. From outpatients paediatric clinic 28 teenagers (mean 14.8 years, range 10-20, male 14) with T1DM on multiple daily injections insulin therapy, with glicated haemoglobin (HbA1c) over 7% and >2 years' duration of the disease (9.1 years, range 2-15), were consequently randomized to telecare (glucometer transmission with feedback, group A) or control (standard communication by phone and face-to-face visits, group B). Glycaemia was tested four times per day and data transmitted every 2 weeks; clinician feedback returned within the following week. Two controls were excluded after randomization. Outcomes of 14 patients of A were compared with 12 of B. RESULTS: In intervention group average HbA1c% decreased from baseline at 3 and 6 months in comparison with controls (9.5, 9.0, 9.1, vs 9.1, 9.4, 9.4 respectively). Controls after 6 months were introduced to Gb, and similar trend of HbA1c was observed in the following examinations at 3 and 6 month (9.4, 8.9, 8.7). Then, in both groups HbA1c after 12 months of Gb increased, and after 18 reduced (A: 9.2, and 8.8, B 9.1 and 8.5 respectively). The enhancement of HbA1c from baseline to end was significant (P=0.01). CONCLUSION: The tool improves metabolic control in teenagers with T1DM.     

Inhibition in vitro of platelet aggregation and arachidonic acid metabolism by flavone

The effects of flavone on platelet aggregation and arachidonic acid (AA) metabolism were tested in vitro. When incubated at a concentration of 50 μM, flavone completely suppressed platelet aggregation induced by 150 μM AA in thirty-six out of forty-three subjects tested. A lower concentration (10 μM) was effective in about 50% of the donors. Flavone also inhibited the second wave of aggregation induced by epinephrine and ADP. Platelet thromboxane formation, estimated both by radioimmuno-assay measurements and by studies of ¹⁴C-labeled AA metabolism, was depressed by flavone. Flavone-treated platelets preferentially utilized [¹⁴C]AA for the lipoxygenase pathway while cyclo-oxygenase activity was depressed. Adenosine 3':5'-cyclic monophosphate (cAMP) was measured in flavone-treated and control platelets. While their baseline levels were similar, flavone-treated platelets showed a lower stimulation of cAMP induced by prostacyclin (PGI₂) than did controls. Phosphodiesterase activity was not affected by flavone as judged from the decay rates of PGI₂-stimulated cAMP levels. From these findings we conclude that the antiaggregating activity of flavone is not a consequence of changes in platelet cAMP but is due to inhibition of cyclo-oxygenase.     

Clinical experience with hepatic resections for hepatocellular carcinoma in patients with cirrhosis

The results of 31 resections of the liver performed upon patients with cirrhosis and hepatocarcinoma are reported herein. The lesions were discovered mainly during routine echographic surveillance. Twenty-five of these patients with small tumors underwent a segmentary or subsegmentary resection. Intraoperative ultrasonography proved to be of paramount importance in these instances as it helped to recognize the lesion and outline the limits of the resection. In another 11 instances of primary tumors of the liver in patients with cirrhosis who underwent laparotomy, findings from intraoperative ultrasonography advised against exeretic operation because other intrahepatic lesions or neoplastic thrombi in portal branches were detected. The operative mortality rate in the 31 patients who underwent resection of the liver was 12.9 per cent. The actuarial three year survival rate is 58 per cent. The presence of an intact peritumoral capsule seems to be the best prognostic factor.     

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA). We report the endovascular repair of an AAA rupture into the inferior vena cava. A 78-year-old woman was admitted to our hospital for acute hypotension. She presented with a pulsatile abdominal mass and became rapidly anuric. Abdominal computed tomography (CT) showed an AAA rupture into the inferior vena cava. The features of the AAA made it suitable for endovascular repair. To prevent pulmonary embolism caused by the presence of sac thrombosis near the vena cava lumen, a temporary vena cava filter was deployed before the procedure. A bifurcated stent-graft was placed with the patient under local anaesthesia, and the AAA was successfully treated. A transient type II endoleak was detected on CT 3 days after endograft placement. At routine follow-up 6 and 12 months after the procedure, the patient was in good clinical condition, and the type II endoleak had sealed completely. Endovascular treatment offers an attractive therapeutic alternative to open repair in case of ACF; however, only small numbers of patients have been treated, and long-term follow-up interval is lacking.     

Non-traumatic acute bowel disease: differential diagnosis with 64-row MDCT

To evaluate the role of 64-row multidetector computed tomography (MDCT) in the differential diagnosis of non-traumatic acute bowel disease. We retrospectively reviewed CT findings of 57 patients (29 men and 28 women; mean age, 65.5 years, range 19–99) who presented to our institutions with symptoms of acute abdomen. All patients underwent MDCT. MDCT diagnosis was compared with surgical findings and histological examinations. A total concordance between the MDCT findings and discharge diagnosis (based on surgical findings and histological examinations) was found in 47/57 cases (82.4%); partial discordance was seen in 10 of 57 cases (17.5%) and discordance in 0 of 57 (0%) cases. The overall sensitivity of MDCT was 82.4%. MDCT is a very reliable method in the diagnostic management of non-traumatic acute bowel diseases allowing a fast and precise differential diagnosis and therefore a timely treatment.     

Progression of MRI abnormalities in herpes simplex encephalitis despite clinical improvement: natural history or disease progression?

Abstract. Herpes simplex virus encephalitis (HSVE) is associated with a high mortality rate and a high probability of neurological sequelae. Good results are obtained when HSVE is promptly diagnosed and treated with acyclovir. We present a 71-year-old woman with clinically diagnosed HSVE, confirmed by PCR detection of HSV-1 DNA in the cerebrospinal fluid. She was treated with acyclovir (30 mg/kg day) for two weeks. Clinical and neuropsychological assessments 6 months after admission were normal; however MRI at 2, 6 and 12 months showed progressive deterioration with extensive white matter and cortical damage. Imaging studies of a cohort of patients surviving PCR-confirmed HSVE are needed to determine whether this pattern is occasional or a frequent form of progression.     

Arterial embolism, venous thrombosis, pulmonary embolism: a suggestive triad]

The aim of this study is to present a relatively rare case of paradoxical arterial embolism, found in a patient who was sent to us for serious pulmonary embolism. Taking into account that the foramen ovale, despite being functionally competent, remains anatomically patent in 30% of the adult population, we cannot neglect the possibility of a paradoxical embolism, in the presence of a sudden embolic limb ischemia unless heart pathology or aortic lesions can be held responsible. Furthermore it must not be forgotten that deep venous thrombosis in the lower limbs or in the pelvic plexus may go unobserved on a purely clinical evaluation.