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At present, there is limited information on the nature and extent of speech-language pathology services in the U.S. specific to people with mild aphasia (PWMA). The goal of the present study was to determine how speech-language pathologists (SLPs) perceive the assessment, treatment, and discharge of PWMA. According to anecdotal reports from SLPs and PWMA, current services may be inadequate and those with more severe aphasia types are being prioritized. To investigate factors potentially limiting SLP involvement and to determine gaps in service, a 26-question survey, consisting of both open-ended and closed-ended questions, was developed and distributed via email and social media to selected groups of SLPs. A total of 133 SLPs responded to the survey. In this brief report, we discuss only the primary findings. Reports of assessment, treatment, and discharge procedures were diverse; however, a number of central themes were observed. The majority of respondents had more than ten years of experience. They reported greater use of informal measures in assessing people with mild aphasia as compared to people with more severe forms of aphasia. Discharge procedures and recommendations were found to involve primarily referrals to the next level of care, recommendations for continued social interaction, and maintenance programs to preserve treatment progress. Responses tended to be appropriate, yet, not necessarily indicative of the actual standard of care. SLPs reported the need for additional assessment tools and resources in order to better serve people with mild aphasia. Perceived constraints included large caseloads, resource limitations, awareness of health professionals, and the prioritization of those with more severe deficits. Information gathered in this survey highlights the gap in services for this population and provides some tangible guidelines for how to proceed. Given that PWMA have the greatest chance of returning to work, we argue that any prioritization bias should lean toward favoring this population., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit., Methods: The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases., Results: Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN., Conclusions: Some factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.

Background: Amyand's hernia (AH) is an inguinal hernia containing the vermiform appendix, with an incidence between 0.4% and 1% of all inguinal hernias. Acute or perforated appendicitis can complicate AH., Case Presentation: A 75-year-old Caucasian man presented with incarceration of vermiform appendix in inguinal hernia sac. Diagnosis was posed preoperatively with computed tomography (CT) scan. Patient underwent urgent surgery and simultaneous appendectomy and hernia repair by Bassini's technique were performed., Conclusions: Preoperative diagnosis of AH is rare; however it could be useful for surgeon to choose operative approach. Treatment of AH depends on grade of appendix inflammation and/or perforation. The technique utilized to repair hernia depends largely on surgeon's preferences; the presence of inflamed or perforated appendix is not an absolute contraindication for using a prosthetic mesh.

Background: The aim of our study was to assess the outcome of hemorrhoidal dearterialization, achieved by a dedicated laser energy device., Methods: From November 2012 to December 2014, 51 patients with second- or third-degree hemorrhoids were studied. The primary end point was a reduction in the bleeding rate; secondary end points were: postoperative complications, reduction in pain and prolapse, resolution of symptoms, and degree of patient's perception of improvement. The procedure was carried out as 1-day surgery. A diode laser device was employed to seal the terminal branches of the hemorrhoidal arteries, detected by a Doppler-equipped proctoscope. Follow-up was scheduled at 1 and 4 weeks, 3, 12, and 24 months. The rate and degree of symptoms was assessed with a four-point verbal rating scale. The rate of subjective symptomatic improvement was also evaluated with the Patient Global Improvement (PGI) Scale., Results: Mean bleeding and pain scores at baseline were 2 and 0.57. All the patients were discharged on the day of surgery. Postoperative complications were bleeding (n = 4) and external hemorrhoidal thrombosis (n = 4). Mean bleeding and pain scores at 3, 12, and 24 months were significatively reduced. After 24 months, complete resolution of bleeding was observed in 28/29 patients (96.7 %), resolution of pain in all patients, and resolution of the mucosal prolapse in 15/18 patients (76.9 %). At 12-month follow-up, 86.3 % of patients reported improvement with the PGI Scale., Conclusions: The hemorrhoid laser procedure was effective in improving bleeding and pain symptoms in patients with grade II and III hemorrhoids.

Background: As stapled hemorrhoidopexy (SH) becomes more widely used, we see more patients with chronic postoperative anal pain after this surgery. Its presentation is variable and difficult to treat. The aim of our study was to investigate the impact of chronic anal pain after SH and whether tailored therapy was likely to achieve a favorable outcome., Methods: We retrospectively analyzed 31 consecutive patients with chronic anal pain who had undergone SH in other hospitals and were referred to our institutions. Depending on the type of pain, unrelated (at rest) or related to defecation, two groups of patients were identified. Moreover, the mean distance of the staple line from the anal verge was calculated in both groups. Treatments included: topical nifedipine, local anesthetic and steroid infiltration, removal of retained staples, anal dilation, and scar excision with mucosal suturing. A visual analog scale (VAS) was used to compare pain at baseline, postoperatively, and in the follow-up. This mean difference of the VAS score between stages was always used as the main outcome measure, depending on the type of presentation, type of pain, and type of treatment. Treatment response was defined as a 50 % decrease of VAS from baseline., Results: There were 22 males and 9 females. The overall median age was 43 years (range 21-62 years). On digital examination and proctoscopy, 15 (48 %) patients had inflammatory changes, 19 (61 %) patients had staple retention, 8 (26 %) patients had anorectal stenosis, and 30 (97 %) patients had scar tissue. All patients had one or more of the following treatments listed from the least to most invasive: topical nifedipine in 12 (39 %) patients, anal dilation in 6 (19 %) patients, anesthetic and steroid infiltration in 18 (58 %) patients, removal of staples in 10 (32 %) patients, and scar excision in 18 (58 %) patients. The mean VAS score at baseline was 6.100, ± 1.953 SD, which dropped significantly after treatment to 1.733, ± 1.658 SD (p < 0.001) and remained low at follow-up (1.741 ± SD 1.251; p < 0.743). In patients with pain at rest (n = 20, 65 %), the symptoms improved in 19 (95 %) patients, while the VAS score decreased from 5.552 ± 2.115 SD to 1.457 ± 1.440 SD (95 % CI 3.217-4.964; p < 0.001). In patients with post-evacuation pain (n = 11, 35 %), the symptoms improved in 11 (100 %) patients, while the VAS score decreased from 6.429 ± 1.835 SD to 1.891 ± 1.792 SD (95 % CI 3.784-5.269; p < 0.001). Rating of response based on presentation was 90.0 % (0.9/10) after treatment of staple retention, which led to a significant decrease in the mean VAS score from 6.304 ± 1.845 SD to 1.782 ± 1.731 SD (95 % CI 3.859-5.185; p < 0.001). Anal stenosis was successfully treated in 100.0 % (n = 8/8) of cases with the mean VAS score dropping from 6.500 ± 1.309 SD to 2.125 ± 1.808 SD (95 % CI 2.831-5.919; p < 0.001). Anal inflammation improved in 60.0 % (n = 9/15) of patients and the mean VAS score dropped from 6.006 ± 2.138 SD to 1.542 ± 1.457 SD (95 % CI 3.217-4.964; p < 0.001). The response after scar tissue treatment was 94 % (n = 17/18) of patients with a mean VAS decreasing from 6.117 ± 2.006 SD to 1.712 ± 1.697 SD (95 % CI 3.812-4.974; p < 0.001). Success for topical nifedipine was between 13 and 25 % of patients depending on the clinical presentation. Anal dilation was successful in 75 % of patients, while Anesthetic and steroid infiltration in 23-54 % of patients depending on the clinical presentation. Staple removal was successful in 77 % of patients, and scar excision with mucosal suturing in 94 % of patients., Conclusions: Our retrospective study suggests that most patients with chronic anal pain after SH may be cured with treatment by applying a stepwise approach from the least to the most invasive treatment.

Aim: Accurate preoperative discrimination between extra- and intraperitoneal rectal cancer has important treatment implications. Our main objective was to compare the diagnostic performance of MRI with rigid rectoscopy (RRS) in assessing the location of rectal cancers above or below the peritoneal reflection (PR), using the findings obtained during abdominal surgery for treatment of the cancer as the reference standard. We also compared the accuracy of MRI and RRS in assessing the level of the lower border of the tumour from the anal verge., Method: Patients with rectal carcinoma awaiting surgery underwent MRI and RRS. The MRI images were reviewed by two abdominal radiologists who determined the location of the inferior border of the tumour in relation to the PR. Receiver-operating characteristics (ROC) curve analysis was performed to determine the diagnostic performance of RRS at different cut-off values., Results: The sensitivity and specificity were 98.15% and 100%, respectively, for MRI, and 100% and 76.92%, respectively, for RRS at a cut-off value of < 10 cm. The mean level of the lower border of the tumour from the anal verge was 68 ± 44.3 mm on RRS and 73.5 ± 42.4 mm on MRI (P = 0.25), with a trend towards overestimation with MRI., Conclusion: RRS is still the main means of assessing the level of a rectal tumour from the anal verge, but MRI has value in determining the level of the tumour in relation to the PR, which cannot be seen on endoscopy., (Colorectal Disease © 2014 The Association of Coloproctology of Great Britain and Ireland.)

Aim: Transanal haemorrhoidal dearterialization (THD) has become well established for the treatment of haemorrhoids. In this study we describe a technical modification of this technique, targeted mucopexy (THD TM), and report the results for advanced haemorrhoids., Method: The study included a prospective evaluation of patients with Grade IV (fourth-degree) haemorrhoids operated on with the THD TM technique. This consisted of an initial dearterialization when the haemorrhoidal arteries were transfixed and a second phase of mucopexy, using a different needle from that usually used in the original technique., Results: From January 2007 to December 2011, 31 consecutive patients with Grade IV haemorrhoids were operated on using the THD TM technique. Postoperative pain was reported by 22 (70%) patients on day 1 and 19 (61%) on day 7, while nine (30%) did not experience any pain at all. Severe pain was reported by only nine (16%) patients. At a mean follow-up of 32 months, two (6.4%) patients required a further intervention for on-going symptoms., Conclusion: Transanal haemorrhoidal dearterialization TM is effective for advanced haemorrhoids., (© 2014 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background: The aim of our study was to evaluate gas retention, abdominal symptoms and changes in girth circumference in females with bloating using an active or sham abdominal wall mechanical stimulation., Methods: In 14 female patients, complaining of bloating (11 with irritable bowel syndrome and 3 with functional bloating according to the Rome III criteria) a gas mixture was continuously infused into the colon for 1 h (accommodation period). Abdominal perception and girth were measured. At the beginning of the 30-min period of free rectal gas evacuation (clearance period), an electromechanical device was positioned on the abdominal wall of all patients. The patients were randomly assigned to an active or a sham stimulation protocol group. Gas retention, perception and abdominal distension were measured at the end of the clearance period., Results: All patients tolerated the volume (1,440 ml) of gas infused into the colon. Abdominal perception and girth measurements was similar in both groups during the accommodation period. At the end of the clearance, the perception score and the girth changes in the active and sham stimulation groups were similar (2.8 ± 2.0 vs. 1.4 ± 1.2, p = 0.2 and 4.9 ± 4.5 vs. 2.8 ± 2.3 mm, p = 0.3 active vs. sham, respectively). Furthermore, the mechanical stimulation of the abdominal wall did not significantly reduce gas retention (495 ± 101 ml vs. 566 ± 55, active vs. sham, p = 0.1)., Conclusions: An external mechanical massage of the abdominal wall did not improve intestinal gas transit, abdominal perception and abdominal distension in our female patients complaining of functional bloating.

Purpose: The aim of this study is to test in a double-blinded, randomised placebo-controlled study the effects of a commercially available multi-strain symbiotic mixture on symptoms, colonic transit and quality of life in irritable bowel syndrome (IBS) patients who meet Rome III criteria., Background: There is only one other double-blinded RCT on a single-strain symbiotic mixture in IBS., Methods: This is a double-blinded, randomised placebo-controlled study of a symbiotic mixture (Probinul, 5 g bid) over 4 weeks after 2 weeks of run-in. The primary endpoints were global satisfactory relief of abdominal flatulence and bloating. Responders were patients who reported at least 50 % of the weeks of treatment with global satisfactory relief. The secondary endpoints were change in abdominal bloating, flatulence, pain and urgency by a 100-mm visual analog scale, stool frequency and bowel functions on validated adjectival scales (Bristol Scale and sense of incomplete evacuation). Pre- and post-treatment colonic transit time (Metcalf) and quality of life (SF-36) were assessed., Results: Sixty-four IBS patients (symbiotic n = 32, 64 % females, mean age 38.7 ± 12.6 years) were studied. This symbiotic mixture reduced flatulence over a 4-week period of treatment (repeated-measures analysis of covariance, p < 0.05). Proportions of responders were not significantly different between groups. At the end of the treatment, a longer rectosigmoid transit time and a significant improvement in most SF-36 scores were observed in the symbiotic group., Conclusions: This symbiotic mixture has shown a beneficial effect in decreasing the severity of flatulence in IBS patients, a lack of adverse events and a good side-effect profile; however, it failed to achieve an improvement in global satisfactory relief of abdominal flatulence and bloating. Further studies are warranted.

Background: Chromo-zoom endoscopy has been demonstrated to be valuable in assessing the degree of intestinal villous atrophy in patients with suspected celiac disease., Objective: To evaluate the diagnostic accuracy of chromo-zoom endoscopy in patients with difficult diagnosis because of nonconcordant test results and/or the confounding of a gluten-free diet initiated before an appropriate diagnosis of celiac disease and to compare the findings to a recent reference standard, the in vitro gliadin challenge test., Design: Prospective, case-control study., Setting: Tertiary-care referral hospital., Patients: Patients without celiac disease (negative control group, n = 9), patients with celiac disease (positive control group, n = 41), and patients with difficult diagnosis (n = 27)., Intervention: Chromo-endoscopy with indigo carmine and endoscopic zoom-magnification were performed. Duodenal fragments were collected for the in vitro gliadin challenge test. The area under the receiver operating characteristic curve (ROC) was used for statistical analyses on accuracy., Main Outcome Measurements: Diagnostic accuracy of chromo-zoom endoscopy for detection of mucosal abnormalities in patients with difficult diagnosis., Results: Chromo-zoom endoscopy had a high accuracy for celiac disease diagnosis in analyses on negative controls and positive controls (area under roc = 0.99). In the difficult diagnosis group, the accuracy of chromo-zoom endoscopy was lower (area under roc = 0.83), but it increased after exclusion of patients with celiac disease on gluten-free diet (area under roc = 0.88)., Limitations: There was a 4% failure rate in the ability to cultivate biopsies. Also, the study was done at an academic medical center., Conclusion: Chromo-zoom endoscopy has high accuracy for cases of difficult diagnosis of celiac disease but only in untreated patients with celiac disease., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Chronic anal fissure (CAF) is a painful condition that is unlikely to resolve with conventional conservative management. Previous studies have reported that topical treatment of CAF with glyceryl trinitrate (GTN) reduces pain and promotes healing, but optimal treatment duration is unknown., Methods: To assess the effect of different treatment durations on CAF, we designed a prospective randomized trial comparing 40 versus 80 days with twice daily topical 0.4% GTN treatment (Rectogesic, Prostrakan Group). Chronicity was defined by the presence of both morphological (fibrosis, skin tag, exposed sphincter, hypertrophied anal papilla) and time criteria (symptoms present for more than 2 months or pain of less duration but similar episodes in the past). A gravity score (1 = no visible sphincter; 2 = visible sphincter; 3 = visible sphincter and fibrosis) was used at baseline. Fissure healing, the primary endpoint of the study, maximum pain at defecation measured with VAS and maximum anal resting pressure were assessed at baseline and at 14, 28, 40 and 80 days. Data was gathered at the end of the assigned treatment., Results: Of 188 patients with chronic fissure, 96 were randomized to the 40-day group and 92 to the 80-day group. Patients were well matched for sex, age, VAS and fissure score. There were 34 (19%) patients who did not complete treatment, 18 (10%) because of side effects. Of 154 patients who completed treatment, 90 (58%) had their fissures healed and 105 (68%) were pain free. There was no difference in healing or symptoms between the 40- and the 80-day group. There was no predictor of fissure healing. A low fissure gravity score correlated with increased resolution of pain (P < 0.05) and improvement of VAS score (P < 0.05) on both univariate and multivariate analysis. A lower baseline resting pressure was associated with better pain resolution on univariate analysis (P < 0.01). VAS at defecation and fissure healing significantly improved until 40 days (P < 0.001), while the difference between 40 and 80 days was not significant., Conclusion: We found no benefits in treating CAF with topical GTN for 80 days compared to 40 days. Fissure healing and VAS improvement continue until 6 weeks of treatment but are unlikely thereafter.

On the basis of a review of the literature and description of a clinical case, the aim of this paper was to evaluate the role of pancreaticoduodenectomy as the primary therapeutic choice in a rare, serious condition such as cystic dystrophy of the duodenal wall in heterotopic pancreas. The diagnosis is difficult because of the non-specific clinical manifestations, and radiological and endoscopic imaging are decisive. Computed tomography and magnetic resonance are very useful for demonstrating the presence of cysts in a thickened duodenal wall but endoscopic ultrasonography is the most useful imaging examination. The choice of therapeutic option is still debated. Although some Authors have proposed a medical approach using octreotide or endoscopic treatment for selected patients, pancreaticoduodenectomy is usually proposed for symptomatic patients. When surgery is needed, pancreaticoduodenectomy should be preferred, reserving by-pass procedures for high-risk patients. Because of the non-specific clinical manifestations and the very difficult diagnostic and therapeutic management, these patients need to be studied and treated in specialised, dedicated centres.

Background: We investigated which factors are significantly associated with long-term quality of life after laparoscopic total fundoplication in the treatment of gastroesophageal reflux disease., Methods: Patients (n = 144) were given a standardized frequency-intensity symptoms questionnaire and the Short-Form 36 Health Survey for quality-of-life evaluation before and after laparoscopic total fundoplication., Results: At follow-up evaluation (n = 102), patients had a significant reduction in their symptoms score and no deterioration in quality of life. A significant association with postoperative dysphagia for solids and/or liquids was found in the physical component summary score of the Short-Form 36 administered to patients postoperatively (P = .003)., Conclusions: In this study, laparoscopic total fundoplication was a safe and effective surgical treatment for gastroesophageal reflux disease, generally offering an improved long-term quality of life, with the exception of a minority of patients (6 of 102 patients; 5.8%) who experienced persistent severe dysphagia.

An elite mountaineer reported severe acute mountain sickness and ataxia during an 8000-m expedition and concomitant use of transdermal nitroglycerin patches aimed to prevent frostbites. Use of nitroglycerin for this purpose is off-label, and its safety has not been assessed. Moreover, a relation between nitrate-induced cerebral vasodilation and high altitude cerebral edema is theoretically possible on a pathophysiological basis. It is our opinion that nitroglycerin use at high altitude should be discouraged, as efficacy in the prevention of frostbites is questionable and safety has not been assessed.

Hydatid disease of the liver is a relatively frequent disease. Although the natural history is almost completely known, several complications may occur. The aim of this study was to show that radical surgical resection of the hepatic hydatid cyst is a safe and very effective technique, based on our results after 30-year experience. A review of most significant studies was carried out. We retrospectively evaluated our surgical cases. From January 1973 to December 2003 we treated 216 patients, 98 males and 118 females. Survival was compared with the Kaplan-Meier test, using log-rank analysis to compare data. Differences with a p value less than 0.05 were considered significant. A total of 279 cysts were excised. We performed pericystectomy in 122 cases, 73 of which closed. We also performed 19 atypical resections, 10 segmentectomies, 20 lobectomies and 2 percutaneous treatments. In more than 90% of cases, preoperative data collection was completed by preoperative ultrasound. The cumulative morbidity was 13%. The recurrence rate amounted to 4.3% at 5 years and 7% at 10 years: of these, 6 occurred after non-radical surgery and 2 after total pericystectomy or liver resection (p < 0.001). Technical advances and accumulated experience permit safe treatment of hepatic hydatid cysts by radical resection, with an almost zero recurrence rate, making it the treatment of choice over partial resection. The utility of percutaneous treatment remains confined to limited indications, such as laparoscopy.

Background: Gastroesophageal reflux disease (GERD) is a chronic disease. Sexual behavior is often altered in chronic illness. The aim of this study was to evaluate sexual behavior in patients affected with GERD before and after medical or surgical treatment in comparison to healthy controls (HC)., Methods: Upper GI endoscopy and 24-h ambulatory pH testing were performed to confirm GERD in symptomatic patients. GERD patients completed an anonymous questionnaire on sexual life before and after medical or surgical treatment., Results: Compared with HC, untreated patients with GERD showed more frequent difficulty in attaining orgasm and painful intercourse. GERD patients after surgical treatment had significantly more difficulty in attaining orgasm, while after continuous medical treatment GERD patients compared with HC had significantly more difficulty in attaining orgasm, higher painful intercourse, lower sexual desire, and perceived more frequently that the partner was unhelpful. When compared with untreated conditions, GERD patients after surgical treatment had a significant improvement in attaining orgasm and in painful intercourse but a significant decrease in sexual desire, a lower satisfaction with their sexual life, and a higher prevalence of an unhelpful partner, whereas GERD patients after medical treatment had a decrease in all indices of sexual behavior., Conclusion: Untreated GERD is associated with disorders in sexual behavior. Compared with HC, only the surgical group partially improved after treatment.

There is an increased prevalence of gastro-oesophageal reflux and symptoms in obese patients. Information about the proximal stomach in obese patients with reflux is lacking. Gastric volume and compliance are similar between obese and lean subjects. To study the proximal stomach function and perception in obese patients with normal or abnormal oesophageal acid exposure, thirty-one obese patients, with normal or abnormal oesophageal acid exposure, underwent medical evaluation of oesophageal and gastrointestinal symptoms by a questionnaire and measurement of proximal stomach function and perception by an electronic barostat and a standardized questionnaire. Nineteen obese patients had abnormal oesophageal acid exposure. The percentage of total time with pH <4 is significantly related to the presence of hiatal hernia, the oesophageal intensity-frequency symptom score and gender, i.e. higher percentage in men. The perception cumulative score was significantly different between patients with normal and abnormal oesophageal acid exposure after adjusting for covariates (gender, body mass index, age, minimal distending pressure, gastric tone and gastric compliance). Gastric tone and compliance were significantly related to the perception cumulative score. In conclusion, patients with abnormal oesophageal acid exposure have increased gastric perception. A significant relation among gastric tone, gastric compliance and upper gastrointestinal sensations was shown.

The authors report their experience in evaluating abdominal aorta aneurysms (AAA) by ultrasound examination. The incidence of this kind of disease is growing up in the last years and an earlier diagnosis increases the surviving possibilities of the patient affected, above all if symptomless, leading to a correct treatment: a semestral or annual follow-up of the aneurysms with a diameter smaller than 5 cm and surgery of the aneurysms with a diameter wider than 5 cm, because of high risk of rupture. The authors stress the importance of extending abdominal ultrasound examination to the aorta in all patients over 50 year old especially if affected by vascular diseases, hypertension and diabetes. In their experience the authors found 106 AAA; 61% of them with less than 4 cm diameter.