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Background Data: The use of surgical drains after traditional splenectomy has been largely debated and several Authors have been unfavorable to their use. With the advent of laparoscopic splenectomy, their role has been re-discussed. The increased risk of undetectable pancreatic, gastric or colon injury in challenging laparoscopic removal of the spleen have induced some surgeons to reconsider the advantages related to their use., Methods: One hundred seventeen consecutive cases of laparoscopic splenectomy with routine use of surgical drains have been reviewed. Indications for surgery, length of operations, post-operative day of drain removal, post-operative complications were retrospectively analyzed., Results: Laparoscopic splenectomy was performed for idiopathic thrombocytopenic purpura in 77 patients (65,8%), splenic lymphoma in 11 (9,4%), hereditary spherocytosis in 12 (10,2%), β-thalassemia in 6 (5.1%), other diseases in 11 (9,4%) cases. Conversion to open surgery was necessary in 11,1% of cases. Drains were removed 2-3 days after surgery in 95,8%, within 10 days in 3.4%, within 2 months in 0,8% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient with myelofibrosis and massive splenomegaly developed a late post-operative subphrenic abscess, successfully treated by a percutaneous drainage., Conclusions: In Authors' experience, the use of drains after laparoscopic splenectomy helped detect early post-operative bleeding. Surgical drains could reduce the incidence of fluid intra-abdominal collections and infections. Their use should be recommended in the laparoscopic approach, especially in technically demanding surgical procedures., Key Words: Laparoscopy, Surgical drainage, Splenectomy.

Pneumomediastinum usually occurs after esophageal or chest trauma. Subcutaneous cervical emphysema as a presentation of non-traumatic colonic perforation following colorectal cancer or diverticulitis, is very rare. We report a case of a patient with rectal cancer who developed a diastatic cecum retroperitoneal perforation with a secondary pneumomediastinum and cervical emphysema. The patient was in treatment with a neoadjuvant chemo-radiotherapy for a low rectal cancer. Treatment consisted in an emergency right hemi-colectomy with ileostomy and performance of distal colonic fistula. The Authors discuss the occurrence of pneumomediastinum and cervical emphysema complicating rectal cancer, pointing out ethiopathogenesis, clinical presentation, diagnosis and treatment. The importance of performing a diverting colostomy when neoadjuvant chemotherapy is scheduled in patients with stenotic rectal cancer, although not clinically occluded.

Myeloid sarcoma is a tumor composed of myeloblasts occurring at an extramedullary site. It may develop in patients with acute myeloid leukemia, myeloproliferative or myelodysplastic syndrome, sometimes preceding onset of the systemic disease. Frequent sites of myeloid sarcoma are bones or various soft tissues. Gastrointestinal involvement is very rare. We report a unique case of myeloid sarcoma presenting as a painful anal fissure, in a patient with a history of acute myeloid leukemia. The diagnosis was achieved by a surgical excisional biopsy and immunoistochemical staining.

Background: Pressure ulcers are frequent complications for long term hospitalized bed-ridden patients which are not able to move or move very little. In fact, the lesion forms in a skin and muscle region which undergoes a constant pressure between an underlying bone protrusion and a support structure such as a bed or a wheelchair. Initially only the outer layers are involved but in time, the ulcer can spread to the deeper structures and reach the bone., Patients and Methods: In our work we described the anatomical areas that are most often subject to developing a pressure ulcer and we considered the surgical treatment and reconstructive procedures which are applied using a logical and rigorous sequence., Results: We considered 4 clinical cases (2 ischiatic sores, 1 sacral sore and 1 gluteal-trochanteric sore) which demonstrate the surgical treatment and the reconstructive procedures., Conclusions: It is crucial to cover the defects with a thick flap to give more support and protection to the areas which undergo pressure and to lower the incidence of recurrences.

Objective: The Authors report their experience with the routine use of surgical drainage in a large series of splenectomies., Summary of Background Data: Benefits and risks related to surgical drains have been always discussed, with some surgeons in favor of them and skeptic others considering not physiological their use. After splenectomy, their use is also largely debated, especially because of susceptibility of operated patients to infections., Patients and Methods: Two thousand nine cases have been reviewed. Indications for splenectomy, performed either by open or laparoscopic approach, included idiopathic thrombocytopenic purpura in 137 patients (65,4%), splenic lymphoma in 36 (17,2%), hereditary spherocytosis in 15 (7,4%), β-thalassemia in 8 (3,7%), other diseases in 13 (6,1%)., Results: "Active" or "passive" drains were placed in 80% and 20% of cases, respectively. Drains were removed 2-3 days after surgery in 90,2%, within 10 days in 4,3%, within 2 months in 0,4% of cases. In 2 cases a post-operative bleeding, detected through the drainage, required re-operation. One patient developed a subphrenic abscess, successfully treated by a percutaneous drainage. One case of pancreatic fistula was observed., Conclusions: In Authors' experience, the use of drains after splenectomy does not affect the risk of subsequent infectious complications, independently on the type of the drainage system used. Early removal of drains in this series might have played an important role in the very low incidence of abdominal infections reported. The use of surgical drains after splenectomy might play an important role to early detect post-operative bleeding, as it happened in 2 cases of this series.

Small bowel perforation is a unique, serious complication during endometrial biopsy. The authors report a case of a double uterine-ileal perforation totally managed by primary laparoscopic repair. A 63-year-old female was admitted with acute abdomen 2 days after an endometrial curettage. Abdominal X-ray shows signs of pneumoperitoneum. Emergency diagnostic laparoscopy was performed and a uterine-ileal perforation was identified. Repair was accomplished by a totally laparoscopic intracorporeally suturing of the 2 breaches. Postoperative course showed only a delayed ileus and the patient was discharged after 5 days with no complications. When acute abdomen arises following uterine biopsy, a potential iatrogenic intestinal laceration always has to be ruled out. Laparoscopic approach is a quick and safe technique in these cases. Totally laparoscopic primary closure of the iatrogenic ileal laceration may be accomplished with low morbidity.

Background: We performed a retrospective study on patients with idiopathic thrombocytopenic purpura (ITP) to evaluate the response to splenectomy in relation to preoperative platelet count., Materials and Methods: Two groups of patients operated on with laparoscopic or open splenectomy for ITP, with a platelet count ≤30,000/μL (study group: 22 patients) and >30,000/μL (control group: 18 patients), respectively, were compared. The two groups were homogeneous in relation to age, sex, length of preoperative steroid therapy, and time interval between diagnosis and surgery (Student t test with P > .1). The results of surgery were evaluated at one year after splenectomy. Positive response to surgery, according to the American Society of Hematologic Guidelines, was considered in patients with a postoperative platelet count ≥100,000/μL or in patients with a postoperative platelet count ≥30,000/μL and a twofold increase in platelet count from baseline, in the absence of bleeding. The postoperative platelet count increase rate was statistically related to preoperative platelet count in both the study and control groups. Statistical analysis was performed using the Student's t test for independent sample and the Pearson correlation in a 2-tailed test., Results: No relationship between preoperative platelet count and postoperative platelet percent increase was observed in the control group (r = -0.41; P = .089), whereas a significant negative correlation (r = -0.68; P = .0004) was found in the study group., Conclusions: A higher increase of postoperative percent platelet count may be predicted in patients with a low preoperative platelet count.

Aim: Colorectal cancer is one of the most common malignancies in general population. The incidence seems to be higher in older age. Surgery remains the treatment of choice and laparoscopic approach offers numerous benefits. We report our personal experience in elderly patients operated on for colorectal cancer with laparoscopic resection., Patients and Methods: From January 2003 to September 2013, out of 160 patients aged 65 years or older and operated with minimally invasive techniques, 30 cases affected by colorectal cancer and operated on with laparoscopic approach were analyzed in this study., Results: Male/female ratio was 1.35 and mean age 72 years. Constipation, weight loss, anemia and rectal bleeding were the most commonly reported symptoms. Lesions involved descending-sigmoid colon in 53% of cases, rectum in 37% and ascending colon in 10%. Among laparoscopic colo-rectal operations laparoscopic left colectomy was the most frequently performed, followed by right colectomy, abdominoperineal resection and Hartmann procedure. Operative times ranged from 3 to 5 hours depending on surgical procedure performed. Mean hospital stay was 6 days (range 4-9). Conversion to open approach occurred only in a case of laparoscopic right colectomy (3%) for uncontrolled bleeding. A single case of mortality was reported. In two cases (7%) anastomotic leakage was observed, conservatively treated in one patient and requiring reoperation in the other one., Conclusions: Laparoscopic colorectal surgery is feasible and effective for malignancies in elderly population offering several advantages including immunologic and oncologic ones. However an experienced surgical team is essential in reducing risks and complications.

This paper describes development and validation of a new method for the simultaneous determination of six antithyroid drugs (ATDs) in surface waters by using liquid chromatography-triple quadrupole mass spectrometry (LC-MS/MS). Target compounds include two ATD classes: thiouracil derivatives (thiouracil (TU), methyl-thiouracil (MTU), propyl-thiouracil (PTU), phenyl-thiouracil (PhTU)) and imidazole derivatives (tapazole (TAP), and mercaptobenzimidazole (MBI)). Sensitivity and selectivity of the LC-multiple reaction monitoring (MRM) analysis allowed applying a simple pre-concentration procedure and "shooting" the concentrated sample into the LC-MS/MS system without any other treatment. Recoveries were higher than 75% for all analytes. Intra-day precision and inter-day precision, calculated as relative standard deviation (RSD), were below 19 and 22%, respectively. Limits of detection (LODs) ranged from 0.05 to 0.25 μg/L; limits of quantitation (LOQs) varied between 0.15 and 0.75 μg/L. The validated method was successfully applied to the analysis of ATD residues in surface water samples collected from the Tiber River basin and three lakes of Lazio (central Italy). The analytes were quantified based on matrix-matched calibration curves with mercaptobenzimidazole-d4 (MBI-d4) as the internal standard (IS). The most widespread compound was TAP, one of the most common ATDs used in human medicine, but also TU and MBI were often detected in the analysed samples., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Background: Arm paresis remains a major impairment after stroke despite the best conventional rehabilitation. Randomized, controlled trials of intensive exercise programs have demonstrated improvements in arm function for patients with chronic stroke. However, the gains achieved have been relatively modest for the large investments in patient and therapist time., Objective: To evaluate the safety, acceptance, adherence, and effectiveness of a community-based exercise program for upper limb paresis in patients with chronic stroke and the effects of telerehabilitation monitoring in kiosks distributed through the community., Methods: Longitudinal cohort with geographic control group. The experimental group received devices needed for a home exercise program based on the Carr and Shepherd "Motor Learning Program" and were instructed to practice the exercises at least twice a week at the kiosk and at least 3 more days a week at home. The control group received usual care., Results: Compared with the control group, patients in the experimental group demonstrated significant gains in arm function as measured by the Wolf Motor Function Test, 9-Hole Peg Test, Motricity Index, and Nottingham Extended Activities of Daily Living Questionnaire. The intervention received high satisfaction ratings and produced no adverse events. Only 30% of the subjects attended kiosks regularly. Outcomes for this group did not differ significantly from those who only practiced at home., Conclusions: Home- and community-based exercise for arm paresis is safe and effective. Telerehabilitation interventions will need additional enhancements to improve effectiveness. The optimal upper extremity exercise prescription poststroke remains to be established., (© The Author(s) 2014.)

Background and Objectives: The aim of this study was to evaluate the results of laparoscopic surgery performed for coexisting spleen and gallbladder surgical diseases., Methods: Between May 2004 and October 2012, 12 patients underwent concomitant laparoscopic splenectomy and cholecystectomy. Indications for surgery included idiopathic thrombocytopenic purpura in 5 patients, hereditary spherocytosis in 4 patients, and thalassemia intermedia in 3 patients., Results: The mean operative time was 100 minutes (range, 80 -160 minutes), and the blood loss ranged from 0 to 150 mL (mean, 50 mL). The mean longitudinal diameter of the spleen was 14 cm. One patient required conversion to open procedure. An accessory spleen was detected and removed in one case. The mean length of hospital stay was 5 days. No deaths or other major intraoperative and/or postoperative complications occurred., Conclusion: Provided that the technique is performed by an experienced surgical team, concomitant laparoscopic splenectomy and cholecystectomy is a safe and feasible procedure and may be considered for coexisting spleen and gallbladder diseases.

Background: Solitary subcutaneous hydatid cyst is not frequent and the only symptom is generally a silent growing mass. Total excision remains the mainstay of treatment. Aim of the study was to present a case surgically treated and perform a statistical analysis reviewing previous published works in order to define a correct approach to diagnosis and treatment., Methods: 264 documents from Medline database were considered for primary subcutaneous hydatid cyst cases. Data concerning geographic region, gender, age, job, location, evolving time, history and physical, mobility, diameter, laboratory, imaging, locularity (uni- or multilocular cyst), fine-needle aspiration, preoperative diagnosis, neoadjuvant chemotherapy, treatment, spillage, adjuvant therapy, follow-up and recurrences were ordered in a database and analysed performing t-test, Fisher's test and Pearson's test., Results: 23 cases, included ours, resulted suitable for our study. Lower extremities were involved in most cases (60.9%) and the thigh represented the most common site (34.8%), whereas upper extremities were the rarest location (8.7%). Patients with head and neck located cysts were younger than those with upper extremities cysts (P=0.037). Patients who underwent multiple imaging approach received a significantly correct first diagnosis (P=0.001) and ultrasonography, unlike other techniques, appeared to be essential (P=0.013)., Case Report: A 68-year-old man who lived and worked in his farm in Sicily (Italy) presented with a 30-year-growing mass in the deltoid region measuring 10 cm. Ultrasonography and magnetic resonance imaging strongly suggested hydatid cyst. Therefore the cyst was excised and pathology confirmed the diagnosis., Conclusion: Solitary subcutaneous hydatid cyst must always be considered in the differential diagnosis of silent growing mass in soft tissues. History and physical associated with ultrasound and magnetic resonance imaging are sufficient to achieve a correct preoperative diagnosis., (© 2013 Elsevier Ireland Ltd. All rights reserved.)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and they often require a surgical removal. Gastrointestinal stromal tumors can originate from any part of the gastrointestinal tract but gastric location is the most common. In the past the risk of rupture of pseudocapsula and peritoneal dissemination have discouraged surgeons from making a minimally invasive surgical treatment. Recently laparoscopic wedge resection has been proposed. Performance of this mini-invasive technique is however difficult in some gastric location of gastrointestinal stromal tumors, such as iuxta-cardial region. The Authors report and discuss a new technique they used to remove a gastrointestinal stromal tumor located just below the cardia, using a rendez-vous endoscopic and laparoscopic technique.

Background: Only a few studies have addressed long-term results comparing laparoscopic and open splenectomy in idiopathic thrombocytopenic purpura (ITP). We analyzed the 1-year results comparing age, sex, length of preoperative steroid therapy, diagnosis-to-splenectomy interval, and preoperative platelet count in relation to postoperative response after open and laparoscopic splenectomy., Subjects and Methods: Data collected from two groups, treated by laparoscopic and open splenectomy, respectively, of 20 patients each were retrospectively reviewed. Positive response to splenectomies, evaluated according to the International Working Group guidelines reported by the American Society of Hematology, was statistically related through Student's t test and the Pearson correlation test to the above-mentioned factors., Results: Positive response to splenectomy was observed in 80% and 85% of patients, respectively, in the laparoscopic and open groups (P > .10). No statistical differences were observed comparing each of the studied factors between laparoscopic and open splenectomy responder patients (P > .10). When percentage increase of postoperative platelet count was related to diagnosis-to-splenectomy interval, a positive correlation was found in the laparoscopic group (r = 0.544, P < .05). In addition, a significant negative correlation in both groups was observed comparing preoperative platelet count and percentage postoperative platelet increase, with a greater increase of postoperative platelet count in patients with a lower preoperative platelet count (laparoscopic group, r = -0.663; open group, r = -0.656; P < .01)., Conclusions: In this series long-term results after laparoscopic splenectomy in ITP patients were as effective as after the open approach. Higher postoperative platelet percentage increase was achieved in both groups in patients with a lower preoperative platelet count. Finally, laparoscopic splenectomy in this study seems to be superior to the open approach in patients with a longer diagnosis-to-splenectomy interval.

Background: Tracheostomy mechanical ventilation (TMV) is performed in amyotrophic lateral sclerosis (ALS) patients with a respiratory failure or when the non-invasive ventilation (NIV) is no longer effective. We evaluated the clinical characteristics and survival of a cohort of tracheostomized ALS patients, followed in a single ALS Clinical Center., Methods: Between 2001 and 2010, 87 out of 279 ALS patients were submitted to TMV. Onset was spinal in 62 and bulbar in 25. After tracheostomy, most patients were followed up through telephone interviews to caregivers. A complete survival analysis could be performed in fifty-two TMV patients., Results: 31.3% ALS patients underwent tracheostomy, with a male prevalence (M/F=1.69) and a median age of 61 years (interquartile range=47-66). After tracheostomy, nearly all patients were under home care. TMV ALS patients were more likely than non-tracheostomized (NT) patients to be implanted with a PEG device, although the bulbar-/spinal-onset ratio did not differ between the two groups. Kaplan-Meyer analysis showed that tracheostomy increases median survival (TMV, 47 months vs NT, 31 months, p=0.008), with the greatest effect in patients younger than 60 at onset (TMV ≤ 60 years, 57.5 months vs NT ≤ 60 years, 38.5 months, p=0.002)., Conclusions: TMV is increasingly performed in ALS patients. Nearly all TMV patients live at home and most of them are fed through a PEG device. Survival after tracheostomy is generally increased, with the stronger effect in patients younger than 60. This survival advantage is apparently lost when TMV is performed in patients older than 60. The results of this study might be useful for the decision-making process of patients and their families about this advanced palliative care., (Copyright © 2012. Published by Elsevier B.V.)

The Authors discuss on a laparoscopic-assisted approach for excision of a sessile villous adenomatous polyp of the cecum, unresectable by endoscopy. Because of the large implant of the polyp, endoscopic polypectomy was considered at high risk and a surgical laparoscopic procedure was scheduled for removal of the lesion. After right colon mobilization, an intraoperative endoscopy confirmed the location of th polyp in the posterior wall of the cecum, closed to the ileo-cecal valve. A small 10 cm laparotomy, through which the cecum was pulled out the abdominal cavity, was performed. Then, a minimal colotomy along the intestinal taenia was carried out to allow a safe and complete excision of the polyp. This laparoscopic approach differs from the other laparoscopic-assisted methods reported in the Literature since it provides at the same time the postoperative advantages associated with minimal access surgery and a safe oncological removal of the polyp with low risks of complications.

Introduction: Estrogens regulate the proliferation of normal and neoplastic breast epithelium. Although the intracellular mechanisms of estrogens in the breast are largely understood, little is known about how they induce changes in the structure of the mammary epithelium, which are characteristic of breast cancer. In vitro three dimensional (3D) cultures of immortalised breast epithelial cells recapitulate features of the breast epithelium in vivo, including formation of growth arrested acini with hollow lumen and basement membrane. This model can also reproduce features of malignant transformation and breast cancer, such as increased cellular proliferation and filling of the lumen. However, a system where a connection between estrogen receptor (ER) activation and disruption of acini formation can be studied to elucidate the role of estrogens is still missing., Methods/principal Findings: We describe an in vitro 3D model for breast glandular structure development, using breast epithelial MCF-12A cells cultured in a reconstituted basement membrane matrix. These cells are estrogen receptor (ER)α, ERβ and G-protein coupled estrogen receptor 1 (GPER) competent, allowing the investigation of the effects of estrogens on mammary gland formation and disruption. Under normal conditions, MCF-12A cells formed organised acini, with deposition of basement membrane and hollow lumen. However, treatment with 17β-estradiol, and the exogenous estrogens bisphenol A and propylparaben resulted in deformed acini and filling of the acinar lumen. When these chemicals were combined with ER and GPER inhibitors (ICI 182,780 and G-15, respectively), the deformed acini recovered normal features, such as a spheroid shape, proliferative arrest and luminal clearing, suggesting a role for the ER and GPER in the estrogenic disruption of acinar formation., Conclusion: This new model offers the opportunity to better understand the role of the ER and GPER in the morphogenesis of breast glandular structure as well as the events implicated in breast cancer initiation and progression.

Background: The division of the splenic hilum is the most delicate step during laparoscopic splenectomy. An incorrect approach could lead to a series of related complications. Aim of the study was to report authors' personal experience in a series of 107 laparoscopic splenectomies where the splenic hilum was approached by means of stapling device. A possible relationship between instruments used to divide the splenic artery and vein and complications was analyzed., Methods: Laparoscopic splenectomy was performed in 107 cases at authors' institution between 1998 and January 2011. In all the patients, splenic hilum was approached by means of vascular stapler., Results: Indications for the spleen removal mainly were hematologic disorders. Associated surgical procedures were performed in 32 cases. Among the 13 patients who required a conversion to open splenectomy, only in 3 cases the reason was related to the hilum management. Postoperative complications included portal vein thrombosis in 3 cases, pancreatic fistula in 1 case, and bleeding, requiring reintervention, in 2 cases., Conclusions: The use of the stapling device is a safe and effective method to approach the splenic hilum during laparoscopic splenectomy. In experienced hands it showed a low rate of related complications.

Background: The imbalance between the increasing prevalence of acutely decompensated respiratory diseases and the shortage of intensive care unit beds has stimulated the growth of respiratory high-dependence care units (RHDCUs)., Methods: We conducted a national survey to analyze the changes, in the past 10 years, in the number, structures, staff, procedures, diagnoses, and outcomes in Italian RHDCUs that satisfy the European Respiratory Society's criteria (modified according to the Italian Association of Hospital Pneumologists) for high level (respiratory intensive care unit), intermediate level (respiratory intermediate intensive care unit), and low level (respiratory monitoring unit) RHDCU care., Results: The number of RHDCUs increased from 26 to 44. The relative prevalence among all the RHDCUs increased only for the low-level units (P = .03). Compared to 1997, in 2007 a higher percentage of Italian RHDCUs were located within respiratory wards than located outside of respiratory wards (P = .03), and the physician-to-patient mean ratio and the nurse-to-patient mean ratio per shift were lower (P = .001 and P = .002, respectively). Admissions for only monitoring decreased (P < .001), and admissions for active interventions increased: noninvasive ventilation (P = .002), invasive ventilation (P < .001), weaning from invasive ventilation (P < .001), and tracheal decannulation (P < .001). The complexity of RHDCU patients' conditions increased: there was a reduction in the percentage of COPD patients (P < .001) and an increase in the percentage of patients with neuromyopathies (P < .001) and de novo hypoxemia (P = .006)., Conclusions: Between 1997 and 2007 there was an increase in the number and expertise of Italian RHDCUs, with a shift toward less expensive care, and greater complexity of interventions and patient dysfunctions. These findings support the crucial role of RHDCUs in the management of respiratory critical patients.

Background: Pediatric surgery is now in the forefront of minimal access procedures. Although pediatric surgeons have been skeptic about laparoscopic splenectomy, recently minimally invasive approach for spleen removal has been revaluated also in young patients. Purpose of this study was to report Authors' personal experience in patients under eighteen who underwent laparoscopic splenectomy. Results of the procedure were evaluated., Patients and Methods: A retrospective review was undertaken in 18 splenectomised patients under the age of eighteen. Indications were hereditary spherocytosis in 10 patients, β-thalassemia in 4, idiopathic thrombocytopenic purpura in 3 and a splenic cyst in 1 child., Results: No intra-operative complications occurred. No conversion to open surgery was reported. During the follow-up one case of portal vein thrombosis, treated by medical therapy, was encountered and no other postoperative complications were observed., Conclusions: Laparoscopic approach has to be preferable for all those children undergoing spleen surgery. In experienced hands, it is of beneficial effects with a very reasonable rate of complications.

Introduction: Portal vein thrombosis (PVT) could be a life-threatening complication after splenectomy if not diagnosed promptly and treated properly. Risk factors of PVT are not completely clarified. Spleen size and underlying hematologic diseases are main potential risk factors for this complication. Laparoscopic surgery might increase the risk of developing PVT, as it reduces the blood flow in the portal system due to the pneumoperitoneum but, on the other hand, it seems to be associated with less postoperative modifications of coagulation parameters than open surgery, thus preventing PVT itself. The authors reviewed their series on open and laparoscopic splenectomies, pointing out their experience on PVT and discussing their surveillance and prophylaxis programs to prevent this complication., Materials and Methods: In this series, the authors report their experience on postsplenectomy PVT in 162 patients who have been splenectomised (102 operated on laparoscopically and 60 by open surgery)., Results: PVT was clinically observed in 1 case out of 60 open splenectomies and in 3 cases out of 102 laparoscopic procedures. Patients were treated with conservative anticoagulation therapy. In one case, additional ileal resection was needed. Mortality was 0%., Conclusion: Low-molecular-weight heparin should be administered to all patients who have been splenectomised, especially if they are at high risk of PVT. If symptoms appear, patients need to be treated with high-dose heparin followed, after at least 3 weeks, by oral anticoagulant therapy.

Laparoscopic colo-rectal surgery has been increasingly accepted and performed in several surgical centres. However, there are still concerns about the intra-operative risks and therefore on the safety of the procedure especially during the learning curve. As a matter of fact, in approximately one third of laparoscopic colo-rectal procedures, an intra-operative complication, mainly bleeding or iatrogenic injuries, may occur. In this paper, according to our experience, we analyse step by step the surgical technique of the laparoscopic left colectomy and evaluate the technical difficulties and complications in order to avoid them.

A rapid, simple and sensitive method based on liquid chromatography/tandem mass spectrometry (LC/MS/MS) with an electrospray ionization (ESI) source for the simultaneous analysis of fourteen water-soluble vitamins (B1, B2, two B3 vitamers, B5, five B6 vitamers, B8, B9, B12 and C) in various food matrices, i.e. maize flour, green and golden kiwi and tomato pulp, is presented here. Analytes were separated by ion-suppression reversed-phase liquid chromatography in less than 10 min and detected in positive ion mode. Sensitivity and specificity of this method allowed two important results to be achieved: (i) limits of detection of the analytes at ng g(-1) levels (except for vitamin C); (ii) development of a rapid sample treatment that minimizes analyte exposition to light, air and heat, eliminating any step of extract concentration. Analyte recovery depended on the type of matrix. In particular, recovery of the analytes in maize flour was > or =70%, with the exception of vitamin C, pyridoxal-5'-phosphate and vitamin B9 (ca 40%); with tomato pulp, recovery was > or =64%, except for vitamin C (41%); with kiwi, recovery was > or =73%, except for nicotinamide (ca. 30%).

Objectives: To describe survival, predictors of long-term outcome and attitudes in patients treated at home by tracheostomy-intermittent positive-pressure ventilation (TIPPV) for respiratory failure during a 10-year period (1995-2004)., Methods: Seventy-seven consecutive patients were treated by TIPPV at home. Patients were divided into three groups: neuromuscular, pulmonary, and non-pulmonary patients. Effects of TIPPV on survival, factors influencing outcome after TIPPV, and attitudes of patients and caregivers regarding mechanical ventilation were studied., Results: Forty-one patients (53%) were neuromuscular, 19 (25%) were affected by pulmonary diseases, and 17 (22%) by non-pulmonary diseases. The median survival time after TIPPV in the group was 49 months (range 3-149 months). There was statistically significant longer survival in neuromuscular compared to pulmonary patients (p=0.006), and a trend toward longer survival for non-pulmonary when compared to pulmonary patients (p=0.048). Chronic obstructive pulmonary disease (COPD) patients (n=14) showed the poorest outlook (median survival 26 months, range 3-45 months) and the highest number of emergency readmissions to hospital. The median survival in amyotrophic lateral sclerosis (ALS) patients was 49 months (range 30-61), lower than the whole group of neuromuscular patients. Major tracheostomy complications were low: 2.6%. Multivariate analysis showed that COPD and ALS patients had a three-fold higher risk of death than patients with other diagnoses. Lastly, 64 patients (83%) were pleased they had chosen TIPPV and 69 (90%) would choose it again. Forty-two caregivers (55%) were pleased the patients had chosen home ventilation, but 29 (38%) reported major burdens., Conclusions: TIPPV is well-received by the patients, is safe, and provides survival for long periods of time. Underlying conditions (COPD and ALS) might represent important prognostic factors for survival.

Summary: During the last decade we assisted to relevant progress in rehabilitation studies and in technological development. From the combination of these issues rises the tele-rehabilitation--a subfield of telemedicine consisting of a system to control rehabilitation "at distance"--as an actual possibility of application and a promising development in the future. The present paper offers a short review of the state of the art in the field of tele-rehabilitation, with a special focus on upper limb tele-rehabilitation. The experience is also briefly reported of the preliminary application of the H-CAD (home care activity desk) system and the HELLODOC (Healthcare service linking tele-rehabilitation to disabled people and clinicians) tele-rehabilitation service, conducted by the authors within two European projects in the period 2003-2005 and 2005-2007 respectively.

Summary: A technical assessment activity has been conducted by Istituto Superiore di Sanità (ISS) in the European project HELLODOC (Healthcare service linking tele-rehabilitation to disabled people and clinicians) for evaluating the tele-rehabilitation service. The activity was mainly focussed on architectural aspects and a step by step monitoring of the service. It was mainly related to the following aspects: service implementation, service performances, service integration and fault management. The technical assessment analysis demonstrated that the service worked in a quite satisfactory way, also considering the pioneering aspect of the project; the set of malfunctioning occurred, which had a low impact on the service continuity, are typical of a post-debug phase.

Summary: A web-based learning activity in the field of tele-rehabilitation was conducted by Istituto Superiore di Sanità (ISS), the Italian National Institute of Health, within the EU project HELLODOC. The activity aimed at training professionals to effectively manage the tele-rehabilitation service. ISS adapted the Moodle e-learning platform and implemented the problem-based learning (PBL) methodology. One clinical and one technical module were prepared by using traditional learning sources as well as interactive tools. Each module included 4 units; each unit was based on a 5-days cycle. The courses remained open from January to October 2006. Fifty percent of the registered students attended the courses. Traditional and interactive learning resources were equally used. Overall feedback was positive, unless for the amount of time requested for the study and the lack of an official certificate of attendance. Both modules are now in the process of being revised, improved and generalised, in order to be integrated into the ISS Rehabilitation website.

Objective: To determine whether the amyotrophic lateral sclerosis functional rating scale (ALSFRS), which is a validated instrument that assesses the functional status and the disease progression in patients with amyotrophic lateral sclerosis (ALS), predicts hospital length of stay and survival time in ALS patients treated with tracheostomy-intermittent positive-pressure ventilation (TIPPV)., Methods: Thirty-three consecutive ALS patients with acute respiratory failure who received therapy with TIPPV were prospectively followed up from their admission to the hospital until death. The association of ALSFRS score at hospital admission with length of hospital stay and survival after TIPPV were examined using Cox proportional hazard models, adjusting for age at baseline, sex, and symptom duration., Results: The median ALSFRS score of the ALS patients at hospital admission was 11 (range, 4 to 22). The median length of hospital stay was 55 days (range, 7 to 124 days), with a hospital mortality rate of 9%. For the 30 patients (91%) discharged from the hospital, the median survival time was 37 months (range, 2 to 64 months). The total ALSFRS score (above or below the median score) was a significant predictor of length of hospital stay (hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.2 to 6.5; p = 0.003) and survival after TIPPV (HR, 3.76; 95% CI, 1.4 to 9.7; p = 0.002). The total ALSFRS score at hospital admission was also associated with length of hospital stay (HR, 2.1; 95% CI, 1.1 to 5.1; p = 0.005) and survival (HR, 0.52; 95% CI, 0.1 to 0.8; p = 0.002) when included in a Cox multivariable model together with the other demographic and clinical variables., Conclusion: In ALS patients with acute respiratory failure who have been treated with TIPPV, the total ALSFRS score may predict length of hospital stay and long-term survival after invasive mechanical ventilation.

Early prediction of respiratory muscle involvement and chronic hypoventilation (CH) in amyotrophic lateral sclerosis (ALS) patients can help to plan mechanical ventilatory aids and palliative care interventions well before respiratory failure occurs. To describe the natural history of the progressive pulmonary dysfunction leading to CH, and to identify potential parameters associated with its development in ALS, we prospectively followed 38 ALS patients up to 26 months, starting from their first presentation at our Clinic. At study entry, median FVC was 87% (interquartile range: 72-104%) and declined by 10% after 6 months (range: 2-49%), showing a very high inter-patient variability. Over the 26-months follow-up, 19 patients (50%) presented CH in the first 12 months, and eight patients (21%) developed CH in the remaining 14 months of the study. The remaining 29% of patients did not show signs of CH during the whole period of observation. In the Cox model, the category of disease progression (rapid vs. intermediate and slow), assessed using the Appel ALS Rating Scale (AARS) in the first 3 months after presentation, was the only variable associated with a significantly increased likelihood of CH. We conclude that CH can occur within 1 year from presentation in a great proportion of patients, independently from their initial respiratory status. Including the patients in specific categories of early disease progression, as assessed with the AARS, could be a sensitive method to identify patients with different risk of developing CH, and may help physicians to more efficiently plan the frequencies of respiratory evaluations, initiate mechanical ventilation and discuss advance directives with the patients and their caregivers.

Within the European Union the use of anabolic steroids for promoting growth and improving meat-to-fat ratio in food-producing animals has been banned since 1988. For the unequivocal identification of hormone residues in a complex matrix such as meat we have developed a rapid, specific and sensitive liquid chromatography/tandem mass spectrometry (LC/MS/MS) method, in combination with a simple extraction procedure based on the matrix solid-phase dispersion (MSPD). The performances of a triple quadrupole (QqQ) and a quadrupole/time-of-flight (QqTOF) were compared: the QqQ mass spectrometer was found to be more sensitive for almost all studied analytes, but the selectivity was superior using the QqTOF system; the full-scan spectra (acquired without losing sensitivity), mass accuracy and resolution of the hybrid instrument enabled a more probatory analyte identification than that obtained selecting two multiple-reaction monitoring (MRM) transitions with a QqQ. Average recoveries ranged from 80 to 100%, and the detection capabilities (CCbetas) were less than 1.06 ppb with the QqQ instrument and less than 5.20 ppb with the QqTOF instrument for the bovine meat, which proved to be the most complex matrix., (Copyright (c) 2006 John Wiley & Sons, Ltd.)

Knowing the likelihood of failure of noninvasive positive pressure ventilation (NPPV) in patients with exacerbation of chronic obstructive pulmonary disease (COPD) could indicate the best choice between NPPV and endotracheal intubation instituted earlier. For this purpose, two risk charts were designed (at admission and after 2 h of NPPV) that included all relevant measurable clinical prognostic indicators derived from a population representing the patients seen routinely in clinical practice. Risk stratification of NPPV failure was assessed in 1,033 consecutive patients admitted to experienced hospital units, including two intensive care units, six respiratory intermediate care units, and five general wards. NPPV was successful in 797 patients. Patients with a Glasgow Coma Score <11, acute physiology and chronic health evaluation (APACHE) II > or =29, respiratory rate > or =30 breaths x min(-1) and pH at admission <7.25 have a predicted risk of failure >70%. A pH <7.25 after 2 h greatly increases the risk (>90%). The risk charts were validated on an independent group of 145 consecutive COPD patients treated with NPPV due to an acute ventilatory failure episode. To identify patients with a probability of failure >50%, the sensitivity and specificity were 33% and 96.7% on admission and 52.9% and 94.1% after 2 h of NPPV, respectively. The prediction chart, based on data from the current study, can function as a simple tool to predict the risk of failure of noninvasive positive pressure ventilation and thus improve clinical management of patients tailoring medical intervention.

This paper describes a new method for the rapid extraction and unequivocal confirmation of 13 sulfonamides (SAs) in raw meat and infant foods. The highly automated extraction procedure is based on accelerated solvent extraction followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) as a confirmatory analysis. After 1 g of food matrix was blended with 2 g of C18 as a solid support material, the mixture was packed into the extraction cell and the SAs were extracted with 10 mL of hot water at 160 degrees C and 100 atm; 100 microL of the extract was directly injected into the LC-MS system. The analytes were ionized in an electrospray interface operating in the positive ion mode and were identified by selecting two multireaction monitoring transitions, which guaranteed method specificity. Typical recoveries from crude meat and baby food samples ranged from 70 to 101% at a fortification level of 100 ppb, corresponding to the maximum residue limits established by the European Union and the U.S. Food and Drug Administration. The interday method precision was less than 8.5%, and the limits of detection were below 2.6 ppb. This study has taken matrix-induced suppression of ionization into account, by comparing standard and matrix-matched calibration curves. Four of the 13 monitored SAs have been detected in some baby foods and raw meat samples, bought from Roman supermarkets and butchers' shops, using the described methodology., (Copyright 2004 American Chemical Society)

A simple and rapid method using reversed-phase liquid chromatography/tandem mass spectrometry (LC/MS/MS) for the simultaneous determination of the urinary metabolites of benzene, toluene, xylene and styrene in human urine specimens and standard solutions is described. A hybrid quadrupole/time-of-flight (QqTOF) mass spectrometer was compared for the determination of metabolite of aromatic solvents in urine samples. The metabolites selected were: trans,trans-muconic acid, hippuric acid, o-, m- and p-methylhippuric acid and phenylglyoxylic acid. The compounds were well separated from each other on narrow-bore 1-mm i.d. reversed-phase LC C-18 columns. Average recoveries for loading 100 microL of urine samples varied from 88-110% and the quantification limits were less than 30 ng/mL for each analyte (3 ng/mL for trans,trans-muconic acid). The qualitative information obtained (mass accuracy, resolution and full-scan spectra) with the QqTOF mass spectrometer allows a secure identification of analytes in biological matrices., (Copyright 2004 John Wiley & Sons, Ltd.)

This paper describes a rapid extraction method, based on a matrix solid-phase dispersion technique using diatomaceous earth as solid support and 50:50 (v/v) chloroform/methanol as extracting solvent, that can determine 11 free fatty acids in chocolate. The extraction procedure is followed by reversed-phase liquid chromatography/tandem mass spectrometry (LC/MS/MS) using a normal-bore (4.6 mm i.d.) C-18 column and an electrospray interface operating in the negative ion mode. The tandem mass spectra of selected compounds show that charge-remote fragmentation (CRF) mechanisms are occurring; the intensities of the CRF reactions increase with the carbon number and degree of unsaturation of the fatty acids. Average recoveries, evaluated by the standard addition method, vary between 79-103%, and the estimated quantification limits are less than 153 ng/g. The proposed method has been used to analyse nine chocolate samples from various price ranges, bought from supermarkets., (Copyright 2004 John Wiley & Sons, Ltd.)

A triple-quadrupole instrument and a hybrid quadrupole/time-of-flight (TOF) mass spectrometer were compared for the determination of pharmaceutical compounds in water samples. The drugs investigated were the analgesics Ibuprofen, Fenoprofen, Ketoprofen, Naproxen, and Diclofenac. The recently introduced Q2-pulsing function, which enhances the transmission of fragment ions of a selected m/z window from the collision cell into the TOF analyzer, improved the sensitivity of product ion scans on the quadrupole/TOF instrument. The selectivity is much better on quadrupole/TOF systems than on triple quadrupoles because the high resolving power of the reflectron-TOF mass analyzer permits high-accuracy fragment ion selection. This minimizes interferences from environmental matrices and allows acquisition of full spectra for selected analytes with better signal-to-noise characteristics than comparable spectra obtained with a scanned quadrupole. The qualitative information obtained (mass accuracy, resolution and full-scan spectra) by hybrid quadrupole/TOF mass spectrometry allows a more certain identification of analytes in environmental matrices at trace levels. Sample enrichment of water samples was achieved by a solid-phase extraction procedure. Average recoveries for loading 1 L of samples varied from 88 to 110%, and the quantification limits were less than 1.2 ng/L for the triple-quadrupole instrument (in MRM mode) and less than 3 ng/L for the quadrupole/TOF instrument., (Copyright 2003 John Wiley & Sons, Ltd.)

A multiresidue method was developed and validated for the determination of pesticide residues (omethoate, dimethoate, carbendazim, propoxur, thiabendazole, carbaryl, pirimicarb, azinphos-methyl, methidathion, and iprodione) in fruit juices. The samples were extracted by matrix solid-phase dispersion with diatomaceous earth and analyzed by liquid chromatography/tandem mass spectrometry. The method detection limits were <0.2 ppb for all pesticides; the relative standard deviations for analyses of samples fortified over the range of 2-50 ng/g were <9%, and the recoveries for each pesticide were all between 77 and 102%. The proposed method was used to analyze 21 commercial fruit juices; pesticide residues were found in 71% of the samples.

An evaluation was made of the feasibility of using reversed-phase liquid chromatography/tandem mass spectrometry with an electrospray interface (LC/ESI-MS/MS) to measure traces of phenoxyacid herbicides and their metabolites in surface and drinking water samples. The procedure involved passing 0.5 L of river and drinking water samples through a 0.5 g graphitized carbon black (GCB) extraction cartridge. Recovery was higher than 85% irrespective of the aqueous matrix in which the analytes were dissolved. A conventional 4.6-mm i.d. reversed-phase LC C-18 column operating with a mobile phase flow rate of 1 mL/min was used to chromatograph the analytes. A flow of 200 microL/min of the column effluent was diverted to the ESI source. The limits of detection (signal-to-noise ratio = 3) of the method for the pesticides considered in drinking and surface water samples are less than 0.1 ng/L for phenoxyacid herbicides, and about 5-10 ng/L for their metabolites (2,4-dichlorophenol and 4-chloro-2-methylphenol)., (Copyright 2001 John Wiley & Sons, Ltd.)

Study Objectives: Evaluation of the effectiveness of negative-pressure ventilation (NPV) with the use of the iron lung vs noninvasive positive-pressure ventilation (NIPPV) in the treatment of COPD patients with acute on chronic respiratory failure., Design: A retrospective case-control study., Setting: Four Italian respiratory intermediate ICUs., Patients: Of a total of 393 COPD patients admitted to the ICU in 1996, 53 pairs were treated with the iron lung (NPV group). Patients treated with NIPPV (NIPPV group) were matched according to mean (+/- SD) age (70.3 +/- 7.1 vs 70.3 +/- 6.9 years, respectively), sex, causes of acute respiratory failure (ARF), APACHE (acute physiology and chronic health evaluation) II score (22.4 +/- 5.3 vs 22.1 +/- 4.6, respectively), pH (7.26 +/- 0.05 vs 7.27 +/- 0.04, respectively), and PaCO(2) (88.1 +/- 11.5 vs 85.1 +/- 13.5 mm Hg, respectively) on admission to the ICU. The effectiveness of matching was 98.4%., Results: Five patients from the NPV group (9.4%) and seven patients from the NIPPV group (13.2%) needed endotracheal intubation (EI). The treatment failure rate (ie, death and/or need of EI) was 20.7% in the NPV group and 24.5% in the NIPPV group (difference was not significant). The mean duration of mechanical ventilation (29.6 +/- 28.6 vs 62.3 +/- 35.7 h, respectively) and length of hospital stay (10.4 +/- 4.3 vs 15 +/- 5.2 d, respectively) among the 35 concordant surviving pairs were significantly lower in the NPV group than in the NIPPV group (p = 0.001 and p = 0.001, respectively)., Conclusions: These data suggest that both ventilatory techniques are equally effective in avoiding EI and death in COPD patients with ARF. Prospective trials are needed to confirm these preliminary results.

A simple method is described for the simultaneous determination of residues of 2 carbamate herbicides (phenmedipham and desmedipham) and related metabolites (m-aminophenol, aniline, and m-toluidine) in soil. The analytes are extracted from spiked soils with methanol. The solvent/soil suspension is centrifuged, and the supernatant is directly injected, without any further cleanup, into a reversed-phase liquid chromatography/mass spectrometry apparatus equipped with a TurbolonSpray interface. The method was tested on 5 soils having different physicochemical properties. Recoveries from the soil types, spiked over the range of 50-200 ppb, were essentially quantitative for each analyte. The detection limits of the method are < or = 25 ng/g.

Chemosensory proteins (CSPs) are a class of small, soluble proteins present at high concentrations in chemosensory organs of different insect species. Several pieces of evidence suggest their involvement in carrying chemical messages from the environment to chemosensory receptors. However, a structural description of the mechanism of delivery has not been reported. In order to provide the first detailed conformational characterization of these molecules, we cloned a specific isoform (CSP-sg4) from Schistocerca gregaria and expressed it in Escherichia coli. The product was obtained with yields of more than 20 mg per L of culture, all in its soluble form. The recombinant protein was identical to the native one with respect to pairing of the disulfide bridges, aggregative state and secondary structure elements. Structural investigations revealed a significantly stable polypeptide with respect to variations in temperature and acidity. CD analysis, preliminary NMR data and secondary structure prediction pointed to a correctly folded structure where helical regions and loops are alternated in a similar fashion as that observed for other classes of odorant- and pheromone-binding proteins presenting no sequence similarity to CSPs.

This paper addresses the development of an apparatus designed to evaluate clinically the presence of spasticity affecting the elbow. The biomechanical contributions due to the lever-arm muscles and to the gravity force are accounted for using software algorithms that express gravity force and lever arm as functions of the elbow angle and are able to provide information on the force exerted by the muscles at a known speed. The preliminary data indicate that the device can be applied easily in the clinical setting. Further studies are required to demonstrate conclusively the validity and reliability of this device in quantifying spasticity at the elbow.

A sensitive and specific analytical procedure for determining arylphenoxypropionic herbicides in soil samples, using Ionspray ionization (ISI) liquid chromatography/mass spectrometry (LC/MS), is presented. Arylphenoxypropionic acids are a new class of herbicides used for selective removal of most grass species from any non-grass crop, commercialized as herbicide esters. Previous studies have shown that the esters undergo fast hydrolysis in the presence of vegetable tissues and soil bacteria, yelding the corresponding free acid. The feasibility of rapidly extracting arylphenoxypropionic herbicides from soil by accelerated solvent extraction (ASE) techniques was evaluated. Four different soil samples were fortified with target compounds at levels of 5 and 20 ng/g by following a procedure able to mimic weathered soils. Herbicides were extracted by a methanol/water (80:20 v/v) solution (0.12 M) of NaCl at 90 degrees C. After clean-up using graphitized carbon black (GCB) as absorbent, the extract was analyzed by HPLC/ISI-MS. The effect of concentration of acid in the mobile phase on the response of ISI-MS was investigated. The effects of varying the orifice plate voltage on the production of diagnostic fragment ions, and on the response of the MS detector, were also investigated. The ISI-MS response was linearly related to the amounts of analytes injected between 1 and 200 ng. The limit of detection (signal-to-noise ratio = 3) of the method for the pesticides in soil samples was estimated to be less than 1 ng/g.

We evaluated the feasibility of extracting selectively and rapidly herbicide residues in soils by hot water and collecting analytes with a Carbograph 4 solid-phase extraction (SPE) cartridge set on-line with the extraction cell. Phenoxy acid herbicides and those nonacidic and acidic herbicides which are often used in combination with phenoxy acids were selected for this study. Five different soil samples were fortified with target compounds at levels of 100 and 10 ng/g (30 ng/g of clopyralid and picloram) by following a procedure able to mimic weathered soils. Herbicides were extracted with water at 90 °C and collected on-line by the SPE cartridge. After the cartridge was disconnected from the extraction apparatus, analytes were recovered by stepwise elution to separate nonacidic herbicides from acidic ones. The two final extracts were analyzed by liquid chromatography/mass spectrometry with an electrospray ion source. At the lowest spike level considered, analyte recoveries ranged between 81 and 93%, except those for 2,4-DB and MCPB, which were 63%. For 16 herbicides out of 18, the ANOVA test showed recoveries were not dependent on the type of soil. The method detection limit was in the 1.7-10 ng/g range. For the analytes considered, method comparison showed this extraction method was overall more efficient than Soxhlet and sonication extraction techniques.

An odorant-binding protein, migrating in SDS-PAGE with an apparent molecular weight of 22 kDa and an isoelectric point of 4.2, has been purified from pig nasal mucosa. Its complete amino acid sequence was determined by a combination of mass spectrometry and Edman degradation procedures. The protein consists of a single polypeptide chain of 157 amino acids, presenting at the N-terminus a pyroglutamic acid residue. The two cysteine residues, occurring in the primary structure at positions 63 and 155, are involved in an intramolecular disulphide bridge. Sequence comparison with other lipocalins revealed a good similarity with bovine odorant-binding protein, the only member of this class which does not contain disulphide bonds and of which the three-dimensional structure recently has been resolved. Nine out of the 1 6 residues lining the binding pocket in bovine OBP are conserved in the porcine protein, suggesting structural similarities in this region of the molecule. The synthesis of a fluorescent photoaffinity labelling agent and of two tin-containing thymol analogues is also described. These compounds together with other ligands were able to bind the protein as revealed by competitive binding experiments.