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Reuse of wastewater to irrigate food crops is being practiced in many parts of the world and is becoming more commonplace as the competition for, and stresses on, freshwater resources intensify. But there are risks associated with wastewater irrigation, including the possibility of transmission of pathogens causing infectious disease, to both workers in the field and to consumers buying and eating produce irrigated with wastewater. To manage these risks appropriately we need objective and quantitative estimates of them. This is typically achieved through one of two modelling approaches: deterministic or stochastic. Each parameter in a deterministic model is represented by a single value, whereas in stochastic models probability functions are used. Stochastic models are theoretically superior because they account for variability and uncertainty, but they are computationally demanding and not readily accessible to water resource and public health managers. We constructed models to estimate risk of enteric virus infection arising from the consumption of wastewater-irrigated horticultural crops (broccoli, cucumber and lettuce), and compared the resultant levels of risk between the deterministic and stochastic approaches. Several scenarios were tested for each crop, accounting for different concentrations of enteric viruses and different lengths of environmental exposure (i.e. the time between the last irrigation event and harvest, when the viruses are liable to decay or inactivation). In most situations modelled the two approaches yielded similar estimates of risk (within 1 order-of-magnitude). The two methods diverged most markedly, up to around 2 orders-of-magnitude, when there was large uncertainty associated with the estimate of virus concentration and the exposure period was short (1 day). Therefore, in some circumstances deterministic modelling may offer water resource managers a pragmatic alternative to stochastic modelling, but its usefulness as a surrogate will depend upon the level of uncertainty in the model parameters.

This study presents an environmental-friendly and cost effective method for the extraction of arsenic from contaminated soils. Laboratory experiments using inorganic salts, potassium phosphate (KH2PO4), potassium chloride (KCl), potassium nitrate (KNO3), potassium sulfate (K2SO4), and sodium perchlorate (NaClO4) were evaluated as arsenic extractants. An Andosol soil was artificially contaminated with arsenite [As(III)] and arsenate [As(V)]. The soil was washed in a batch process with different salt solutions in the pH range 3-11 for 24 hours at 20 degrees C. Among the various potassium and sodium salts tested, KH2PO4 was found to be highly effective in extracting arsenic from As(III)-soil attaining more than 80% and 40% from As(V)-soil in neutral pH range. Other salts were particularly ineffective in extraction of arsenic from both soils. More arsenic was extracted more from the As(III)-soil than the As(V)-soil.

The biliodigestive fistula is not a rare affection in the context of acute pathology of the gastrointestinal tract. It often affects patients between 63 and 85 years old , particularly the female sex, and the most common cause is acute or chronic cholecystolithiasis. Open issues are the delayed in the pre-operative diagnosis, and controversies exist regarding the best surgical approach. The choice of treatment options is influenced by the age of the patients and their clinical conditions and also by the presence of comorbidities and of a delayed right diagnosis. In the 1 to 3% of cases, the biliodigestive fistula presents a gallstone ileus as complication, whose diagnosis is particularly difficult for the lack of specific signs and symptoms. The contrast-enhanced CT is considered the gold standard for a specific pre-operative diagnosis, as it directly shows the fistula. Surgical treatments include one-stage procedure or two-stage procedure. Many studies seem to favor a deferred definitive procedure. The Authors describe 4 cases: in 3 cases, women between 70 and 80 years old presenting an history of recurrent cholecystitis, in 2 cases, and in 1 case presenting a bowel obstruction; in 1 case a 50-years-old man, with no significant past medical history, presenting a bowel obstruction. The Authors have performed in the 2 cases of gallstone ileus an enterolithotomy with cholecysto-duodenal fistula repair and cholecystectomy, in one-stage, and this has been possible because of the good clinical conditions of the patients and their low operative risk. In the case of fistula without the complication of gallstone ileus, the treatment approach has been cholecysto-gastric fistula closure with a gastroplastic using separate stitches and cholecystectomy, in one-stage. We are in agreement with data in the literature regarding the delay into the diagnosis of biliodigestive fistula and with the importance to suspect it or gallstone ileus presence, although the clinical presentation is extremely non-specific. In our experience, cholangiopancreatography-CT and CECT have made easier the pre-operative diagnosis and so reducing the delay of the treatment.

The mortality rate due to road traffic accidents is 11.3 deaths per 100,000 inhabitants during 1994 in the area; morbidity incidence (per 100,000 inhabitants) we estimate to be 1,170 arrivals to first-aid centers and 263 hospitalizations during 1997. The cases at General Hospital "Umberto I" during 1997 represent about one-third of the whole area. In severe cases (ISS > 16) 15-29 year-old males account for modal value; women are concentrated at elder age, and males represent 72% of the total number. Vehicle type and sex are determinants of the risk of severe trauma. There is a strong linear relationship between age, severity, and lethality rate (R 2 = 0.88), but severity is the variable that plays the major role on lethality. These variables (age, severity, and lethality rate) are crucial to define death risk. Most deaths occur within the early 24 hours of hospitalization. Lethality reflects a system failure phenomenon with critical points at 24 hours and after 7 days since the accident.

Several studies have demonstrated the clinical and technical benefits of the laparoscopic surgery for complicated and uncomplicated appendicitis. Our retrospective study included 12 patient who underwent SILS appendectomy (SILS-A), 14 who received conventional laparoscopic surgery (VL-A), and 12 who received laparotomic appendectomy (OA); performed in all cases by the same surgeon (C.F.). The aim of this study was the comparison between this three different surgical techniques on same features: post operative leukocytosis, post operative pain, need abdominal drainage, esthetic viewpoint, incidence of complication, hospital stay. The results showed no significant differences between SILS-A and VLS-A, while an evident improvement shows versus O-A, even though not statistically significative. SILS was more effective in decreasing the risk of postoperative wound infection.

Cardiac resynchronization therapy (CRT) can be considered as an established therapy for patients with moderate or severe heart failure (HF), depressed systolic function and a wide QRS complex. Biventricular stimulation through the CRT is applied at patients with an intra and/or inter-ventricular conduction delay. The goal of this technique is to resynchronize contraction between and within ventricles. A numerical model of the cardiovascular system, together with the numerical model of the biventricular pacemaker (BPM), can be an useful tool to study the better synchronization of the BPM in order to reduce the inter-ventricular and/or intra-ventricular conduction delay.Within a group of patients which were representative of the most common disease etiologies of heart failure, seven patients, affected by dilated cardiomyopathy undergoing CRT with BPM, were studied and simulated using the numerical model of the cardiovascular system CARDIOSIM. The patients were submitted to echocardiographic evaluation (with pulsate Doppler and tissue Doppler imaging) and electrocardiography evaluation in order to evaluate intra-ventricular and/or inter-ventricular dyssynchrony. These evaluations were made three times: the first one before BPM implantation, the second and the third one respectively within seven days and six months after BPM implantation. Also haemodynamic parameters were measured. Using the software simulator, the pathological conditions before CRT, within seven days and within six months since CRT were reproduced for each patients in order to evaluate the following haemodynamic parameters: the end-systolic and end-diastolic left ventricular volume, the systolic pulmonary arterial pressure, the systolic, diastolic and mean aortic blood pressure and the ejection fraction. Also the trend of the left ventricular elastance was studied for each patient in order to evaluate the benefits produced by the CRT.The results obtained by means the numerical simulator were in good agreement with clinical data measured on the patients. For each patient also the evolution of the left ventricular elastance was in accordance with the literature data.The cardiovascular numerical model seems to be a useful tool to study the synchronization of the BPM in order to reduce the inter-ventricular and/or intra-ventricular conduction delay and to reproduce the condition of a patient.

Abdominal blunt trauma is the main cause of death in people younger than 40 years old. The liver injury still represents a challenging problem. Isolated hepatic injury is rare and it occurs more frequentely in polytraumatizated patients and causes massive haemoperitoneum. The Authors report a case of a 83 years-old woman admitted to Emergency Department for syncope due to an active bleeding arising from a rupture of a right hepatic lobe unsuspected tumor. The computer tomography (CT) scans showed a clear pattern of liver laceration of the VI segment with contrast enhancement spreading in the surrounding tissues, and detected a multifocal hepatocarcinoma located in the VI, VII and VIII segments. Patient's haemodinamically unstable conditions suggested an urgent laparotomy. An accurate perihepatic packing with sterile-drape were successfully employed to control liver hemorrage. Temporary abdominal closure, followed by hepatic arteriography and the right hepatic artery embolization, completed the damage control. Re-exploration laparotomy after 72 hours confirmed the definitive haemostasis and the pack removal was performed without complications.CT plays a leading role in the diagnosis of liver damage. The patient's haemodynamic status is the principal criterion determining conservative or operative therapy in blunt liver injury. The early perihepatic packing followed by artheriographic embolization to stop liver hemorrhage showed efficacy and safety for the patient. The packing performed with sterile-drape is able to avoid removal complications and 72 hours timing for the pack removal is effective to avoid re-bleeding.

Umbilical primary endometrioma is a rare extra-uterine localization of endometriosis with a documented neoplastic risk. It is often difficult to distinguish primary umbilical endometriosis from other benign and malignant tumors of the abdominal wall. The Authors report a case of umbilical endometriosis in a 36-year old female. Endometriosis was suspected because of the presence of the typical cyclic bleeding and swelling. Abdominal CT excluded the presence of other endometriotic localizations. The umbilical mass was widely excised together with umbilicus, fascia and peritoneum. The tissue defect was primary closed without prosthetic mesh. Histological examination of the specimen showed the presence of endometrial glands with stromal component, compatible with the diagnosis of endometriosis. The Authors suggest that surgery should be performed in the first 3-4 days of the follicular phase, to minimize the risk of diffusion of endometriotic cells. Moreover, the excision should be wide in order to prevent local recurrence.

This study was undertaken to compare the efficacy, side effects and patient acceptance of standard 4-liters polyethylene glycol (PEG) and 2 doses of sodium phosphate (NaP) solution for precolonoscopy colon cleansing.A total of 182 patients were randomized to receive either standard 4-L PEG (88 patients) or 80 mL of NaP (94 patients) in a split regimen of two 40 mL doses separated by 24 h, prior to colonoscopic evaluation. The primary endpoint was the segmental assessment of colonic wall visualization. Secondary outcomes included percent of assumed preparation, and the patient tolerance and acceptability.A significantly higher completion rate was found in the NaP group compared to the PEG group (84.3% vs 62.9%; difference, 21.40%; 95% confidence interval [CI], 8.29% to 34.51%; p = 0.001). PEG solution caused more nausea than NaP solution (p = 0.024). Patient acceptance for bowel preparation with NaP was greater (p = 0.019). Adequate colon wall visualization was achieved in similar proportion of patients in both groups with exception of the descending colon, where NaP regimen was superior (72.0% vs 52.9%; difference, 19.10%; 95% CI, 5.20% to 33.00% ; p = 0.012).Two doses of NaP solution, taken 24 h and 12 h before colonoscopy, tend to guarantee superior results in colonic cleansing with respect to standard 4-liters PEG solution. Taking the second dose of NaP 24 h after the first dose reduces side effects and allows achieving a more satisfactory compliance of the patient.

Hepatocellular carcinoma (HCC) is the most common malignancy of the liver and the third most common cause of cancer mortality worldwide. The major risk of developing HCC is associated with HBV and HCV hepatitis. Liver transplant (LT) is the gold standard for "small" HCC (HCCs) in Child-Pugh class A cirrhotic patients. However its use has been restricted by the severe shortage of donors, so that hepatic resection (HR) is often performed in these patients. In the last two decades image-guided interventional catheterization and ablative regional treatment procedures have revolutionized the therapy of unresectable primary and secondary liver tumors. The Authors present a case of a 61-years old man with Child-Pugh class A HCCs. The age and the previous history of bladder carcinoma made the patient not suitable for LT. The patient refused HR so that transarterial chemoembolization combined to thermo-ablation therapy and oral intake of tamoxifen were proposed. Patient's tolerance to the treatments has been good. During 11-year follow-up there was earlier intrahepatic progression of the tumor followed by reduction in size and number of the lesions. In spite of the scarce prognosis, chemoembolization and immunotherapy allowed to achieve a satisfactory local control of disease in our patient and guaranteed a good quality of life at long-term follow-up.

The Authors report a rare case of a 57 years old man affected by a left radial nerve schwannoma that occurred as an asymptomatic lesion of the axilla. At clinical examination the lump was undistinguishable from the most common axillary lymphadenopathy. A lymphoadenopathy was erroneously diagnosed with ultrasonography (US). This mistake was due to the low specificity of the instrumental methodology and to the rarity of an asymptomatic schwannoma of the infraclavicular brachial plexus. The neoplasia was excised without using the microscope. In the early post-operative follow up, a "falling" attitude of the wrist, the hand and the fingers appeared, peculiar for a lesion of the radial nerve. Furthermore a hypoaesthesia of the skin of first finger and of the first interosseus space was associated. The sensitive and motor electromyography showed a radial nerve suffering. The "stupor" of the nerve trunk was treated with steroid therapy for 7 days and the patient underwent to some series of neuro-rehabilitative physical therapy for 12 weeks. The postoperative total body CT, showed that the lesion was unique: therefore it was possible to exclude the diagnosis of neurofibromatosis. After 28 months electromyography and axillary US were performed showing the complete resolution of the motor and sensitive deficit and the absence of local recurrence.

Diverticular disease is very frequent in Western countries; in 5% of the cases it is the cause of serious bleeding, haemodynamic instability and death. The authors report a case of 74 years old patient with severe lower gastrointestinal bleeding. She was in antiplatelet treatment with acetylsalicylic acid (100 mg/die) and clopidogrel (75 mg/die) for preventing the restenosis of medicated stents positioned to treat an acute coronary syndrome. At the same time the patient was under treatment for primary hypercholesterolemia with rosuvastatin (20 mg/die). The severe haemorrhage demanded haemodynamic stabilization, achieved by colloid infusion and blood transfusions. The bleeding continued; selective arteriography showed it's origin from the areas of the sigmoid and superior hemorrhoidal arteries. During the procedure, embolization of the inferior mesenteric artery using spiral type BALT was performed, with consequent bleeding interruption. Fifteen days after the embolization, a rectosigmoid colonoscopy showed a sigmoid diverticular disease. The treatment with acetylsalicylic acid and clopidogrel has surely contributed to the severity of the hemorrhage. Recent experimental and clinical evidence suggests a possible antiplatelet effect of the statins.

The management of traumatic retroperitoneal haematomas is still a much debated question. Although the diagnosis has become easier using CT with contrast medium, the therapeutic decisions are still difficult because of the great variability of the lesions, which may be simple but very often complicated. Our study is based on 1086 treated patients, 29.5% of the 3682 critical abdominal polytrauma seen in 35 years. Mortality has been 12.9% with a medium ISS (Injury Severity Score) of 23.4. 71.4% of the cases were closed traumas, 28,6% were open traumas. The most common single lesions have been pelvic (43%), followed by the renal traumas (39%). Regarding the associated lesions, the thoracic traumas cause an increment of the ISS score up to 26.2% and of mortality up to 14.6%. The maxillofacial traumas associated with traumatic retroperitoneal haematomas represent 11%, mainly associated with motorcycle accidents, which have increased in the last years from 2,4% in the 70s to 32% these days. Our approach to these patients has been basically conservative. Following the indications obtained by the CT, we widely used interventional angiography, especially for renal lesions and, after pelvic stabilization, for pelvic haematomas. We have chosen surgery considering the kind of traumas (open or closed), the location of the haematoma and especially, the clinical course of the patient's hemodynamic condition.

There have been millions of people found to have AIDS. Death rates from AIDS have declined 15% to 20% in the past 5 years. However, nearly 75000 people will die with AIDS in this year. Patients with AIDS are also at risk for developing both Aids-defining cancers, such as Kaposi's sarcoma and non-Hodgkin lymphoma, and non-Aids-defining cancers and opportunistic infections. In patients with advanced Aids, the Cytomegalovirus is a frequent cause of chorioretinitis, pneumonitis, chronic perineal ulcerations and oesophagitis. It has been involved in endocrine, bone marrow, central nervous system and kidney abnormalities. CMV infection of the small bowel accounts for only 4.3% of all cytomegalovirus infection of the GI tract (large bowel 47%, duodenum 21,7%, stomach 17,4%); isolated cases of small bowel perforation due to CMV have been reported in AIDS patients, and all but one patient died. The Authors report a rare case of an HIV-positive young man with gastroenteric Cytomegalovirus infection responsible for generalized peritonitis from multiple perforations.

Authors report their initial experience in surgical treatment of thyroid diseases in an area with high percentage of thyroid tumors. Since January 2006, we examinated 428 patients. By clinical features, hormonal profile, imaging and US-guided FNAB, we selected 134 of them for surgery; 93 patients underwent thyroidectomy in January-November 2006. The Authors analyse therapeutic choises and surgical techniques, stressing the high percentage of thyroid neoplasms.

The femoral hernia can be defined as infrequent, and predominantly found in females, with the highest incidence between 30 and 40 years of age. It shows a high tendency to strangulation, also up to 40% of cases, due to the presence of the Gimbernat ligament, which with its tense fibrous margins, aids strangling known as "raised crest". The diagnosis may not be easy, overall in the clinical presence of acute abdomen in elderly patients, disabled people or people who are uncooperative during physical examination. Therefore, it should be sought with an adequate bilateral exploration of the region in all occlused patients and especially with the use of radiological images of the small intestine. The solution currently practiced is prosthetic, proposed by Lichtenstein, and variously modified by Gilbert, Rutkow, Bendavid, and other which uses a prolene plug in the shape of a cigar, umbrella, or basket, according to the size and characteristics of the parietal defect. In emergency conditions, the technique doesn?t change; but if there is stercorary contamination, it is advisable to use direct repair according to the old method of Bassini. In the last 10 years, we have treated 37 femoral hernias in emergency, using direct repair in only 2 cases. In 3 cases we used PTFE; in the other 32 cases prolene was always used; 20 patients were operated under local anesthetic, 12 under general anesthetic and 5 under peridural anesthetic. Satisfactory results were achieved, with average hospital recovery time of 1.4 days, with an early recovery between 3 and 5 days, with only 2 relapses.

We present a case of sigmoid colon injury after blunt abdominal trauma. The patient was submitted to sigmoid resection with primary end-to-end colo-colic anastomosis. He died 22 days after operation with septic shock and acute respiratory failure. Post-mortem examination showed left lung generalized pneumonia with no signs of intra-abdominal pathology; colo-colic anastomosis was intact. We reviewed the literature about the management of this rare trauma.

The abdominal compartment syndrome is a high grade abdominal hypertension with clinical evidence of multiorgan failure (MOF). It is more and more frequently observed in intensive-care units as a complication in critical patients, but especially in traumatology and surgery. The incidence is highly variable according to the different trials but the severity of scores is the common factor. All the possible mechanical, haemorrhagical, inflammatory and traumatological causes act but do not enable the stability of the abdominal content, abdominal compliance and parietal tension. The initial triad of effects consists in diaphragm elevation and visceral and vascular compression and therefore triggers a physio-pathological way that leads to a respiratory, renal and cardiovascular dysfunction and to parietal, hepatic and intestinal ischaemia and consequent bacterial translocation: sepsis and MOF. Burch's classification (1996) reports four levels of gravity from low (15 mmHg) to severe (35 mmHg): both of the first grades should be managed in intensive-care units with conservative pharmacological procedures, while for the two others a surgical approach of laparotomy with drainage and temporaneous closure of the abdominal wall should be considered. As mortality is still very high (29-62%), especially when multiorgan failure is already set; bladder pressure of all critical patients should be monitorized to treat immediately any potential abdominal hypertension.

Diverticulitis of the right colon is a rare disease in the Western countries, so that the diagnosis still remains very difficult and frequently indistinguishable from acute appendicitis preoperatively. In presence of acute abdominal discomfort with pain referred to the right lower quadrant region, fever and hyperleukocytosis, nausea and vomiting, surgeons operate with a margin of uncertainty, because of the increased morbidity and mortality associated with delay in diagnosis and consequent perforation of acute appendicitis. Moreover the unexpected inflammatory colonic mass of uncertain etiology is sometimes mistaken for carcinoma at laparotomy and consequently a right hemicolectomy is performed. In these cases it should be better that right-sided colonic diverticulitis should be taken into account allowing a more correct surgical approach and even conservative treatment alone. Therefore, in case of suspected appendicitis, since our experience and literature data indicate that the mean age for right diverticulitis is over 40 years, also in presence of a significative Alvarado's score, computed tomography is strongly recommended, if the age is over 40 years.

The Authors studied 30 cases of diaphragmatic traumatisms from 1972 to 2003 to stress the difficulty to achieve an early diagnosis and the need of their immediate treatment: 26 of these patients were male and 4 female (6.5:1); the pathogenesis was in 50% of cases an open trauma and in 50% a closed trauma. The mean age was 36.6 years (33.4 in the open trauma and 41.4 in the closed). The left hemi-diaphragm was affected more frequently (63%) than the right (37%). The associated lesions were mainly of the parenchymatous abdominal organs (spleen 43.3% and liver 49%), while in the thorax lung was involved in 20% of cases and heart in 3.3%. All patients underwent plastic surgical intervention of the diaphragm. In only one case, particularly severe, the operation consisted in placing a pleuric drain and death occured a few hours later. Mean mortality was 30% (33.3% in open and 26.6% in closed traumas) and mean hospital stay was 36.2 days. Accurate diagnosis in emergency is difficult because of the frequent associated lesions, typical of these patients. Despite of the optimisation of the rescue and the new imaging technologies, the gold standard for treatment is not yet reached. There is still a considerable amount of misdiagnosis, a relevant mean hospitalization, a high mortality and a very high morbidity. The best approach to thoraco-abdominal traumas is still to fear a diaphragmatic lesion up to contrary demonstration, in order to achieve precocious diagnosis and surgical treatment, to avoid complications of delayed treatment.

Peritoneal papillary serous carcinoma (PPSC) is a rare tumour that involves the surface of the peritoneum, with prevalence in female patients and can originate from a single or multicentric focus is here described. A primary peritoneal serous carcinoma is here described. The patient has been treated with paclitaxel 175 mg/m2 and carboplatinum AUC 6.

Superior vena cava syndrome is due to an intrinsic or extrinsic caval obstruction that evolves in acute or subacute way with distinctive clinical feature such as respiratory symptoms and venous stasis. Since 1998 we have treated three cases of spontaneous superior vena cava thrombosis in neoplastic patients who underwent several infusion of chemotherapy, respectively for a breast, uterine and rectum cancer. All patients was female, 52, 58 and 70 years old. The first two cases was treated with locoregional thrombolysis by infusing Urokinase 50,000 UI/h during 24 hours and Urokinase 50,000 UI/h during 12 h the third one. After that, we have positioned a 16/9 wallstent: in the first two cases directly into the superior vena cava, in the third case in the subclavian-anonyma truncus. We had in all cases the complete opening of the stent within the first 48 hours without complications, enabling us to reach a free caval diameter of about 2 cm with resolution of the clinical signs. In patients with high surgical risk, the caval wall-stent is the first choice to solve the vein recanalization.

Small bowel tumours are relatively rare neoplasms; unusual occurrence associated with nonspecific symptoms, and low-sensitivity tests availability, are responsible for diagnostic delay. A retrospective study was performed on 42 cases with acute presentation, from 1972 to 2001; median age was 52 years (range 14-79) and there was a slight female prevalence (57.1% vs 42.9%). The most common acute presentation was occlusion (57.1%), followed by gastrointestinal (GI) bleeding (23.8%), perforation (14.3%) and occlusion/perforation (4.8%). Benign neoplasia were 38.1% (16 cases) and adenoma is was the most common type; malignant forms were 61.9 (26 cases) and adenocarcinoma and lymphomas were the most common histotype. Radical surgical procedures were possible only in 57% of malignant forms (24 patients); morbility was 4.8% (2 cases: 1 anastomotic dehiscence and 1 subphrenic abscess); mortality was 14.3%. From our retrospective study, we can state that survival for malignant lesions is strictly dependent of early TNM staging and possibility of radical surgical procedure. An extremely high index of suspicion in evaluating mild and often misleading symptoms, integrated with specific diagnostic studies, should be the proper approach. Prognosis for benign from is excellent in all cases.

Although endoscopic injection therapy is an effective method for bleeding peptic ulcers, it is associated with significant re-bleeding rate; whether the addition of thermal method improves the outcome is still unclear. Our previous experience showed that Argon Plasma Coagulation (APC) alone is not sufficient in stopping spurting haemorrhage, and potentially dangerous for large non bleeding visible vessels (NBVV). Our hypothesis was that combination of adrenaline injection (AI) and thermal therapy could be more efficient than thermal therapy alone for permanent haemostasis of active bleeding peptic ulcers, and particularly appropriate for NBVV treatment. From October 1998 to February 2000 we examined two hundred patients with upper gastrointestinal bleeding. Fifty-three patients with major peptic ulcer haemorrhages received combined injection therapy with adrenaline 1:10.000 and Argon plasma coagulation; there were 34 male and 19 female with a mean age of 63.2 +/- 1.2 years (range 22-93). The bleeding site was duodenal in 30 patients, gastric in 17 patients, anastomotic in 5 patients and esophageal in 1 patient. Endoscopic findings were the following: active bleeding in 23 patients (6 spurting, 17 oozing), non bleeding visible vessels in 12 patients and fresh adherent clots in 18 patients. Initial haemostasis was achieved in 52/53 patients (98.1%). Re-bleeding was observed in 5/52 cases (9.6%). Surgery was necessary in 3/53 patients (5.6%). Mortality was 7.5% (4 cases). No major complications resulted from this treatment. Primary adrenaline injection provided initial bleeding arrest, facilitating the following application of APC, because of a more precise definition of the active bleeding site. Rates of initial hemostasis were significantly higher with combined therapy (injection + APC) compared to APC treatment alone. We believe that Adrenaline and APC combined therapy is an effective and safe method for treatment of non-variceal gastrointestinal bleeding.

From June 1987 to April 2000, 167 (74%) of 223 patients suspected of swallowing foreign bodies were treated. Hundred-sixty-three were successfully treated endoscopically. The surgery rate was 2.4%. There was failure to remove a tablespoon, a tooth-brush, a dental prostheses with metallic hook, a knitting-needle. The sharp and pointed foreign bodies were 35 (20.9%). Endoscopic removal of sharp and pointed foreign bodies in the upper gastrointestinal tract can be very difficult to manage. The Authors report iatrogenic perforation of esophagus-gastric-fundus in a patient with hiatus hernia who ingested a big knitting-needle in order to suicide. They think that it is absolutely necessary to use special endoscopic equipment during the taking out of foreign-body procedure, especially when pointed and sharp-edge shaped bodies are involved and when there is high risk of iatrogenic lesions.

Merkel cell carcinoma is an unusual cutaneous malignancy with a propensity for spreading to regional lymph nodes, with recurrence at original site or/and in lymph node. Occurring most often on the head and neck of the elderly patients. Complete surgical resection is the mainstay of treatment of the primary tumor. A case is here described of an old patient with more than one local relapse and in regional lymph nodes too, complete surgical resected, actually in good state of health, treated with radiotherapy.

Abdominal packing and planned reoperation is a lifesaving technique for temporary control of haemorrhage in severely injured patients. Morbidity and mortality, however, remain significant. The purpose of this study is to evaluate all surgical technique and our results during 31 years of trauma surgery. In the last 12 years the Authors have performed 11 packing. They stressed fully "damage control technique" in trauma surgery in the last four years. Overall mortality was 45.5%.

The construction of evaporative ponds and wetlands for the disposal of waste water high in ionic concentrations is a waste disposal strategy currently considered by many industries. However, the design, construction and management of these ponds and wetlands are not straightforward as complex chemical interactions result in both spatial and temporal changes in water quality. The effects of evaporation and drainage on the water quality in two constructed ponds, an adjacent man-made wetland and local groundwater at Portland Aluminium were investigated. The minimum volume of water entering the ponds during the study period was 0.96 +/- 0.16 ML per month. The predicted theoretical evaporative capacity of the two ponds was calculated to be 0.30 +/- 0.07 ML per month. More water enters the ponds than it is theoretically possible to evaporate under the ambient weather conditions at Portland, yet the ponds do not overflow, suggesting percolation through the pond lining. No spatial differences in solute concentrations (fluoride, sulphate, bicarbonate, carbonate, sodium, potassium, calcium, and magnesium ions) were found within the waters of either pond, although temporal differences were apparent. The results support the conclusion that the ponds are not impermeable, and that much of the waste water entering the ponds is being lost through seepage. The impacts on local groundwater chemistry of this seepage are addressed. Significant correlations exist between solute presence within and between the ponds. wetland and groundwater. Fluoride and sulphate concentrations were significantly higher in pond waters throughout the duration of the experiment. Pond sediments revealed a high degree of spatial and temporal heterogeneity in the concentration of all monitored ions resulting from the chemical heterogeneity of the material making up the pond linings. Adsorption isotherms for fluoride indicate that the adsorption capacity of the pond linings remains high for this ion. Implications for the management of waste water by this strategy are discussed.

In a prospective study, the Authors present an analysis on the use of surgical adhesives in the wounds treatment. In sixteen months we have treated 157 patients exclusively with a surgical tissue adhesive 2-octylcianoacrylate to repair traumatic wounds and surgical ones. In the Emergency Department were treated 110 patients (70%) with 2-octylcianoacrylate for skin incisions, lacerations and the length of lesion. We have paid attention to prepare regular wound edges, irrigation and debridement when appropriate to reduce skin tension at the site of laceration. Forty-seven patients (30%) whit surgical skin incisions for thyroidectomy, appendicectomy, hernio-plastic and safenectomy were treated with 2-octyl-cianoacrylate. In both groups of patients, the surgical adhesive has made possible a simple and quick wounds repair as well as good aesthetic results. No relevant complications have been arisen. The writers recommend the surgical adhesive in Emergency Department to abridge waiting time and to avoid the psychological impact caused by local anaesthesia, suture and medications especially in the treatment of all wounds types in children.

In the last 30 years 1,484,576 patients with traumatic lesions of different kind of seriousness were observed and managed. By mean of retrospective investigation, the authors selected and statistically analysed a sample of 95 patients treated for accidental tracheobronchial foreign bodies inhalation: authors' aim was to punctually determinate--step by step--diagnosis and treatment procedure in a "time-saving" frame. Inhalation of foreign bodies is a very dangerous event, particularly in children. In authors' experience, in 60% of cases they were children under 3 years; in 25% of cases children under 10; in 10% patients from 10 to 60 and in 4.5% over 60. As regards the gender of the patients, the male/female ratio has been 2 to 1 in favour of male. Since 85% of the study population was represented by children under 10, its clear that male children in this range of age has a greater statistical risk for accidental tracheobronchial foreign bodies inhalation.

Deep vein thrombosis incidence is 1/1000 per year; it is associated with many risk factors which is considered as "thrombophilic states". Its pathogenesis is complex, caused by alterations of hemostasis system. Many studies have established the relation between cancer and subsequent venous thromboembolism, confirming the relationship of neoplastic cell interaction with coagulation system. Forty-seven patients admitted to the hospital from 1987 to 1996 with symptomatic clinically proved deep vein thrombosis were included in a retrospective study. Routine examination at the time of diagnosis of deep vein thrombosis revealed an occult cancer in 8 out of 47 patients; 9 out of 47 patients were admitted in hospital with vein thrombosis and known cancer. The aim of this study is to suggest the best, first treatment of vein thromboembolism in emergency to avoid the dangerous pulmonary embolism complication. The patients affected with deep vein thrombosis and cancer were elderly (over 70 years old, in mean); the neoplasia was of digestive system (8/17) in advanced metastatic stage there was cancer familiarity in 7 out of 47 patients. The high risk of pulmonary embolism associated to deep vein thrombosis suggests the importance of early starting the anticoagulant therapy and placing caval filter.

Somatostatin (SST) is used in the treatment of acute pancreatitis (AP) to inhibit pancreatic exocrine secretion, which represents one of the goals of medical treatment in this disease. Its therapeutic efficacy, however, is poor. One hypothesis, which has not yet been investigated, is that i.v. SST might be broken down by blood proteolytic enzymes. In order to evaluate the structural integrity and biological activity of infused SST, somatostatin-like immunoreactivity (SLI) and levels of pancreatic enzymes were monitored in the blood stream during the infusion of SST-14 (3,5 micrograms/kg/h for 48 h) in eight patients with severe acute pancreatitis. SLI was measured by both radioimmunoassay (RIA) and high-pressure liquid chromatography (HPLC). The results indicate that SLI levels increase promptly after the beginning of infusion, with a slower increase between 6 and 36 h, and a rapid increase again at 48 h. HPLC analysis shows a single peak of SLI with the same retention time as standard SST-14. Total amylase, lipase, and trypsinogen significantly decreased compared with pretreatment values (48, 63.1, and 77.4%, respectively) after 24 h of SST infusion, while a decrease in elastase 1 (62.6%) was observed later at 48 h. These results indicate that in severe AP, somatostatin recovered in plasma retains its biological activity: it inhibits pancreatic circulating enzymes, an action not influenced by breakdown of the peptide, as demonstrated by HPLC of the SLI measured in plasma.

Based on a survey of 47 cases of left colonic occlusive cancer operated on at the Emergency Surgery Department-University of Rome "La Sapienza", the authors concluded that in such condition, when the patient is not seriously ill, the Hartmann procedure is a valid alternative to the anastomosis-resection because: a) it solves intestinal obstruction in a short time with consequent improvement of general conditions; b) it allows to perform the second oncologically radical operation early with less risk of neoplastic spread. The latter procedure, therefore, is carried out under better conditions, relative to the stage of the disease and the status of the patient.

Personal experience in the treatment of acute pancreatitis with glucagon is reported. Results are highly satisfactory and encouraging in oedematous, interstitial and circumscribed steatonecrotic forms, disappointing where the disease has caused extensive damage to the gland.

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