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Nowadays, the functions and roles of the father are the consequence of a gradual transition from a "patriarchal" family to a contemporary family organization. New fathers today, are increasingly the point of reference of the mother, particularly during the perinatal period, and are ever more involved in the care of their offspring. The significant adjustments in the paternal functions are also accompanied by hormonal, neurobiological and psychological changes. Considering a gender-based approach, this chapter discussed the underlying mechanisms and the characteristics of perinatal affective disorders in fathers, by integrating empirical evidence from neurobiological and behavioral studies with anthropological and clinical observations. Perinatal psychological distress in men can be displayed, not only with traditional depressive-like symptoms, but rather through a wide array of other clinical manifestations (anxiety disorders, somatic complains, behavioral problems, and addictions) which can overlap or mask depressive symptoms, generating complex clinical pictures. Therefore, the definition of Paternal Perinatal Affective Disorders (PPAD) has been proposed to replace the term Paternal Perinatal Depression (PPND). Following this perspective, the chapter includes indications to implement effective prevention, screening and early diagnosis considering male expression of paternal perinatal distress. Implications for treatment are also discussed.

Se siete uno psicologo, uno psichiatra o svolgete una professione d’aiuto (psicoterapeuta, assistenti sociale, educatore) questo è un libro potenzialmente “pericoloso”. La sua lettura potrebbe cambiare radicalmente il vostro modo di concepire il trattamento e l’aiuto psicologico da fornire alle persone in difficoltà e alle loro famiglie. Le ragioni che rendono Attaccamento e Terapia Familiare così importante sono molte

Background: Most studies on parental reactions to a preterm birth and to hospitalization of the newborn in Neonatal Intensive Care Units (NICUs) have involved mothers. However, emotional responses and behaviors of fathers are equally important. Usually, the father is the first to meet the preterm newborn, to find out information about baby's condition and to communicate to the mother and other family members. In this context he is often left alone and can show psychological difficulties including affective disorders such as depression or anxiety. This paper describes the role of fathers in the NICU, the best practices to support fathers, and to explain the role of a psychologist in the NICU staff. Considerations and suggestions are provided on the difficulties encountered to support parents, with a focus on the role of fathers during the COVID-19 pandemic.Methods and Discussion: Considering contemporary research data and following an attachment perspective, we analyze the role of the father of a preterm-born child in the relation with the partner and in newborn caring. Research has shown that involving fathers in newborn care in NICU and at home is essential not only because it promotes the father/son attachment relationship and has positive effects on the psychological and somatic development of the newborn, but also for the health of the mother and whole family.Conclusion: Recommendations are provided to enhance the functions of fathers in the NICU, promote their involvement in the care of their infant, and interventions to prevent the manifestation of psychological suffering and/or perinatal affective disorders. The commitments of a psychologist in a NICU team are presented and require not only clinical skills, but also the ability to manage the emotional and relational difficulties of fathers, family and NICU staff. Considerations and suggestions are provided on the difficulties encountered by parents in the NICU during the COVID-19 pandemic.

Importance: Prenatal stress exposure has been linked to increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in the offspring, although the evidence is inconsistent. Objective: This systematic review and meta-analysis was performed to systematically critically review the existing literature on the association between prenatal stress and the risk of ASD and ADHD. Data sources: Based on a registered protocol, we searched electronic databases PubMed, PsycINFO, Web of Science, Scopus and EMBASE for articles in accordance with a detailed search strategy. Study selection: Two investigators independently searched titles, abstracts and full-text articles. Cohort and case-control studies assessing prenatal exposure to stress and the risk of ASD or ADHD as an outcome measure were included. Study extraction and synthesis: Data extraction and quality assessment were performed independently by two investigators. We performed this study following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Main Outcomes and Measures: Random-effects meta-analyses were performed to calculate adjusted and unadjusted pooled estimates for prenatal stress and risk of ASD and ADHD, using the generic inverse variance method. Results: Of 1456 studies emerged from the databases, 27 studies in total met the inclusion criteria of the systematic review (15 for ASD, 12 for ADHD). Prenatal stress was significantly associated with an increased risk of both ASD (pooled OR=1.64, [95% CI=1.15 – 2.34]; I2=90%) and ADHD (pooled OR=1.72, [95% CI= 1.27-2.34]; I2=85%). A significant association between prenatal and ASD was observed in the meta-analysis of the cohort but not case-control studies. Significant associations for between prenatal stress and ASD and ADHD were observed in low to moderate quality studies but in high quality studies. Conclusions and relevance: This study suggests that prenatal stress may be associated with an increased risk of ASD and ADHD in the offspring. However, several limitations in the included literature should be noted including significant heterogeneity, potential recall bias and lack of adjustment for key potential confounders. Future research exploring this association should address the limitations in the current literature in order to test whether this association is potentially causal or attributable to methodological limitations.

Previous studies documented gender-related differences in the expression of Perinatal Affective Disorders. However, little attention has been paid to screening the male population during the perinatal period. This study was based on three aims: (1) to investigate the mental health of expectant fathers based on their levels of depression, anxiety, addiction, anger attacks/hostility, and somatization, identifying psychological profiles, (2) to analyze the association between these profiles and the individual variable of perceived stress, (3) and to examine the association between these profiles and the couple&rsquo, s variable of marital adjustment. A total of 350 Italian expectant fathers in the last trimester of pregnancy were asked to fill in questionnaires concerning perceived stress, dyadic adjustment, psychiatric symptomatology, and depression. Three different clusters were found: &ldquo, psychologically healthy men&rdquo, (68%) with low levels of symptoms on all the scales, &ldquo, men at risk of externalized behavioral problems&rdquo, (17.1%), characterized by one or more addictive or risky behaviors and moderate levels of scales scores, and &ldquo, men experiencing psychological distress&rdquo, (14.9%), with the highest scores on all the scales. A significant association emerged among the perceived stress, marital adjustment, and cluster membership. These results highlight the importance of screening fathers in perinatal health services, which are still predominantly mother-centered, and underscore the necessity to create tailored and personalized interventions.

In Western society, with the gradual transition from the patriarchal family to the contemporary nuclear one (both parents work and contacts with the extended family are limited), fatherhood has been increasingly linked to more expectations and responsibilities in childcare and family life (Quilici, 2010; Biehle and Mickelson, 2012; Crespi and Ruspini, 2015). At biological level, neural plasticity and hormonal changes that occur in men may also increase the risk of psychological distress during the transition to parenthood (Poromaa et al., 2017; Baldoni, 2020). Research has clearly demonstrated that during the perinatal period the emotional states of mothers and fathers influence each other showing a significant correlation between paternal and maternal perinatal depressive disorders (Baldoni and Ceccarelli, 2010; Paulson and Bazemore, 2010; Musser et al., 2013). Thus, in the last decades there has been an increased interest in men's perinatal mental health (Baldoni, 2010; Garfield, 2015; Gutierrez-Galve et al., 2015; Field, 2018). In this scenario, Paternal Perinatal Depression (PPND) is considered a specific condition that affects many fathers between pregnancy and the first year after childbirth. PPND is associated with maternal depression (Baldoni et al., 2009; Paulson et al., 2016) and adverse outcomes in children and adolescents, including externalizing and internalizing symptoms (Ramchandani and Psychogiou, 2009; Baldoni, 2016; Sweeney and MacBeth, 2016). Specifically, a longitudinal study on 12,884 fathers has confirmed the influence of PPND on the psychophysical development of children evaluated from birth to 7 years of life (Ramchandani et al., 2005, 2008), with an increase, more significant in males, in emotional and behavioral control problems at 21 and 42 months and childhood psychiatric disorders and oppositional behaviors at 7 years. Other studies (Baldoni et al., 2009, 2011) conducted with the CARE-Index (Crittenden, 1979–2007) documented the influence of depression and poor paternal sensitivity on the psychomotor development of infants (assessed with the Bailey scales). Two recent metanalyses showed a PPND prevalence in the word ranging from 10.4% (Paulson and Bazemore, 2010) to 8.4% (Cameron et al., 2016) and longitudinal studies found that pregnancy is the most sensitive period for the onset of symptoms in both men and women (Madsen and Juhl, 2007; Figueiredo and Conde, 2011). Therefore, the term Paternal Perinatal Depression (PPND) is gradually replacing Paternal Post-partum/Post-natal Depression (PPD), to consider and identify the possible onset of depressive symptoms in fathers since the prenatal period (Baldoni, 2010; Cameron et al., 2016; Bruno et al., 2020). Although these terms are commonly used in research, these diagnoses are not even mentioned in the current DSM-5. The manual only specifies the criteria for a major depressive episode “with peripartum onset” referring to the mother only, which is defined as the most recent episode occurring during pregnancy as well as in the 4 weeks following delivery. Anyhow, fathers are not usually the focus of the prevention and screening of perinatal affective disorders, and PPND remains underestimated and undertreated compared to maternal depression. A possible explanation is that men tend to show a less clear clinical picture than women do and thus the use of screening questionnaires developed for mothers may be not appropriate. Given that perinatal depression risks and psychological responses differ significantly based on gender (Habib, 2012), it would be useful to rethink perinatal psychological disorders considering the wide array of paternal affective symptoms and the limitations of current tools developed to assess maternal depression. Hence, the aim of this opinion article is to emphasize the need to consider male-specific responses to perinatal distress following an integrative and gender-based perspective. Secondly, we have commented on the limits of research on PPND based on current self-reported measurements.

Stress is associated with dyadic adjustment during transition to parenthood, but little is known about mechanisms underlying this link, particularly during prenatal period. This dyadic study explored the mediating role of depressive symptoms in the relationship between perceived stress and dyadic adjustment in expectant couples. One hundred and fourteen couples at the third trimester of pregnancy completed self-reports of perceived stress, depression, and dyadic adjustment. Results indicated that both parents’ perceived stress was associated with their own lower relationship satisfaction directly and indirectly, through their own higher depressive symptoms. Mothers’ perceived stress was also linked to higher fathers’ depressive symptoms, and thus also to lower fathers’ relationship satisfaction. Both parents’ perceived stress was only directly associated with their own dyadic consensus, and their own and their partners’ affectional expression. Findings suggest that interventions aimed at reducing expectant parents’ perceived stress could protect against depressive symptoms and promote the couple’s adjustment during pregnancy.

Objective To evaluate the influence of the severity of prematurity based on birth weight on maternal distress and sensitivity and on infant development. Methods Sixty-eight mothers and their preterm babies (30 babies classified into Extremely-Low-Birth Weight-ELBW and 38 into Very-Low-Birth Weight-VLBW) were assessed at 9 months of infant corrected age, using: Griffiths Scales for infant development, CARE-Index for maternal sensitivity during 5-minute of mother-infant interaction, and Parenting Stress Index-Short Form (PSI-SF) for maternal distress. Sixty-six healthy full-term infants (FT) and their mothers were assessed with the same procedure. Results ELBW, VLBW and FT groups showed similar levels at CARE-Index and PSI-SF. Nevertheless, considering infant development as outcome, a significant interaction between birth weight and maternal distress emerged, with higher Hearing & Language mean quotients in association with Non-Distressed mothers, but only in VLBW infants, compared to FT ones. Also the interaction between birth weight and maternal sensitivity influenced infant development: higher quotients (Eye-hand coordination, Hearing & Language, Locomotor) were significantly associated with sensitive mothers but only in ELBW infants. Conclusion The severity of prematurity, in interaction with the degree of maternal distress and sensitivity, influenced the level of infant development. Practical implications Taken together, these results suggest the relevance of considering severity of prematurity and maternal variables in order to implement appropriate interventions for supporting parenting role after a preterm birth and promoting an adequate infant development.

Few studies have compared different systems in classifying Adult Attachment Interview (AAI) transcripts. In this study, the AAI was administered to 90 Italian parents (45 couples), and the AAI transcripts were independently classified according to Main, Goldwyn, and Hesse’s (Berkeley) and Crittenden’s (Dynamic-Maturational Model [DMM]) criteria. The two classification systems were not significantly associated, with some limited convergent results only when the interviews resulted in organized (Berkeley) and normative (DMM) attachment classifications. Otherwise, the Berkeley system identified more secure individuals than the DMM system, and many texts judged secure on the Berkeley system were identified as insecure on the DMM system. Since the Berkeley and the DMM systems rest on remarkably different conceptualizations of the nature and functioning of the attachment behavioral system (e.g. fear is conceived as organizing in the DMM and as potentially disorganizing in the Berkeley), the attachment classifications resulting from their applications should not be considered measurements of the same phenomena.

Background: Prenatal maternal stress (PNMS) is defined as the experience of significant levels of prenatal stress, depression or anxiety during pregnancy. PNMS has been associated with increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in exposed offspring. However, these findings are inconsistent and other studies found no association, meaning a clear consensus on the impact of PNMS on ASD and ADHD risk is required. The purpose of this systematic review and meta-analysis is to summarize and critically review the existing literature on the effects of PNMS on ASD and ADHD risk. Methods: Electronic databases (PubMed, PsycINFO, Web of Science, Scopus and EMBASE) will be searched for articles following a detailed search strategy. We will include cohort, case-control and cross-sectional studies that assessed maternal exposure to psychological and/or environmental stress and had ASD or ADHD as an outcome. Two reviewers will independently screen the titles, abstracts and full articles to identify eligible studies. We will use a standardised data extraction form for extracting data and a bias classification tool for assessing study quality. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The generic inverse variance method will be used if possible to perform meta-analyses. Ethics and dissemination: Ethical approval is not required for this study because it will not involve the conduct or inclusion of any experimental or personal data that would require informed consent. The systematic review will be disseminated in peer-reviewed journals. PROSPERO registration number: CRD42018084222.

Background: Prenatal maternal stress (PNMS) is defined as the experience of significant levels of prenatal stress, depression or anxiety during pregnancy. PNMS has been associated with increased risk of autism spectrum disorder (ASD) and attention-deficit hyperactivity disorder (ADHD) in exposed offspring. However, these findings are inconsistent and other studies found no association, meaning a clear consensus on the impact of PNMS on ASD and ADHD risk is required. The purpose of this systematic review and meta-analysis is to summarize and critically review the existing literature on the effects of PNMS on ASD and ADHD risk. Methods: Electronic databases (PubMed, PsycINFO, Web of Science, Scopus and EMBASE) will be searched for articles following a detailed search strategy. We will include cohort and case-control studies that assessed maternal exposure to psychological and/or environmental stress and had ASD or ADHD as an outcome. Two reviewers will independently screen the titles, abstracts and full articles to identify eligible studies. We will use a standardised data extraction form for extracting data and a bias classification tool for assessing study quality. This systematic review will be reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). The generic inverse variance method will be used if possible to perform meta-analyses. Ethics and dissemination: Ethical approval is not required for this study because it will not involve the conduct or inclusion of any experimental or personal data that would require informed consent. The systematic review will be disseminated in peer-reviewed journals. PROSPERO registration number: CRD42018084222.

Background Since 2005, we refined the technique of perihepatic packing including complete mobilization of the right lobe and packing around the posterior paracaval surface, lateral right side, and anterior and posteroinferior surfaces. Methods Two groups of patients with grade IV/V liver trauma underwent perihepatic packing before and after 2005. The study group included 12 patients treated with the new technique. The control group included 23 patients treated with the old technique. Results All 13 patients except one who died within 24 hours were treated with the old technique. The overall survival rate was 75% in the patients treated with the new technique (vs 30.4%, P P = not significant). The mean survival time in the intensive care unit was longer in the latest group (39.4 vs 22.3 days, P = not significant). The incidence of rebleeding requiring repacking was 16.7% in the patients who underwent new packing versus 45.5% in the patient who were treated with the old technique ( P = not significant). The overall (81.8% vs 100%, P = not significant) and liver-related morbidity rate (18.2% vs 41.7%, P = not significant) and the incidence of abdominal sepsis (9.1% vs 41.7%, P = not significant) decreased. Conclusions Our refined technique of perihepatic packing seems to be safe and effective.

Abdominal trauma rarely causes injuries involving the duodenum and pancreas. Associated injuries occur in 46% of all pancreatic injuries. The morbidity and mortality of pancreaticoduodenal injuries remain high. The present study is a retrospective review of our experience from 1989 to 2008 in the surgical treatment of traumatic pancreaticoduodenal injuries. Mortality, morbidity, prognostic factors, and the value of surgical techniques were analyzed. In our level I Trauma Center, between 1989 and 2008, 55 patients had a pancreaticoduodenal injury. In 68.5% of cases pancreatic injuries were found, 20.4% had duodenal injury, and 11.1% suffered combined pancreaticoduodenal injuries; 85.3% of the patients had blunt abdominal trauma, while 14.9% had penetrating injuries. We treated 78.1% of the patients with external drainage and/or simple suture; distal pancreatectomy was performed in 9% of cases and duodenal resection with anastomosis (3.7%) and diversion procedures (3.7%) were performed in an equal number of patients. Age, American Association for the Surgery of Trauma (AAST) grade, organ involved, hemodynamic status, intraoperative cardiac arrest, and operative time remained strongly predictive of mortality on multivariate analysis. The AAST grade represented, on multivariate analysis, the only independent prognostic factor predictive of overall morbidity. In the past decade we have used feeding jejunostomy more frequently, with a reduction of mortality and operating time, due also to a better approach from a dedicated trauma team. Optimal management and better outcome of pancreaticoduodenal injuries seem to be associated with shorter operative time, and with simple and fast damage control surgery (DCS), in contrast to definitive surgical procedures.

Secondo la teoria dell'attaccamento una funzione principale dell'essere genitori č fornire una "base sicura", cioč una particolare atmosfera di sicurezza e di fiducia all'interno della relazione con la figura di attaccamento. Questa necessitŕ si manifesta anche nella vita di coppia, in particolare durante la gravidanza e nel periodo successivo alla nascita di un figlio. Per studiare l'influenza di alcuni aspetti psicologici e comportamentali nelle madri e nei padri durante il periodo perinatale, gli autori hanno studiato un campione di 40 coppie valutate dal secondo trimestre di gravidanza al primo trimestre dopo il parto. In quattro occasioni a tutti i soggetti sono stati somministrati quattro questionari: il CES-D, il Symptom Questionnaire, l'Illness Behaviour Questionnaire e il Perinatal Couple Questionnaire. L'analisi statistica ha evidenziato che in questo periodo i padri manifestano alterazioni emotive con oscillazioni che sono correlate con la sofferenza materna. I padri le cui compagne hanno sofferto di disturbi affettivi durante il post-partum sono risultati piů depressi, ansiosi e irritabili, tendono a manifestare la loro sofferenza sotto forma di sintomatologia somatica e ad essere preoccupati per la propria salute e per il ruolo paterno. Gli interventi psicologici sui disturbi affettivi nel periodo perinatale dovrebbero perciň riguardare non solo la madre, ma entrambi i genitori. Nelle situazioni maggiormente a rischio, un aiuto psicoterapeutico finalizzato a ridurre la sintomatologia depressiva e ansiosa, le preoccupazioni ipocondriache e le difficoltŕ genitoriali puň favorire una migliore relazione di attaccamento non solo nei confronti del bambino, ma anche del proprio partner.

Les tumeurs stromales gastro-intestinales (GIST) sont les neoplasies mesenchymateuses les plus frequentes du tube digestif. L’atteinte gastrique est la plus courante (60–70 %), suivie de celle de l’intestin grele (20–30 %). Les GIST possedent des caracteristiques immunohistochimiques specifiques, essentielles au diagnostic. Pres de 95%des GIST expriment le c-kit (antigene CD117), un recepteur transmembranaire tyrosine-kinase dont l’activation declenche la proliferation cellulaire. La chirurgie est le traitement de choix des tumeurs resecables, alors que le traitement standard des tumeurs non resecables est l’administration d’imatinib (Glivec®), un inhibiteur competitif de c-kit/PDGFRA. Le taux de reponse au traitement par imatinib est d’environ 80 %. Le diagnostic des GIST peut etre accidentel ou resulter de l’apparition de symptomes non specifiques tels que des douleurs abdominales, une masse abdominale ou un saignement gastro-intestinal. Une rupture dans la cavite peritoneale avec peritonite represente un evenement tres rare, et la litterature fait etat de tres peu de cas de peritonite generalisee comme presentation clinique initiale de GIST. Nous rapportons, dans cet article, un cas inhabituel de GIST revele par une peritonite generalisee provoquee par une rupture spontanee dans la cavite abdominale.

Le ricerche sulla trasmissione dell’attaccamento tra genitori e figli sono state svolte quasi totalmente confrontando i risultati delle Strange Situation (Ainsworth, Wittig, 1969; Ainsworth, Bell, Stayton, 1971) con quelli della Adult Attachment Interview somministrate e codificate secondo il protocollo (George, Kaplan, Main, 1984–1996) e i criteri (Main, Goldwyn, 1984, 1991; Main, Goldwyn, Hesse 2003–2008) formulati originariamente da Mary Main e collaboratori. Solo recentemente sono stati svolti studi in questo campo tenendo conto degli strumenti e dei criteri sviluppati all’interno del Modello Dinamico-Maturativo (Dynamic-Maturational Model, DMM) (capitoli 7 e 8).

Un vantaggio del Modello Dinamico-Maturativo (DMM) è che considera tre livelli distinti del funzionamento umano, ognuno dei quali può essere oggetto specifico di trattamenti anche diversi (Crittenden, 2008a): le distorsioni di pensieri e affetti, che possono comportare inadeguatezze del comportamento, gli aspetti relazionali (in particolare quelli familiari) e le strategie utilizzate per proteggersi dal pericolo. Le stesse tecniche di valutazione del DMM, poi, in quanto esperienze relazionali, oltre a fornire informazioni fondamentali sulla configurazione di attaccamento del paziente possono costituire una prima occasione di trattamento e di sviluppo di un’alleanza terapeutica. Le innovazioni introdotte dalla teoria dell’attaccamento e dal DMM risultano quindi straordinariamente utili e compatibili con una psicoterapia di tipo psicoanalitico, per cui oggi si può parlare di una “Psicoterapia Dinamica basata sul DMM” (DMM based Dynamic Psychotherapy o DMM-DP) (Baldoni, 2011).

A partire dagli anni cinquanta la teoria dell’attaccamento e il lavoro svolto da John Bowlby sulla deprivazione materna e sulle esperienze di separazione e di perdita hanno rivoluzionato gli studi in psicologia dell’eta evolutiva, evidenziando l’importanza che la ricerca di sicurezza e la protezione dai pericoli svolgono nelle relazioni umane fin dalla nascita. Verso la fine degli anni sessanta ci si rese conto che questi concetti si prestavano, piu di altri di matrice psicoanalitica, a essere “operazionalizzati”, cioe trasformati in modelli e strumenti utilizzabili sul piano della ricerca e del trattamento (Holmes, 1993; Cassidy, Shaver, 2008). La ricercatrice che ha maggiormente contribuito a questa evoluzione metodologica e stata senza dubbio Mary Salter Ainsworth, che oggi viene considerata, assieme a Bowlby, la coautrice della teoria dell’attaccamento. A lei si deve l’ideazione della Strange Situation (SS) (Ainsworth, Wittig, 1969), una procedura standardizzata per la valutazione degli stili di attaccamento nei bambini da 10 a 18 mesi di vita. Utilizzando questa metodologia furono identificati dalla Ainsworth (Ainsworth, Bell, Stayton 1971; Ainsworth et al., 1978) tre pattern di attaccamento infantile, ciascuno suddiviso in diversi sottotipi. Nell’attaccamento sicuro (tipo B) i bambini sono angosciati (ma non eccessivamente) quando sono separati dalla figura di attaccamento e al momento del ricongiungimento si avvicinano al genitore, richiedono e ricevono conforto e entro poco ritornano a giocare tranquilli. Nell’attaccamento insicuro evitante (tipo A) mostrano pochi segni di angoscia per la separazione e ignorano la madre al momento della riunione, in quanto hanno imparato a inibire i comportamenti di attaccamento come difesa di fronte al distacco e al rifiuto materno.

Background Case control studies that randomly assign patients with diagnosis of acute appendicitis to either surgical or non-surgical treatment yield a relapse rate of approximately 14% at one year. It would be useful to know the relapse rate of patients who have, instead, been selected for a given treatment based on a thorough clinical evaluation, including physical examination and laboratory results (Alvarado Score) as well as radiological exams if needed or deemed helpful. If this clinical evaluation is useful, the investigators would expect patient selection to be better than chance, and relapse rate to be lower than 14%. Once the investigators have established the utility of this evaluation, the investigators can begin to identify those components that have predictive value (such as blood analysis, or US/CT findings). This is the first step toward developing an accurate diagnostic-therapeutic algorithm which will avoid risks and costs of needless surgery. Methods/design This will be a single-cohort prospective observational study. It will not interfere with the usual pathway, consisting of clinical examination in the Emergency Department (ED) and execution of the following exams at the physician's discretion: full blood count with differential, C reactive protein, abdominal ultrasound, abdominal CT. Patients admitted to an ED with lower abdominal pain and suspicion of acute appendicitis and not needing immediate surgery, are requested by informed consent to undergo observation and non operative treatment with antibiotic therapy (Amoxicillin and Clavulanic Acid). The patients by protocol should not have received any previous antibiotic treatment during the same clinical episode. Patients not undergoing surgery will be physically examined 5 days later. Further follow-up will be conducted at 7, 15 days, 6 months and 12 months. The study will conform to clinical practice guidelines and will follow the recommendations of the Declaration of Helsinki. The protocol was approved on November 2009 by Maggiore Hospital Ethical Review Board (ID CE09079). Trial Registration ClinicalTrials.gov identifier: NCT01096927., Article summary Article focus Acute appendicitis can have severe complications including perforation and generalised peritonitis. The appendix is found to be free of disease in 15–30% of appendectomies. As surgery carries various risks, conservative non-surgical treatment with antibiotics for suspected appendix inflammation may avoid needless surgery, in particular as the relapse rate is low and the rate of complications is similar. Key messages Case control studies that randomly assign patients with acute appendicitis to either surgical or non-surgical treatment show a relapse rate of approximately 14% at 1 year. The relapse rate of patients who are treated based on a thorough clinical evaluation should be below 14%. Once factors predictive of outcome and/or the need of surgery are identified, an accurate diagnostic-therapeutic algorithm which will help avoid the risks and costs of needless surgery can be developed. Strengths and limitations of this study This non-randomised controlled study will evaluate the effectiveness and short and long term outcomes of non-operative antibiotic treatment of acute appendicitis. Amoxicillin and clavulanic acid are common and easily managed low cost drugs, available both for intravenous and oral use. Better analysis of clinical data might lead to better decision-making in patients with right iliac fossa pain and suspected acute appendicitis. The study also aims to evaluate the Alvarado score, which is used to diagnose acute appendicitis and discriminate patients needing immediate surgery from patients who may safely undergo observation and antibiotic treatment. A large sample of patients undergoing non-operative antibiotic treatment will allow a statistically powerful evaluation of safety, efficacy and cost. An additional objective is to identify clinical, laboratory and imaging findings that are predictive of failure of conservative treatment and/or relapse of appendicitis and need for appendectomy within 1 year. As efficacy can not be reliably determined in the absence of a control group, a case series observation determining ‘efficacy’ has limited value. The Alvarado score is used to separate those with acute appendicitis from those with similar symptoms but no appendicitis and there is no evidence that this score can identify those who would benefit from antibiotic treatment.

Management of Liver Trauma may vary widely from NOM +/- angioembolization to Damage Control Surgery. Multidisciplinary management is essential for achieving better outcomes.During 2000-2009 period 308 patients with liver injury were admitted to level 1 trauma center and recorded in Trauma Registry. Collected data are demographics, AAST grade, initial treatment (operative or non-operative treatment) and outcome (failure of NOM), death. All patients were initially assessed according to ATLS guidelines. In case of haemodynamic instability and FAST evidence of intra-abdominal free fluid, the patients underwent immediate laparotomy. Hemodynamically stable patients, underwent CT scan and were admitted in ICU for NOM.Two hundred fourteen patients (69.5%) were initially managed with NOM. In 185 patients this was successful. Within the other 29 patients, failure of NOM was due to liver-related causes in 12 patients and non-liver-related causes in 17 Greater the grade of liver injury, fewer patients could be enrolled for NOM (85.8% in I-II and 83.3% in III against 39.8% in IV-V). Of those initially treated non-operatively, the likelihood of failure was greater in more severely injured patients (24.4% liver-related failure rate in IV-V against the 1.3% and 1.0% in I-II and III respectively). One hundred twenty-three patients (40% of the whole population study--308 patients) underwent laparotomy: 94 immediately after admission, because no eligible for NOM; 29 after NOM failure . In the 81 patients in which liver bleeding was still going on at laparotomy, hemostasis was attempted in two different ways: in the patients affected by hypothermia, coagulopathy and acidosis, perihepatic packing was the treatment of choice. In the other cases a "direct repair" technique was preferred. "Early mortality" which was expected to be worse in patients with such metabolic derangements, was surprisingly the same of the other group. This proves efficacy of the packing technique in interrupting the "vicious cicle" of hypothermia, coagulopathy and acidosis, therefore avoiding death ("early death" in particular) from uncontrollable bleeding.NOM +/- angioembolization is safe and effective in any grade of liver injury provided hemodynamic stability. DCS is Gold Standard for hemodynamically unstable patients.

The attachment styles and parental bonding by 64 patients ( M age = 43.2 yr., SD = 13.3) with Gastroesophageal Reflux Disease (GERD) were compared with those of 64 patients ( M age = 42.2 yr., SD = 13.5) with Inflammatory Bowel Disease (IBD) and 126 Healthy participants ( M age = 42.2 yr., SD = 12.1). Analysis of scores on the Attachment Style Questionnaire indicated insecure attachment in both the patient and control groups. The Parental Bonding scores indicated perceptions of Affectionless Control by parents in both patient groups. In particular, the mean Father-Protection subscale scores were significantly higher for in the GERD group than in the Healthy and IBD groups.

It has been two decades since Maggiore Hospital Trauma Center started its formal activity focused on improving and developing Trauma management and Surgery of Trauma. Whilst evaluating the results of the last year, we can not avoid to look behind at the beginning, comparing the actual activity with the settings we have started from, in 1989. Before this date in our hospital all the Emergency and Trauma Surgery was managed by General Surgeons. However since 1989 few surgeons and ICU anaesthetists started to focus their training and activity on management of Trauma. From there has born the first organized, structured Level I Trauma Center holding all diagnostic and therapeutic resoureces and recognized by the Health Management Plan of the Emilia - Romagna Region Authority, within a region including almost two millions inhabitants. The Trauma Surgery team adopted the evolving concept of Damage Control Surgery, applying extensively the intraabdominal packing and improving the perihepatic packing with a relevant refinement in the operative technique. Furthermore Non Operative Management has extensively spread All the above cited improvements, particularly the extensive use of NOM and the reduction of operative times, following the DCS philosophy and techniques, contributed to decrease morbidity and mortality rates of the abdominal trauma surgery patients. Mortality has been brought significantly down to 2.4%, in all cases related to extra-abdominal reasons. Last but least needs to be mentioned our scientific and research activity, including several published articles and scientific presentations at Italian, European and International Conferences. Finally we organize since 8 years a nationally relevant educational event: the "Corso Teorico-Pratico di Chirurgia del Politrauma". It is a theoretic and practical Trauma Surgery Course for Consultant/Attending Surgeons and Senior Registrars/Residents who want to improve their skills in Trauma Surgery and Management, and is now running its XIX edition.

Elhers-Danlos Syndrome (EDS) is an hereditary disease of the connective tissue, which may have clinical appearances varying in its severity from subclinical asymptomatic forms up to dramatic uncontrollable haemorrhage.We have observed three siblings who were carriers of vascular type EDS. They were otherwise healthy at the time of the disease presentation and have become symptomatic since then, developing severe and uncontrollable haemorrhage.We have reported the clinical presentation of this syndrome, the clinical and laboratory characteristics, the treatment and the outcome.Although the severity of this disease, Elhers-Danlos Syndrome becomes symptomatic lately and suddenly in its course, often during emergency surgery for haemorrhagic shock. Several issues are raised such as the possibility for early diagnosis of this disease, the psychological features of a genetic counseling, the need for the patients to have adequate lifestyle and last but not least the risk of genetic transmission of the disease.

The Damage Control Surgery (DCS) approach to massive intraperitoneal hemorrhage has been shown to significantly reduce the morbidity and mortality in severely injured trauma patients. We applied the same principles to patients who developed a massive hemorrhage and the “lethal triad” (acidosis, hypothermia, coagulopathy) during a surgical procedure in order to assess feasibility and efficacy of DCS on nontraumatic grounds. A retrospective analysis of eight consecutive cases was performed aimed at collecting information on laboratory parameters, fluids requirements, operative times, APACHE II score, damage control surgery procedure, angioembolization, morbidity, mortality, and need for repacking. Average APACHE II score was 25.5 (predicted mortality rate = 54%); overall and early mortality in the nontraumatic group was nil, while the intra-abdominal septic (packing-related) complication rate was 12.5%. Intra-abdominal packing was shown to be feasible, safe, and effective for patients with intra-abdominal nontraumatic massive hemorrhage, and the application of the principles of DCS may improve survival in cases of surgical hemorrhage with development of the lethal triad.

Negli anni’ 50 si comincio a parlare di attaccamento quando John Bowlby propose, gradatamente, una posizione critica all’interno della stessa psicoanalisi, nei confronti di quella che fino allora era ritenuta la motivazione principale dell’essere umano. Nella psicoanalisi freudiana e stato dato molto valore alla sessualita come fattore motivazionale. Freud sosteneva, fondamentalmente, che gli esseri umani si legano fra loro, e il bambino alla madre, sotto la spinta di pulsioni di carattere sessuale e in particolare, nei primi mesi di vita, di pulsioni di carattere orale. Bowlby ha proposto una teoria che metteva in discussione queste concezioni, utilizzando dati di ricerca provenienti anche da ambiti non strettamente psicoanalitici, sollevando un certo polverone e, di fatto, anche creando, per alcuni anni, un certo contrasto tra mondo della teoria dell’attaccamento e mondo della teoria psicoanalitica pulsionale.

The incidence of penetrating abdominal trauma in Western Europe is low. While non-operative management of blunt trauma has become the gold standard, the management of penetrating trauma is still controversial. Nonoperative management (NOM) and laparoscopy are currently used in selected patients, reducing the rate of unnecessary laparotomy.We retrospectively reviewed a 20-years period from the Trauma Registry of our Trauma Center. 6523 patients were admitted for thoraco-abdominal trauma (5861 blunt vs 662 penetrating). We sorted the 114 patients with penetrating abdominal trauma in 2 groups for period (1989-2000 vs 2001-08, before and after the establishment of dedicated trauma unit) analyzing their demographics, clinical, therapeutic characteristics and the outcome in comparison.In the latest period a significant increase in the incidence of penetrating trauma has been observed (doubled from 4.17/year up to 8.53/year, accounting now for 13.95% of all trauma laparotomies vs 7.8% in the past decade). A reduction of GSW (30% vs 12.5%, p = ns) occurred while no differences have been recorded in sex, age, prognostic parameters at arrival such as mean GCS (11.8 vs 13.2), ISS (22 vs 18), pH, BE and blood transfusion (6.4 vs 4.3 U) requirement. Interestingly a markedly significant change has been observed in the demographics of the victims (67.2% were of extra-EU origin vs 8% in the previous decade, p0.01). Recently the use of NOM spread widely in selected stable patients (21.9%). The failure rate of NOM was 14.3%. The percentage of unnecessary laparotomies decreased from 36% to 21.1% (p = ns). The introduction of laparoscopy was helpful in achieving a reliable, less invasive exploration, allowing detection of the peritoneal penetration and complete visceral exploration. Two GSW (4%) vs 3 (5.8%) cases of the latest years required Damage Control Surgery. A recent significant reduction in mortality and morbidity rate has been recorded (respectively 3.85% vs 18%, p0.05; 20% vs 39%, p = ns).The recent immigration phenomenon and social changes contributed towards a significant rise in the incidence of penetrating trauma in Italy in the last decade associated to changes in the mechanism of injury. The increased use of NOM and laparoscopy contributed in decreasing the incidence of unnecessary laparotomies as well as overall morbidity and mortality.

Salomone Di Saverio and colleagues discuss the diagnosis and management of a man presenting with symptoms of partial intestinal obstruction.

In October, 2005, the abdomen of a 30-year-old, previously healthy builder was crushed between a wooden board, which fell on his back, and a workbench. He was taken by ambulance to the emergency department at a local hospital. He had back pain. However, the attending doctors found no other symptoms or signs of illness. Notably, examination and ultrasonography of his abdomen showed no abnormality, and vital signs were stable. They therefore discharged him after a few hours of clinical observation. 1 month later, the patient came to our emergency department, with pain in the right lower quadrant of his abdomen. He said that the pain had begun 10 days earlier, and had worsened in the 24 h before his return. He had rebound tenderness in the light lower quadrant; blood tests showed leucocytosis. Suspecting appendicitis, we took the patient to the operating theatre. We found severe infl ammation of 38 cm of the ileum and appendix, with several areas of necrosis. The intestinal wall was thick and oedematous, and coated in white membranes, creating what might be described as an infl ammatory mass—which adhered to the caecum, sigmoid colon, omentum, and bladder. We removed the infl amed tissue. Histopathological analysis of the resected ileum showed acute and chronic infl ammation, fi brosis, and diff use necrosis of the full thickness of the intestinal wall, and serosal connective tissue. We noted haemorrhagic infi ltration of the omentum and mesentery, and diff use erosions of the mucosa, but no pathological features of infl am matory bowel disease. Most of the infl ammatory cells were neutrophils; lymphocytes and histiocytes were distributed irregularly in the intestinal wall. We deduced that the damage had been caused by the earlier crush injury. Postoperative recovery was straightforward. When last seen, in May, 2008, the patient was well. Houdini was struck repeatedly in the abdomen by a fi rst-year university student, while demonstrating his abdominal musculature. He developed worsening abdominal pain, nevertheless continuing his scheduled performances. A few days after being struck, he underwent surgery, which revealed a ruptured appendix and diff use peritonitis. Although the appendix was removed and the peritoneum cleaned, his condition worsened (no appropriate antibiotics were then available), and the renowned magician passed away on Oct 31, 1926. As early as 350 BC, Aristotle stated, “a slight blow [to the abdomen] will cause rupture without injury to the skin.” It is now thought that small-bowel injury occurs in around 1% of cases of blunt abdominal trauma. The extent of damage ranges from mild bruising, with oedema, to full-thickness necrosis. Small-bowel injury usually presents as an acute abdomen, caused by perforation; sometimes, appendicitis has been reported. Ischaemia that is localised or transient, and hence does not induce necrosis, can cause residual chronic infl ammation with fi brosis, leading to bowel obstruction or perforation. Delayed bowel perforation can present several days after trauma; stenosis and obstruction can develop in several weeks or months.

Background Quality control of trauma care is essential to define the effectiveness of trauma center and trauma system. To identify the troublesome issues of the system is the first step for validation of the focused customized solutions. This is a comparative study of two level I trauma centers in Italy and Romania and it has been designed to give an overview of the entire trauma care program adopted in these two countries. This study was aimed to use the results as the basis for recommending and planning changes in the two trauma systems for a better trauma care. Methods We retrospectively reviewed a total of 182 major trauma patients treated in the two hospitals included in the study, between January and June 2002. Every case was analyzed according to the recommended minimal audit filters for trauma quality assurance by The American College of Surgeons Committee on Trauma (ACSCOT). Results Satisfactory yields have been reached in both centers for the management of head and abdominal trauma, airway management, Emergency Department length of stay and early diagnosis and treatment. The main significant differences between the two centers were in the patients' transfers, the leadership of trauma team and the patients' outcome. The main concerns have been in the surgical treatment of fractures, the outcome and the lacking of documentation. Conclusion The analyzed hospitals are classified as Level I trauma center and are within the group of the highest quality level centers in their own countries. Nevertheless, both of them experience major lacks and for few audit filters do not reach the mmum standard requirements of ACS Audit Filters. The differences between the western and the eastern European center were slight. The parameters not reaching the minimum requirements are probably occurring even more often in suburban settings.

To evaluate our experience in the treatment of complex abdominal injuries with the principles of Damage Control Surgery (DCS).A retrospective review was conducted of 55 patients with multiple abdominal injuries and severe haemorrhage induced hypothermia and acidosis admitted to the "Ospedale Maggiore Trauma Center" in Bologna from 1989 to June 2005.All the patients but one had major blunt trauma. Mean age was 40.1; mean ISS 42; mean RTS 4.11; extimated loss of blood was greater than 4000 ml. Packing provide definitive control of bleeding in 44 patients but 10 had recurrent bleeding or bleeding from different injuries such as bone fractures and required further surgery (2) or arterial embolization (8). Twenty eights patients (50.9%) died. Survival was strongly associated with the ISS, GCS, the loss of blood and acidosis.The Authors concluded that in selected circumstances the traditional approach to severe abdominal injuries is not appropiate. In this situation, alternative and aggressive treatment such as the Damage Control Surgery has been recommended as the procedure of choice.

The consequences of low incidence of penetrating injuries in Europe and of the increasing in nonoperative management of blunt trauma are a decrease in surgeons' confidence for managing traumatic injuries. The Corso Teorico Pratico di Chirurgia del Politrauma was developed as model for teaching operative trauma techniques. The aim of this retrospective study is to evaluate the effectiveness of the course and compare it with other similar courses.The Corso Teorico Pratico di Chirurgia del Politrauma is a two day course and consists of lecture on trauma topics and porcine operative experience. Data on the first 124 participants were collected and analyzed.One hundred twenty general surgeons and 2 pediatric surgeons had participated at the course. All the participants judged the course an efficient model to improve knowledge on surgical treatment of trauma.A two days course, focused on trauma, with didactic lectures and operative life-like situations, can be a model for simulated education and useful to improve surgeons' confidence in trauma patients.

The management of traumatic retroperitoneal injuries is still confusing to many surgeons. The presence of injuries of retroperitoneum generally worsens the prognosis in trauma patients and need more attention both the diagnosis and treatment and mortality is high comparated to abdominal traumati injuries.A retrospective review was conducted of 221 patients with retroperitoneal injuries admitted to the Ospedale Maggiore Trauma Center in Bologna from 1989 to March 2005.Two hundred seven were blunt traumas and 14 penetrating. Mean age was 40.3; 25 patients died in operating room and 25 were treated with Damage Control Surgery for both abdominal and retroperitoenal injuries. The mortality rate was 15%. Data about surgical treatments, associate treatments for abdominal injuries, and need of reoperation are reported.Retroperitoneal traumatic injuries are challenging emergencies and need of attention and expertise by the suorgeon. Only with a careful judgement on the tactics and the procedure to carry on it is possible to gain valid results, which often means to safe the patients life.

A 78-year-old man presented to the casualty department, complaining of recurrent and worsening constipation for the previous 2 months. This was associated with central, colicky abdominal pain and melena. In the last days, the symptoms worsened and the patient became partially obstructed, with nausea, vomiting and passing flatus but not stools for 72 h. The past medical history was unremarkable. The radiological findings of the plain abdominal film were consistent with mechanical small-bowel obstruction. CT scan revealed an intraluminal mass in the small bowel, which drew attention away from gross thickening of the caecal wall that was also present. A careful review of the images should not be omitted. One must be aware of a polymorphous appearance and the multiple causes of intestinal obstruction and avoid underestimating even the minor and less evident radiological findings.