The use of biological membranes for correction of congenital malformations

Many congenital malformations often require a multidisciplinary and multistep surgical treatment, including the use of biological membranes. Aims of the study were to describe the use of these membranes for the correction of malformations, their clinical performance at follow-up, and patient's tolerance to them. The study included patients treated between 2009 and November 2020 in two referral centers. They were affected by abdominal wall defects (AWD), esophageal atresia/tracheo-esophageal fistula (EA/TEF), diaphragmatic hernia (CDH), spinal defects (SD), and anorectal malformations (ARM). The human origin membranes used during surgery were amniotic membrane, fascia lata, and pericardium provided by the local tissue bank and the porcine-derived membrane available on the market. Thirty-one patients were retrieved. The sample included 10 AWD, 7 EA/TEF, 5 CDH, 4 SD, 2 ARM, and 3 miscellaneous defects. The median age at repair was 139 days (range: 10,5–1494). The median follow-up was 1021 days (range: 485,5–1535). Two patients were lost at follow-up. The defects were successfully repaired and the membranes perfectly tolerated in 28/29 cases. In 1 case of CDH the fascia lata was replaced with a Goretex patch due to recurrence of the defect. This is the largest series on the use of biological membranes in congenital malformations. The variety of tissues allows to choose the best material for each malformation. The excellent tolerance and performance of this first series of patients encourage the use of these membranes to correct different type of malformations at any age.

Impact of World Tuberculosis Day on digital awareness of tuberculosis: analyses using Google Trends™

BACKGROUND: Tuberculosis (TB) is the ninth leading cause of death worldwide. World Tuberculosis Day is held every year to increase global awareness of TB.OBJECTIVE: To quantify the impact of World Tuberculosis Day using Internet-based data.METHODS: Google Trends™ data were used to quantify digital searches for the term 'tuberculosis' worldwide and in the seven countries with the highest TB incidence. We estimated the mean difference in relative search volume (RSV) between World Tuberculosis Day and control periods. This was done separately for each year (2004-2017) and for the period from 1 January 2004 to 31 December 2017. The mean differences in RSVs with the corresponding 95% confidence intervals (CIs) were estimated. P values were calculated using the Mann-Whitney U-test. P < 0.05 was considered significant.RESULTS: Analyses of single years revealed the mean difference in RSV for worldwide searches on average was 12.5 (95%CI 4.6-20.2). Between 1 January 2004 and 31 December 2017, it was 10.4 (95%CI 6.0-15.0). In high-incidence countries, results ranged from -0.9 (95%CI -5.0 to 6.0) for Nigeria to 13.3 (95%CI 5.0-25.0) for South Africa.CONCLUSION: International campaigns such as the World Tuberculosis Day raise global awareness of TB. More actions are needed to increase TB awareness in high-incidence countries.

Skin substitutes based on allogenic fibroblasts or keratinocytes for chronic wounds not responding to conventional therapy: a retrospective observational study

Chronic wounds are an expression of underlying complex pathologies and have a high incidence. Skin substitutes may represent an alternative approach to treat chronic ulcers. The aim of this retrospective observational study was to evaluate the wound reduction using skin substitutes based on allogenic fibroblasts or keratinocytes in 30 patients not responding to conventional therapy. Wound bed was prepared, then keratinocytes on Laserskin(®) to treat superficial wounds or fibroblasts on Hyalograft 3D(R) to treat deep leg ulcers were applied, and finally wounds were treated with a secondary dressing composed of nanocrystalline silver. Once a week constructs were removed and new bioengineered products were applied, as well as nanocrystalline silver medication. In none of the cases under examination did any complications arise relating to the treatment. We also achieved a reduction in wound dimension and exudates, and an increase in wound bed score. Postoperative assessment shows a degree of healing that is statistically higher in the group treated with keratinocytes as compared with the fibroblast group. This retrospective study improves our understanding and defines the clinical indications for the various uses of the two types of skin substitutes.

Congenital diaphragmatic hernia: focus on abnormal muscle formation

BACKGROUND

CDH is a major birth defect, characterized by high mortality. How the initial defective mesenchymal substructures affects muscle malformation is unclear. Defects of genes involved in diaphragmatic development, such as friend-of-GATA2 (Fog2), may play an important role in its pathogenesis. We investigated the expression of Fog2 and proteins of myogenesis in a series of CDH and in diaphragms at different fetal ages, in order to clarify the role of muscular components during diaphragmatic development in cases with CDH.

MATERIAL AND METHODS

Specimen were obtained from seven diaphragms of CDH cases undergoing surgery, 3 entire diaphragms from non repaired CDH, 5 control diaphragms at different gestational ages (16, 17, 22, 32, and 40g.w.), and 3 biopsy samples of normal voluntary muscle. The thickness of diaphragms at the edge of the defect in CDH and in developing diaphragms was measured. All samples were processed for HE staining and immunohistochemistry. Immunohistochemical expression of MyoD, Myf4, Pax7, Mib1 and Fog2 was evaluated.

RESULTS

Mean thickness at the edge of the defect was 4.14mm. Contralateral hemi-diaphragm in 3 autopsies and in controls at 32 and 40weeks measured 2.25mm; histology showed a higher density of desmin-positive muscular cells at the edge of defect. CDH displayed scattered Myf4-positive cells (range 0%-10%, mean 2.4%), numerous Pax7-positive cells (range 0%-24%, mean 12.1%) and less than 1% Mib1-positive cells. Controls showed a reduction of positive cell with the progression of gestational age for Myf4 (30% at 16 weeks, 20% at 17 weeks, 5% at 22 weeks, 1% at 32 and 40 weeks), Pax7 (85% at 16 weeks and 17 weeks, 35% at 22 weeks, 11% at 32 weeks) and Mib1 (20% at 16 weeks, 8% at 17 weeks, 7% at 22weeks, 2% at 32 weeks). Fog-2 was diffusely positive in mesenchymal, mesothelial and muscular cells, in diaphragms from 16 to 22 weeks, decreasing to 20% of positive muscular cells in 32-week diaphragm. In CDH only mesothelial and mesenchymal cells were positive. Stem cell markers were negative in cases and controls.

COMMENT

CDH shows a thick muscular border, with high number of mature muscle cells and significant increase of quiescent satellite cells (PAX7+, Mib1-). Abnormal architecture may affect the normal process of myogenesis and thus signaling and cell-cell interactions of myocytes. The expression of Fog2 in mesothelial and mesenchymal cells in CDH demonstrates the absence of a genetic defect involving Fog2 in our cases. Being Fog2 expressed in muscle cells at early stage supports the hypothesis that the altered diaphragmatic genesis may undermine also the muscular component instead of the only mesenchymal one.

National policies for risk management in Italy

The Ministry of Health in Italy considers risk management (RM) to be one of the specific objectives to be developed by its national policies, as suggested by the European Union recommendations and by several international organizations, such as the World Health Organization (WHO), the Council of Europe, and the Organization for Economic Cooperation and Development. The National Health Plan stated the need to guarantee and monitor safety of health care and biomedical technology, with the development of a standardized computerized method to collect and analyze data on adverse events and with specific actions for education and training of all stakeholders, which is to be conducted at different levels of the health system governance, national, regional, and local. Over a 4-year period, the National Observatory for the Monitoring of Sentinel Events has collected data on 385 sentinel events, with a mortality rate of 54.8%. Compared with earlier reports, we have observed a reduction from 41% to 17% of sentinel events classified in the "nonspecified sentinel event" and an increase from 20% to 40% of cases in which an action plan has been developed. A manual for root cause analysis has been released with the aim of offering health operators an instrument to analyze the occurrence of an adverse event. Ten recommendations and a manual for safety in the operating room, which includes a checklist for safe surgery adapted on the basis of WHO suggestions, have been published. To date, eight guidelines for safety have been released to improve stakeholders' accountability. The Ministry of Health has also elaborated a program of specific actions to be developed over the next 2 years in several areas of RM. These initiatives confirm the strategic role of policies for RM in our country, allowing for a dynamic and proactive process, ensuring continuity of action and promoting a deep understanding of patient safety issues.