Laparoscopic ovarian tissue collection for fertility preservation in children with malignancies: a multicentric experience

Introduction

Long survivors after childhood cancer are increasing thanks to oncological improvements. Their quality of life and fertility-sparing should be considered in the early phases of each oncological pathway. Cryopreservation of ovarian tissue removed before starting gonadotoxic therapies is the only fertility sparing procedure available for prepubertal children affected by cancer and it does not affect the timing of the start of the treatment.

Materials and methods

The present study shows the surgical and clinical outcomes following laparoscopic ovarian tissue collection (LOTC) for a total of 311 patients aged between 0 and 17 years old from four different European Centers.

Results

Only two major complications were reported according to the Clavien Dindo classification (0.6%).

Discussion

LOTC can be considered a safe procedure.

Ask Doctor Smartphone! An App to Help Physicians Manage Foreign Body Ingestions in Children

BACKGROUND

Foreign body ingestion (FBI) represents the most common cause of emergent gastrointestinal endoscopy in children. FBI's management can be quite challenging for physicians because of the variability of the clinical presentation, and the decision tree becomes even more intricate because of patient-specific variables that must be considered in the pediatric age range (e.g., age of patients and neuropsychiatric disorders) in addition to the mere characteristics of the foreign body. We present an application for smartphones designed for pediatricians and pediatric surgeons based on the latest guidelines from the official pediatric societies. The app aims to help physicians manage FBI quickly and properly in children.

MATERIALS AND METHODS

The latest pediatric FBI management guidelines were reviewed and summarized. The flow chart we obtained guided the development of a smartphone application. A questionnaire was administered to all pediatric surgeon trainees at our institute to test the feasibility and helpfulness of the application.

RESULTS

An app for smartphones was obtained and shared for free on the Google Play Store and Apple Store. The app guides the physician step by step in the diagnostic process, analyzing all patient- and foreign body-specific characteristics. The app consultation ends with a suggestion of the most proper decision to make in terms of further radiological investigations and the indication and timing of endoscopy. A questionnaire administered to trainees proved the app to be useful and easy to use.

CONCLUSION

We developed an app able to help pediatricians and pediatric surgeons manage FBI in children, providing standardized and updated recommendations in a smart and easily available way.

Dirofilaria repens Testicular Infection in Child, Italy

Testicular Dirofilaria repens infection was identified and confirmed by sequence analysis in a child in northeastern Italy. Because human dirofilariasis is emerging in southern and eastern Europe, this parasitic infection should be considered in the differential diagnosis of scrotal swelling in disease-endemic countries to avoid unnecessary interventions, such as orchiectomy.

POS0364 UNMET NEEDS IN THE TREATMENT OF EXTRA-RENAL FLARES IN SLE PATIENTS: REAL LIFE EXPERIENCE VS ARTIFICIAL APPROACH

Background

Systemic lupus erythematosus (SLE) is a heterogeneous disease which can affect various organs and is characterized by different clinical phenotypes. While the treatment of renal involvement is quite standardized, the therapeutic approach to extra-renal manifestations is subjected to a degree of variability.

Objectives

1. To describe extra-renal disease flares in terms of clinical phenotype and outcomes in SLE patients 2. To compare data from a real-life setting with a machine learning (ML) approach.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who experienced a disease flare between 2015 and 2020. Each flare was followed for one year and was classified according to the organ involvement and categorized according to the BILAG definition of flare. At baseline and at 3,6,12 months the following variables were collected: disease activity (SELENA-SLEDAI score), ongoing therapy and disease state (DORIA definition of remission). Demographic data and previous organ involvement were retrieved from clinical charts. Flares’ features at baseline and during follow up were analyzed in terms of explained variance across the dataset’s Principal Components and clustered with a hierarchical unsupervised learning approach. A ML model based on neural networks was built to early detect flares’ therapeutic difficulty: it was validated after data augmentation to satisfy statistical requirements during the training phase.

Results

66 extra-renal flares were investigated (Table 1); 5 flares (7.5%) were treated with glucocorticoid (GC) pulses and 61 (92.5%) with oral GC therapy, while an immunosuppressive (IS) treatment was prescribed in 44 flares (66.7%). The remission rate at 12 months for the whole group was 50%, with musculo-skeletal (MS) flares, mucocutaneous (MC) flares and others (neuropsychiatric, cardiopulmonary, constitutional, haematologic) that was respectively 63.6%, 31.3% and 41.2%, showing lower rate of remission for MC flares. In 12 months, 17 flares (25.8%) did not respond to treatment (non-responders), requiring an increase in the dose of GC or the introduction of a new IS therapy. Using a machine learning approach, we were able to identify 4 flare clusters, grouping flares in relation to phenotypic characteristics (Figure 1), and recognized statistically relevant features for patients’ stratification (cluster 1“flare in systemic disease with high activity”, cluster 2 “outcast flares”, cluster 3 “flare in polymorphic disease with mild activity” and cluster 4 “recurrent skin flares”). Interestingly, cluster 4 (recurrent skin flares) was associated with the lowest rate of remission at 12 months with respect to clusters 1, 2, and 3 (33% vs 40%, 76.5% and 56% respectively). Moreover the neural network model correctly predicts difficult to treat flares in up to 80% of the cases

Table 1.WHOLE GROUPMUSKELMUCOCUTCONSTITUTIONALCARDIOPULMHAEMATOLNEUROpNUMBER (%)6633 (50)16 (24.2)7 (10.6)4 (6.1)5 (7.6)1 (1.5)SLEDAI at baseline median (IQR)7 (4-29)8 (6-10)5.5 (4-10)5 (4-9)9 (4.5-12)5 (5-6)29 (29-29)SLEDAI 12 mos median (IQR)2 (0-20)0.5 (0-4)3 (0-4)3 (2 – 4)0 (0-0)2 (0-3)14 (14 – 14)REMISSION 12 mos number (%)33 (50)21 (63.6)5 (31.3)4 (57.1)2 (40)2 (40%)1 (100)0.217NON RESPONSE 12 mos number (%)17 (25.8)8 (25)5 (31.3)2 (28.6)1 (20)1 (20%)1 (100)0.467Figure 1.

Flare clusters.

Conclusion

These data suggest that, in a real-life setting, the clinical response rate to therapy of patients with an extra-renal flare is not satisfactory, thus identifying an unmet need in the treatment of SLE and highlighting the absence of a standard treatment. Both the real-life data and the machine learning approach identify flares with MC manifestations as the most difficult to treat with the lower rate of remission after one year. Further prospective studies are necessary to improve the neural network model; ML techniques could help in the early identification of difficult to treat flares to be candidates for new and more aggressive therapeutic strategies for extra-renal manifestations.

Disclosure of Interests

None declared

AB0423 STRATEGIES FOR GLUCOCORTICOID TREATMENT IN SYSTEMIC LUPUS ERYTHEMATOSUS FLARES: A REAL-LIFE EXPERIENCE

Background

Glucocorticoids (GC) are a cornerstone for the treatment of Systemic Lupus Erythematosus (SLE) manifestations but there is still open debate concerning their optimal therapeutic employment.

Objectives

To describe and compare the GC therapeutic strategies used in a real-life setting for the initial treatment of SLE flares.

Methods

This study is a retrospective analysis of data from a monocentric cohort of SLE patients who registered a disease flare between 2015 and 2020. Flares were first categorized in “pulse-treated” (PT) and “non pulse-treated” (NPT). PT flares were then divided into “low-dose regimen” (250 mg iv 6MP for 3 consecutive days or less) and “high-dose regimen” (more than 250 mg iv 6MP for 3 days). GC daily and cumulative 6MP doses, rate of remission and relapse were evaluated at 3, 6 and 12 months.

Results

101 flares were analyzed (30 PT and 71 NPT). PT flares were more severe in terms of median SLEDAI (PT 16(12-22) vs NPT 8(5-10) p=0,00) and BILAG score index (BILAG A PT 71% vs NPT 30% p=0,001). PT patients received significantly higher GC doses at 1 month (PT median cumulative dose 1372 IQR 1028 – 3076 mg of 6MP vs NPT median 160 IQR 120-288 mg of 6MP, p=0,000), 6 months (PT median cumulative dose 2964 IQR 2294 – 4305 mg of 6MP vs NPT 880 IQR 720 – 1284 mg of 6MP, p=0,000) and 12 months (PT median cumulative dose 3510 IQR 3014-5025 vs NPT median cumulative dose 1571 IQR 1098 – 2122 mg of 6MP, p=0,000). Characteristics of flares that were treated with low-dose (N=19) or high-dose (N=11) pulse regimen are summarized in Table 1. As expected, the “low-dose regimen” subgroup received lower cumulative GC dosage over time. However, no statistically significant differences were found neither in term of disease severity at baseline nor in term of disease activity, remission rates or new flares over time.

Table 1.

Comparison between low-dose pulse regimen and high-dose pulse regimen in terms of cumulative GC dose and outcome in the first year after a SLE flare

Median GC doses (6MP)Low-dose regimenN=19 (63,33%)High-dose regimenN=11 (36,67%)P value Median SLEDAI16 (12 -20)18 (8-24)0,6186BILAG score (A, B, C)A=14, B=4, C=1A=10, B=1, C=00,488Cum. dose 1 mo1350 (1028 – 1534)1752 (960 – 2356)0,126Cum. dose 3 mos1858 (1604 – 2463)2784 (2184 – 3240)0,040Cum. dose 6 mos2450 (2218 – 3586)3456 (2906 – 4380)0,029Cumulative doses 12 mos3150 (2851 - 4448)4246 (3591 – 5772)0,011Remission 3 mos no – (%)2 (10%)0 (0%)0,265Remission 6 mos no – (%)8 (42%)1 (9%)0,057Remission 12 mos no – (%)12 (63%)5 (45%)0,346Median SLEDAI 3 mos4 (2 – 9)9 (4 – 12)0,138Median SLEDAI 6 mos3 (0 - 4)4 (0 – 9)0,154Median SLEDAI 12 mos2 (0 – 5)2 (0 – 12)0,363New flares 6 mos no – (%)2 (10%)1 (9%)0,900New flares 12 mos no – (%)2 (10%)2 (18%)0,552

GC=glucocorticoids, 6MP=6-methylprednisolone, no=number, Cum.=cumulative, mos=months

Conclusion

These data suggest that in a real-life setting, pulse GC therapy is preferred over oral administration for severe SLE flares and entails administration of high cumulative doses of GC. However, the experience outlined suggests that the low-dose pulse regimen is as effective in remission induction of severe flares as the high-dose regimen, allowing significant GC sparing. Since the cumulative GC dose is a known strong predictor of organ damage, strategies aimed to minimize the GC dosage should be encouraged.

Disclosure of Interests

None declared

AB1410 IMPACT OF COVID-19 PANDEMIC ON HEALTHCARE RESOURCE USE AND CLINICAL OUTCOMES IN A COHORT OF PATIENTS WITH SYSTEMIC AUTOIMMUNE DISEASES- AN INTERIM ANALYSIS FROM THE PER-MAS PROJECT

Background

Management of the health emergency caused by COVID-19 pandemic majorly disrupted the delivery of healthcare services to patients with chronic conditions like Systemic Autoimmune Diseases (SAD), both because resources were mainly channeled towards the care of infected patients, but also because patients tended to avoid seeking medical care for fear of becoming infected. PER-MAS is a 2-year project aimed at assessing the clinical, psychopathological, and socio-economic impact of COVID-19 in a cohort of patients with SAD.

Objectives

To assess the impact of COVID-19 pandemic on drug withdrawal, disease flares and hospitalizations for disease exacerbation in a cohort of patients with SAD through an interim analysis of data from the PER-MAS project.

Methods

A sample of 214 consecutive patients was recruited in a reference center for rare and complex autoimmune diseases from April 2021 to January 2022. Inclusion criteria were definite diagnosis of SAD (Connective Tissue Disease (CTD), Inflammatory Arthritis (IA) or Vasculitis), regular follow-up and at least 2 years of disease. Patients were asked to fill out an extensive self-administered questionnaire on disease activity and healthcare resource use during the pandemic (March 2020-moment of assessment). Pre-pandemic (March 2019-February 2020) and early pandemic (March 2020-February 2021) clinical data were recorded through retrospective chart review and patient interview.

Results

At enrolment, 119 patients were affected by CTDs (55.6%), 71 by IA (33.18%), 24 by vasculitis (11.21%), with mean age 50.44± 12.97, and mean disease duration 11.17 ± 8.94. 30.37% took steroids, 39.7% hydroxychloroquine, 61.68% DMARDs, and 9.3% vasoactive drugs.

Overall, disease course was similar in pre-pandemic and early pandemic phase: in the first period, rheumatologic condition was stable in 57.35% of patients, persistently active in 27.3% and 35.61% had ≥ 1 episode of disease exacerbation (mean 0.665±1.15, range 0-6); in the second period, 60.56% of patients was stable, 24.88% persistently active, and 39.44% had ≥1 exacerbation (mean 0.49 ±0.77, range 0-4). Mean number of visits (2.56±2.57 and 2.61±2.79), hospitalizations (0.168±0.698 and 0.14±0.473, p=0.6), number of patients with outpatient visits=0 (7.47 vs 7%), and number of patients with ≥ 1 hospital admission (10.28 vs 11.6%) were also similar, while the number of patients with hospital admissions for disease exacerbation was significantly higher in the second period (6.1 vs 11.21%, p=0.001).

170 patients completed the survey: from March 2020 to enrolment, 18.2% suspended ≥1 anti-rheumatic drug (6.25% of them for fear of contracting COVID-19 disease, 15.6% for difficulty in obtaining medications), 20% self-managed ≥ 1 disease exacerbation, and 40% had ≥ 1 telemedicine consult. From March to July 2020, 41.76% had their visit rescheduled (35.23% for hospital access restrictions, 5.3% for travel restrictions, 1.17% for fear). Conversely, only 14.7% of patients had their visit rescheduled (8.23% for hospital access restrictions, 4.7% for other reasons) from July 2020 to enrolment.

Conclusion

In the early pandemic phase, overall disease course was similar to the pre-pandemic phase, but we observed an increase in the number of patients with ≥ 1 hospitalization for disease. Moreover, despite our efforts, patients reported a non-negligible rate of drug discontinuation for non-medical indication and difficulty to get access to rheumatologic consultation, highlighting the need of alternative organizational models in case of future pandemics.

Acknowledgements

Giulia Sacco for helping in patient recruitment and data management.

Disclosure of Interests

Francesca Trentin: None declared, Giovanni Fulvio: None declared, Gianni Andreozzi: None declared, Cosimo Cigolini: None declared, Mattia Da Rio: None declared, Valerio Dell’Oste: None declared, Elena Elefante: None declared, Federico Fattorini: None declared, Silvia Fonzetti: None declared, Valentina Lorenzoni: None declared, Michele Maffi: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Virginia Pedrinelli: None declared, Laura Scagnellato: None declared, Davide Schilirò: None declared, Anastasiya Valevich: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Liliana Dell’Osso: None declared, Giuseppe Turchetti: None declared, Marta Mosca Speakers bureau: Lilly, Astra Zeneca, GSK, Consultant of: Lilly, Astra Zeneca, GSK

OP0197 POST-TRAUMATIC STRESS DISORDER AND SYMPTOMS IN PATIENTS WITH RHEUMATIC AND MUSCULOSKELETAL DISEASES DURING THE COVID-19 PANDEMIC: PRELIMINARY RESULTS FROM THE PERMAS STUDY

Background

The COVID-19 pandemic, with its uncertainties, fears of contagion, mass lockdowns and containment measures, has dramatically impacted on people’s everyday lives leading to an increased risk of mental disorders, particularly Post-Traumatic Stress Disorder (PTSD). Despite evidence in general population and healthcare workers1,2, scant data emerged on vulnerable populations, such as of patients with chronic illness, particularly rheumatic and musculoskeletal diseases (RMDs)3,4, who also underwent difficulties in the management and treatment of their disorders.

Objectives

To assess PTSD and post-traumatic stress symptoms in a sample of patients with RMDs, during the COVID-19 pandemic in Italy.

Methods

PERMAS is a monocentric prospective observational study led by the Rheumatology Unit, the Psychiatric Clinic and the Institute of Management of the School of Advanced Studies. Patients with a RMD diagnosis, were consecutively enrolled from May 2021 to January 2022. During the visit, sociodemographic characteristics and psychopathological data were collected through online survey, whereas clinical data were collected by physician. The survey included the Trauma and Loss Spectrum- Self Report (TALS-SR) and the Impact of Event Scale- Revised (IES-R), aimed to assess symptomatological PTSD and post-traumatic stress symptoms related to the impact of the COVID-19 pandemic.

Results

A total of 194 eligible patients, with a mean age of 50.3±12.17 years, was included: 142 (73.19%) were females; 112 (57.74%) patients reported connective tissue diseases (CTD), 63 (32.47%) arthritis and 19 (9.8%) vasculitis. A total of 33 (17%) subjects reported a symptomatological PTSD by means of the TALS-SR. The prevalence of Partial PTSD (defined by at least 2 out of the 4 criteria for DSM-5 diagnosis of the disorder) was 56.7%, with significant higher rates among females (90, 81.8%) with respect to males (20, 18.2%) (p=.013). Accordingly, a IES-R mean total score of 21.90 ±15.98 was found in the total sample and a gender difference emerged, with higher mean scores among females rather than males (23.42 ±16.26 vs 21.90 ±15.98, p=.031).

Conclusion

The present findings point out high prevalence rates of symptomatological PTSD among patients suffering from RMDs, highlighting the potentially traumatic burden of the COVID-19 pandemic in this particular population, especially among females, suggesting the need of further investigations to address tailored prevention and intervention strategies.

References

[1]Fiorillo A, Sampogna G, Giallonardo V, Del Vecchio V, Luciano M, Albert U, Carmassi C, Carrà G, Cirulli F, Dell’Osso B, Nanni MG, Pompili M, Sani G, Tortorella A, Volpe U. Effects of the lockdown on the mental health of the general population during the COVID-19 pandemic in Italy: Results from the COMET collaborative network. Eur Psychiatry 2020; 63(1), e87.

[2]Carmassi C, Dell’Oste V, Bui E, Foghi C, Bertelloni CA, Atti AR, Buselli R, Di Paolo M, Goracci A, Malacarne P, Nanni MG, Gesi C, Cerveri G, Dell’Osso L. The interplay between acute post-traumatic stress, depressive and anxiety symptoms on healthcare workers functioning during the COVID-19emergency: A multicenter study comparing regions with increasing pandemic incidence. J Affect Disord 2022; 298(Pt A), 209-216.

[3]Garrido-Cumbrera M, Marzo-Ortega H, Christen L, Plazuelo-Ramos P, Webb D, Jacklin C, Irwin S, Grange L, Makri S, Frazão Mateus E, Mingolla S, Antonopoulou K, Sanz-Gómez S, Correa-Fernández J, Carmona L, Navarro-Compán V. Assessment of impact of the COVID-19 pandemic from the perspective of patients with rheumatic and musculoskeletal diseases in Europe: results from the REUMAVID study (phase 1). RMD 2021; 7(1), e001546. doi: 10.1136/rmdopen-2020-001546

[4]Wang XA, Duculan R, Mancuso CA. Coping Mechanisms Mitigate Psychological Stress in Patients With Rheumatologic Diseases During the COVID-19 Pandemic. J Clin Rheumatol 2021. doi: 10.1097/RHU.0000000000001757

Disclosure of Interests

Giovanni Fulvio: None declared, Virginia Pedrinelli: None declared, Gianni Andreozzi: None declared, Francesca Trentin: None declared, Sara Fantasia: None declared, Silvia Fonzetti: None declared, Chiara Fustini: None declared, Mattia Da Rio: None declared, Gabriele Cappellato: None declared, Cosimo Cigolini: None declared, Davide Schilirò: None declared, Michele Maffi: None declared, Laura Scagnellato: None declared, Anastasiya Valevich: None declared, Federico Fattorini: None declared, Inmaculada Concepción Navarro García: None declared, Ilaria Palla: None declared, Valentina Lorenzoni: None declared, Andrea Gaglioti: None declared, Claudia Carmassi: None declared, Chiara Tani: None declared, Giuseppe Turchetti: None declared, Liliana Dell’Osso: None declared, Marta Mosca Speakers bureau: Lillly, Astra Zeneca, GSK, Consultant of: Lillly, Astra Zeneca, GSK

Rise of pediatric robotic surgery in Italy: a multicenter observational retrospective study

Background

The minimally invasive surgery (MIS) in term of robot-assisted surgery changed in a dramatic way the surgical approach either in adults or children. For many specialties (urology, gynecology, general surgery) robotic surgery rapidly became the gold standard for some procedures, while the experience in pediatric population is not wide for some reasons. The aim of this study is to retrospective analyze trends of application of robotic surgery in pediatric patients across the country, focusing on indications, limitations, development, and training acquired by national experience and in comparison to the literature.

Methods

We made a retrospective multicenter study on behalf of Italian Society of Pediatric Surgery. We performed a census among all pediatric surgery units in the country to enroll those performing robotic surgery on children between 2013 and 2019.

Results

We enrolled 7 pediatric surgery referral Centers (Ancona, Bologna, Brescia, Genova, Pavia, Pescara, Siena). A total of 303 patients were included in the study, 164 males (54%) and 139 females (46%). The most commonly performed interventions for each anatomic area were respectively atypical pulmonary resection (38%), pyeloplasty (49%), and fundoplication (30%).

Conclusions

Since its first application in Italy, about 10 years ago, several considerations were made about application and feasibility of robotics in children.

Corrigendum: Ovarian tissue cryopreservation and transplantation: 20 years experience in Bologna University

[This corrects the article DOI: 10.3389/fendo.2022.1035109.].

Ovarian tissue cryopreservation and transplantation: 20 years experience in Bologna University

OBJECTIVE

To report the 20-year experience in ovarian tissue cryopreservation (OTC) and ovarian tissue transplantation (OTT) of the Bologna clinical center (Bologna, Italy).

DESIGN

Retrospective cohort study.

PATIENTS

1026 pediatrics and women aged between 2 and 38 years who underwent OTC and OTT between January 2002 to January 2022.

RESULTS

Of the 1026 patients, 238 (22.8%) were pediatrics (≤ 17 years, Group 1) and 788 (77.2%) were adult women (range 18-38 years, Group 2). In Group 1, 184 (77.3%) patients had malignant diseases and 54 (22.7%) had non-malignant diseases. In Group 2, 746 (94.7%) patients had malignant diseases and 42 (5.3%) had non-malignant diseases. No real complications were observed during surgery. In all the samples analyzed most of the follicles were in the resting stage, while only a few follicles were growing. In both fresh and thawed samples, follicular density was higher in Group 1 than in Group 2 (p < 0.01). Regardless of age, good preservation of follicles and stroma was observed in fresh and thawed ovarian tissue by histological and immunohistochemical analyses (estrogen and progesterone receptors; Ki67 and Bcl2 markers; TUNEL). To date, out of 1026 total women, 812 (79.1%) had their tissue stored. Sixty-eight (6.6%) patients died from their primary disease. Twenty-four (2.3%) women performed 33 OTTs between December 2011 and January 2022. Restoration of menstruation was observed in 15 out of 17 menopausal women. Six pregnancies were achieved, two hesitated in abortion and four in the birth of healthy babies.

CONCLUSION

OTC is the only fertility preservation technique applicable in pre-pubertal/pediatrics and in adult patients when stimulation for oocytes/embryos cryopreservation is not possible. The reported data can help future patients and physicians in their discussions and decisions about the need and possibilities of preserving ovarian function.

Consequences of COVID-19 Lockdown on Children and Their Pets: Dangerous Increase of Dog Bites among the Paediatric Population

Background: The SARS-CoV-2 pandemic has not only put our national health systems to the test, but it also notably hit the economy, the society and the psychology of the people. Our pets have been subjected to the pandemic related stress too. The aim of the study was to evaluate whether the stress induced on domestic dogs resulted in an increase of dog bites in the paediatric population. Methods: A retrospective study was conducted on all patients admitted to our paediatric emergency department for dog bite from January 2014 and December 2020. We compared the total mean dog bites of the years 2014–2019 and the mean number per single month with the respective 2020 data. The bites were divided between bites from family dogs and bites from stranger dogs. Continuous data were analysed using single sample t test while categorical values with chi-squared test, considering statistically significant a p value < 0.05. Results: From January 2014 to December 2019, we recorded a mean of 41 ± 5.9 dog bites (range: 30–46) of which a mean 13 ± 2.6 (range: 10–17) were due to family dogs (32%) and a mean of 28 ± 2.4 (range: 25–31) were due to stranger dogs (68%); the male-to-female ratio was 3:2 and 43% of the injuries concerned the head and face, 26% the lower limbs, 25% the upper limbs, 3% the genitalia and 3% the torso. From January 2020 to December 2020, 30 children were admitted for dog bites: 22 were from family dogs (73%) and 8 from stranger dogs (27%); the male-to-female ratio was 14:11 and 72% of the injuries concerned the head and face, 16% the upper limbs, 8% the lower limbs and 4% the torso. The 2020 data’s higher number of family dog bites compared with the mean of those in the 2014–2019 period was statistically significant (p < 0.01) such as the 2020 data’s lower number of stranger dog bites when compared with the mean number of stranger dog bites in the 2014–2019 period (p < 0.01). Between 2014 and 2019, a mean of 9 ± 2 (range: 6–12) of the wounds needed to be sutured (22%), while 32 ± 3 (range: 28–35) wounds were discharged after application of Steri Strips (78%). On the other hand, in 2020, 21 wounds needed to be sutured (70%), and 9 received just Steri Strips application (41%). The frequency distribution of the treatments required (stitches vs. Steri Strips) between the 2014 to 2019 period and the 2020 period was statistically significant (p < 0.0001). Conclusions: The number of family dog bites in children increased in 2020, especially during the lockdown period. Paediatricians should pay a lot of attention now more than ever to educate parents on the importance of always supervising children who are playing with dogs.

Consequences of COVID-19 Lockdown on Children and Their Pets: Dangerous Increase of Dog Bites among the Paediatric Population

BACKGROUND

The SARS-CoV-2 pandemic has not only put our national health systems to the test, but it also notably hit the economy, the society and the psychology of the people. Our pets have been subjected to the pandemic related stress too. The aim of the study was to evaluate whether the stress induced on domestic dogs resulted in an increase of dog bites in the paediatric population.

METHODS

A retrospective study was conducted on all patients admitted to our paediatric emergency department for dog bite from January 2014 and December 2020. We compared the total mean dog bites of the years 2014-2019 and the mean number per single month with the respective 2020 data. The bites were divided between bites from family dogs and bites from stranger dogs. Continuous data were analysed using single sample t test while categorical values with chi-squared test, considering statistically significant a p value < 0.05.

RESULTS

From January 2014 to December 2019, we recorded a mean of 41 ± 5.9 dog bites (range: 30-46) of which a mean 13 ± 2.6 (range: 10-17) were due to family dogs (32%) and a mean of 28 ± 2.4 (range: 25-31) were due to stranger dogs (68%); the male-to-female ratio was 3:2 and 43% of the injuries concerned the head and face, 26% the lower limbs, 25% the upper limbs, 3% the genitalia and 3% the torso. From January 2020 to December 2020, 30 children were admitted for dog bites: 22 were from family dogs (73%) and 8 from stranger dogs (27%); the male-to-female ratio was 14:11 and 72% of the injuries concerned the head and face, 16% the upper limbs, 8% the lower limbs and 4% the torso. The 2020 data's higher number of family dog bites compared with the mean of those in the 2014-2019 period was statistically significant (p < 0.01) such as the 2020 data's lower number of stranger dog bites when compared with the mean number of stranger dog bites in the 2014-2019 period (p < 0.01). Between 2014 and 2019, a mean of 9 ± 2 (range: 6-12) of the wounds needed to be sutured (22%), while 32 ± 3 (range: 28-35) wounds were discharged after application of Steri Strips (78%). On the other hand, in 2020, 21 wounds needed to be sutured (70%), and 9 received just Steri Strips application (41%). The frequency distribution of the treatments required (stitches vs. Steri Strips) between the 2014 to 2019 period and the 2020 period was statistically significant (p < 0.0001).

CONCLUSIONS

The number of family dog bites in children increased in 2020, especially during the lockdown period. Paediatricians should pay a lot of attention now more than ever to educate parents on the importance of always supervising children who are playing with dogs.

Anastomotic Stricture Definition After Esophageal Atresia Repair: Role of Endoscopic Stricture Index

BACKGROUND

To evaluate the feasibility and efficacy of endoscopic stricture index (SI_EN) to define anastomotic strictures (ASs) and to predict the need of dilatations.

MATERIALS AND METHODS

A retrospective longitudinal study was conducted on patients who underwent esophageal atresia repair from 1998-2020 (ethical committee approval CHPED-05-20-AS). SI_EN was calculated on the first endoscopy performed as follows: (D - d)/D, where D is the maximum diameter of lumen of the upper esophagus close to the AS and d is the diameter of lumen of the stricture. Nonparametric variables were examined using Wilcoxon-Mann-Whitney test, and continuous variables were analyzed using Spearman's test and regression analysis. A P value <0.05 was considered statistically significant. The sensitivity, specificity, and positive and negative predictive values of SI_EN were also calculated, and a receiver operating characteristic curve was designed.

RESULTS

A total of 46 patients were included in the study. A statistically significant correlation was found between SI_EN and number of dilations (Spearman's correlation rate, 0.7; P < 0.0005). A SI_EN threshold value ≥0.6 showed sensitivity of 100%, specificity of 80%, positive predictive value of 54%, negative predictive value of 100%, and the area under the curve of 84%.

CONCLUSIONS

SI_EN seems to be a good AS definer and prognostic tool; our study suggests that an AS could be defined by a SI_EN ≥0.6.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience

INTRODUCTION

Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS).

METHODS

A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant.

RESULTS

Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68.

CONCLUSIONS

The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

The APpendicitis PEdiatric (APPE) score: a new diagnostic tool in suspected pediatric acute appendicitis

Our aim was to develop an APpendictis-PEdiatric score (APPE score) in quantifying risk of acute appendicitis based on combination of clinical and laboratory markers. 1025 patients were classified in: acute appendicitis (AA) and non-appendicitis. Demographic/clinical features, and laboratory were collected. They were compared for quantitative-variables and categorical-variables. Significant predictors (P=<0,05) were included in logistic regression model. Based on regression-coefficients, a diagnostic score was tested by calculating the area under the ROC curve. Two cut-offs were established to define classes of risk of AA. 9 variables were identified as potentially predictors for AA. Those underwent logistic regression and a score was assigned, for maximum 21-points. The score showed an area under the curve: 0.831 and a linear proportion with the state of appendicular inflammation (R20.85). Patients with a score ≤8 were at low risk of AA (sensitivity 94%); those with a score ≥15 were at high risk for AA (specificity 93%). Those between 8 and 15 were defined at intermediate risk class. APPE-score guides clinicians in classifying patients with suspected-AA according to clinical and laboratory findings in order to improve their management.

Robotic removal of Müllerian duct remnants in pediatric patients: our experience and a review of the literature

Persistent Müllerian duct syndrome is a disorder of sexual development, which features a failure of involution of Müllerian structures. An enlarged prostatic utricle is a kind of Müllerian duct remnant (MDR) with a tubular shaped structure communicating with the prostatic urethra. Treatment is aimed at relieving symptoms when present, preserve fertility and prevent neoplastic degeneration. We describe 3 cases of successful robot assisted-removal of symptomatic MDRs. The first case came to our attention for pseudo-incontinence; the other two for recurrent urinary tract infections. The patients have not presented such symptoms anymore on follow-up. We then reviewed existent literature on authors who have recently investigated the main issues concerning MDRs and have attempted a roboticassisted approach on them. Robot-assisted laparoscopy can be considered a valid, safe and effective minimally-invasive technique for the primary treatment of prostatic utricle.

Practical and functional classification of the double urethra: A variable, complex and fascinating malformation observed in 20 patients

INTRODUCTION

Urethral duplication is a rare and variable malformation of the urinary tract, with non-univocal and complex management. In addition, different classification schemes have been proposed, but none have considered all the possible variants.

OBJECTIVE

To report experience with the management of 20 urethral duplication patients and propose a classification of this anomaly.

MATERIALS AND METHODS

A retrospective analysis collecting information regarding 20 patients (Table) with urethral duplication treated at a single institution over the past 40 years. Three females and 17 males were treated: two had vesico-urethral duplication, eight had urethral duplication with a single bladder, and eight had 'λ' duplication.

RESULTS

Immediate postoperative complications included urethral dehiescence (n = 1) and urethral stenosis (n = 2). The progressive augmentation by dilating the urethra (PADUA) technique was ineffective. During follow-up, the following were recorded: urinary incontinence (n = 2), urinary tract infection (n = 3), hypertension (n = 3) and erectile dysfunction (n = 1). All patients were satisfied with the aesthetic result.

DISCUSSION

Urethral duplication is a rare anomaly with male preponderance. Four types of duplication were described, on the basis of anatomy and management: vesical and urethral duplication (type 1), urethral duplication with single bladder (type 2), 'λ-type' duplication (type 3) and 'miscellanea' (multiple urethral channels, spindle urethra, other female forms, type 4). A full description of the malformation and surgical approach was given for each type. The advantages of the classification were compared with the literature.

CONCLUSIONS

The proposed classification should be a useful tool, based on the required surgical approach, even if surgery should be tailored to the patient. It is important to restore the anatomy and achieve urinary continence. Surgery can be challenging and a multi-step process, especially in cases of 'λ' duplications.

Thoracoscopic Approach for Congenital Diaphragmatic Hernia: A Useful Tool in Diagnosis and Treatment of Unexpected Associated Lung Lesion

We report the case of a neonate affected by prenatally diagnosed congenital diaphragmatic hernia (CDH), treated by thoracoscopy. During the procedure, we detected an associated extralobar pulmonary sequestration (EPS), which was preoperatively undiagnosed, and we removed it. EPS has been shown to be associated with CDH in up to 15 to 40% of cases. A possible explanation hypothesized is that pulmonary sequestration, which develops at 4 to 5 weeks of gestation, can disturb the fusion of the diaphragm and closure of the pleuroperitoneal canal. The thoracoscopic approach permitted us to identify the thoracic EPS that probably would have been otherwise missed.

Robot-assisted Pyeloureterostomy in Bifid Renal Pelvis With Ureteropelvic Junction Obstruction of the Lower Moiety

Duplications of the urinary collecting system and pyelo-ureteral junction obstruction (PUJO) are common, but the simultaneous presence of both anomalies is rarely encountered. In incomplete duplicated systems, PUJO usually affects the lower moiety. We present the case of a 5-year old boy with left bifid renal pelvis and hydronephosis of the lower moiety treated by robot-assisted pyeloureterostomy.

Octreotide in a Critically Ill Extremely Preterm Infant With Perforated Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is the most severe gastrointestinal complication of prematurity. Surgery, either peritoneal drainage placement or laparotomy with resection of the intestinal necrotic tracts, is the definitive treatment of perforated NEC; however, when clinical conditions contraindicate surgical approaches, little is known about medical treatments adjuvant or alternative to surgery. Octreotide is a synthetic somatostatin analog that inhibits pancreatic secretion and leads to splanchnic vasoconstriction. In preterm neonates, it is mainly used off-label for chylothorax and congenital hyperinsulinism, whereas gastrointestinal indications are limited. We describe the case of a critically ill extremely low birth weight infant with perforated NEC, who had unsuccessfully undergone peritoneal drainage placement and laparotomy. Her unstable condition contraindicated a further laparotomy, thus off-label treatment with octreotide was attempted. No adverse events occurred. The infant's condition gradually improved and progressive reduction of peritoneal outputs and successful resolution of pneumoperitoneum were achieved, with no relapse after octreotide discontinuation.

Laparoscopic treatment of congenital choledochal cyst and hepaticojejunostomy with extracorporeal Roux-en-Y anastomosis: technical aspects and early experience with three cases

Choledochal cyst (CDC) is a congenital dilatation of the extra and/or intrahepatic bile ducts and it is a rare condition in western countries. Classical treatment consists of cyst excision and hepaticojejunostomy. The first case of a laparoscopic CDC excision was described in 1995 and since that time an increasing number of institutions have adopted this technique, with good success. We describe our early experience of 3 cases of CDC treated with laparoscopic approach. We used a 10 mm umbilical port for the camera, and four 3-5 mm operative ports. We performed the laparoscopic removal of the cyst and gallbladder, videoassisted preparation of the Roux-en-Y loop and laparoscopic hepaticjejunostomy. No post-operative complications occurred. Laparoscopic excision of CDCs has been supposed to give better observation, a better cosmetic result, potentially less postoperative pain, and a shorter recovery. The main argument for performing an extracorporeal anastomosis is that it decreases the operative time. We recommend caution to prevent injury to the pancreatic duct and biliary structures during dissection and anastomosis. Lifelong surveillance is mandatory, even after resection of the choledochal cyst.

Long-term follow-up after esophageal replacement in children: 45-Year single-center experience

PURPOSE

We evaluated the results of esophagocoloplasty (ECP) in children by performing a 45-year retrospective cohort study in a single center.

MATERIALS AND METHODS

We collected all of the medical charts of patients who underwent ECP at our hospital from January 1969 to January 2014. We reviewed the medical history for each patient and then contacted the patients by phone to obtain responses to a questionnaire. The questionnaire evaluated the following four areas: overall general state, gastrointestinal function, dependence on the Health Sanitary System, and their aesthetic satisfaction.

RESULTS

We contacted 96 patients, and 72 completed our questionnaire. There were 45 males and 27 female respondents, with a mean age of 34.5 years. The mean Karnofsky performance status index was 96.4%. There were excellent scores obtained from 55 patients and fairly good scores from 16 patients. There was 1 patient with a low score, and there were no scores reported below 70%. Most patients (58/72) reported regular bowel habits, and no patients required drugs or other measures to facilitate defecation. Gastroesophageal reflux was present in 51 patients, and 62.8% have bothersome symptoms. Twenty-five patients used pharmacological therapies. Forty-eight patients (66.6%) were satisfied with the aesthetic result of surgery (mean score in a scale from 0 to 5, is 3).

CONCLUSIONS

ECP can be used in children who require esophageal substitution. The resulting long-term QoL is acceptable. However, the aesthetic outcomes remain a problem.

Laparoscopic resection of a rare gastrointestinal stromal tumor in children

Introduction

Gastrointestinal stromal tumors (GIST) are uncommon mesenchymal tumors of the gastrointestinal (GI) tract, accounting for 0.1% to 3% of all GI malignancies. Paediatric GIST have an annual incidence of 0.02 per million children, have a female predisposition, are usually located in the stomach (50–60%) and in up to 85% of cases CD117-cKit or PDGFRA mutation is absent, resulting in a decreased efficacy of the target therapy.

Case description

We report the case of an incidentally diagnosed gastric GIST in a 14-year-old boy with multiple malformations. Genetic tests and Kariotype resulted negative.

Recently, an abdominal US visualized an hypoechoic heterogeneous abdominal mass. The common tumor markers resulted negative and the abdominal CT-scan confirmed the presence of a solid round lesion (42×36mm) in contact with the stomach and the pancreas. Laparoscopy allowed the recognition and the removal of the nodular mass at the posterior margin of the stomach. The histopathologic and the molecular biology findings were consistent with a kit-wilde type GIST. Surgical margins were microscopically free of tumor cells.

These results justify the decision not to add other surgical or medical therapy. However, for high risk of recurrence and metastasis, a close follow-up was started.

Discussion and evaluation

GIST are asymptomatic in 10% to 30% of patients or present nonspecific symptoms and signs. These tumors present usually irregular, lobulated and ulcerated. CT-scan of the abdomen and pelvis or magnetic resonance imaging (MRI) are mandatory in the diagnostic work-up. The final diagnosis is based on histology and immunohistochemistry. Surgery is the first-line treatment in patients with localized disease.

Conclusion

Guidelines for the management of pediatric GIST are not presently available for the paucity of reports and data. However it is widely accepted that surgery is the first-line treatment and gross resection with negative microscopic margins can be considered therapeutic and lead to full remission of the pathology. Laparoscopy is a safe surgical approach for the exploration of the abdominal cavity, the evaluation of the disease and the complete removal of the tumor.

Ovarian tissue collection for cryopreservation in pediatric age: laparoscopic technical tips

As the number of young girls subjected to chemo and radiotherapy is steadily increasing it is our duty to try to preserve their future fertility and ovarian function. A possibility is to collect ovarian samples, cryopreserve them and reimplant the tissue when the treatments are over. We report our 11 year experience with the use of laparoscopy to collect ovarian tissue samples. In particular we focus on the details of the surgical technique. The procedure was performed in 54 patients affected by malignancies or pathologies requiring chemo or radiotherapy, with good results. Cryopreservation seems to be a good option to preserve future fertility although it is still an experimental method.

An Interesting Case of Double Compound Intussusception without Intestinal Occlusion in a 5-Year-Old Boy

Intussusception is a very common surgical finding in children. Idiopathic intussusception is relatively frequent in children within the first year and it usually causes an acute abdomen. Instead, complex intussusception involving multiple or remote intestinal segments is a very rare entity and it is frequently diagnosed intraoperatively. It is often because of an anatomical cause and it can occur at any age. We report a unique case of contemporary double site anterograde and retrograde ileoileal intussusception without intestinal occlusion because of a submucous intestinal lipoma. In our case, imaging studies were important for clinical suspicion and laparoscopy was essential for final diagnosis and its resolution.

Secondary omental torsion as a rare cause of acute abdomen in a child and the advantages of laparoscopic approach

Omental torsion is an underdiagnosed cause of acute abdomen in children. Most cases occur in adults, with only 15% presenting in children. It is estimated that omental infarct is found in approximately 0.1 to 0.5% of children undergoing operations for appendicitis. It may present with various signs and symptoms, although the clinical presentation usually mimics that of acute appendicitis. Definitive diagnosis is often established during surgery. We report a case of a 9-year-old boy who came to our attention for acute abdomen. We performed a laparoscopy-assisted procedure suspecting acute appendicitis. We therefore identified a secondary omental torsion associated with patency of the right inguinal duct and herniated omentum. Laparoscopy allowed a correct diagnosis and therapy.

A Rare Case of Chylothorax due to Pulmonary Lymphangiectasia in a 7-Year-Old Boy

Pulmonary lymphangiectasia (PL) is a rare condition characterized by dilatation of the lymphatic vessels. Post-neonatal PL is usually associated with pleural effusion and should therefore be suspected in the presence of chylothorax. We describe a post-neonatal manifestation of PL in a 7-year-old boy presenting chylothorax. Radiological examinations included thorax X-ray, ultrasound, and computed tomography scans. After the failure of conservative management (maintenance of the chest tube, total parenteral nutrition, administration of somatostatin synthetic analogues) we performed a thoracoscopic massive ligation of the thoracic duct's collateral along with a lung biopsy. Histology was compatible with type 1 congenital pulmonary lymphangectasia. One month after surgery a thoracoscopic pleurodesis was required for persistent chylothorax. The boy is now doing well 1 year after surgery.

Impact of erythropoietin (EPO) on irradiation effect on the EPO receptor–positive head and neck cancer

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Background: Anemia frequently occurs in Head and Neck Squamous Cell Carcinoma (HNSCC) and has been associated with decreased quality of life, impaired treatment outcomes and shortened survival. Furthermore, anemia is a causative factor of tumor hypoxia, which compromises the efficacy of radiotherapy (RT). In order to circumvent the negative effects of anemia, several attempts have been made including the use of EPO, particularly in HNSCC. However, recent clinical data suggest a detrimental effect of EPO on survival for HNSCC patients treated with RT plus EPO. Methods: The HNSCC CAL-166 cell line, which is wild type p53 and expresses the EPO receptor (EPOR), was investigated in the present study; a MTT test was used to examine the effects of EPO on the cellular response to RT. Extended preliminary experiments were performed to standardize the conditions (time of exposure to hypoxia and time to return of normal culture conditions) and the administration of radiation (fractionated or in single dose) to optimize the effects of hypoxia on radiation response. Cells were exposed to a X-rays source at escalating doses from 2–20 Gy and showed classical dose- response curves. Hypoxia was mimed using a ‘Bug-Box‘ anaerobic workstation for 24–48 hours. Results: After a single RT dose of 10 Gy, the data confirmed the negative effect of hypoxia, directly related to the duration of hypoxia (% surviving cells when irradiated in normoxia: 43.95 ± 4.24; when irradiated after 24 hours of hypoxia, 62.4 ± 8.3 or after 48 hours, % surviving cells 70.8 ± 7.4; p = 0.001 versus RT in normoxia). The addition of EPO, from 24 hours before RT to 72 hours after, until MTT test, did not modify the cytotoxic effect of RT in hypoxic, but also in oxic conditions. Conclusions: These preliminary data do not support a direct negative effect of EPO when treating EPOR positive tumor cells with irradiation. Additional data concern the molecular impact of EPO on tumor cell lines with examination of EPOR, HIF-1 alpha and EGFR.

No significant financial relationships to disclose.

Incidence and correlates of complex ventricular arrhythmias during dobutamine stress echocardiography after acute myocardial infarction

Although previous studies have confirmed the safety of dobutamine stress echocardiography, complex ventricular arrhythmias have been reported. Our aim was (1) to identify the markers of increased arrhythmic risk during dobutamine stress echocardiography and (2) to assess whether the occurrence of major ventricular arrhythmias during the test may represent a clinically useful marker of electrical instability. Three hundred and seventy-seven consecutive survivors from acute myocardial infarction, off cardioactive therapy, underwent dobutamine stress echocardiography 11.4 days after the acute event. Holter monitoring with assessment of heart rate variability and echocardiographic determination of left ventricular ejection fraction. In addition, exercise stress testing, signal averaged ECG and coronary angiography were carried out, respectively, in 357, 150 and 273 patients. Ten subjects showed complex ventricular arrhythmias (eight non-sustained and one sustained ventricular tachycardia and one ventricular fibrillation) during dobutamine stress echocardiography (group A), whilst 366 did not (group B). Complex ventricular arrhythmias were detected by Holter monitoring in 8/10 patients in group A and 45/367 patients in group B (odds ratio 28.6, 95% CI 5.4-92.2) and by exercise testing in 4/10 patients in group A and 33/347 patients in group B (odds ratio 6.3, 95% CI 1.4-27.2). Ejection fraction < 40% was present in 3/10 patients in group A and 50/367 in group B (odds ratio 2.7, 95% CI 0.3-12.2), whilst multivessel disease was present, respectively, in 8/10 and 176/263 patients (odds ratio 1.9, 95% CI 0.3-25.5). Reduced heart rate variability and the presence of late potentials on signal averaged ECG were found in, respectively, 40/367 and 13/140 patients in group B, but none were found in group A. A total of 61 events (35 CABG, 15 PTCA, four cardiac deaths and seven non-fatal reinfarctions) occurred during the follow-up (11.4 months, range 6 to 20): four in group A and 57 in group B. No documented major arrhythmic event was reported. We conclude that (1) complex arrhythmias during dobutamine stress may occur in patients early after acute myocardial infarction; (2) the preexisting evidence of frequent, as well as repetitive, arrhythmias represents a potential marker of increased risk in this connection and, finally, (3) dobutamine-induced arrhythmias seem to represent an uncommon, even though potentially dangerous, event but not a useful new "window' on electrical instability of post-MI patients.

Vasopressin release and water metabolism in patients with cirrhosis

Water retention is a complication in many patients with cirrhosis, usually attributed to excessive release of arginine vasopressin. To investigate the responsiveness of arginine vasopressin to osmotic and non-osmotic stimuli and its relationship to free water excretion, we studied 19 patients with cirrhosis under three different conditions: 45 min with legs raised to 60 degrees, to expand the central blood volume; infusion of 1000 ml of 0.45% saline solution to reduce plasma osmolality; and rapid injection of 50 ml of 2 M NaCl to increase plasma osmolality. Both expansion of central blood volume and decrease of plasma osmolality significantly reduced plasma vasopressin levels (from 2.1 +/- 0.6 to 1.39 +/- 0.3 pg/ml, p < 0.04; and from 1.09 +/- 0.25 to 0.41 +/- 0.13 pg/ml, p < 0.0001). The changes in free water excretion differentiated two subgroups of patients during each test: excretors and non-excretors. In the excretors, increased free water excretion was associated with suppressed vasopressin levels (below 0.5 pg/ml) and normal renal function. In the non-excretors, inability to improve free water excretion was associated with high vasopressin levels or with reduced distal delivery of the glomerular filtrate, except in some cases where vasopressin levels had fallen below 0.5 pg/ml and renal function was normal. For these cases the presence of other vasopressin-independent antidiuretic mechanisms is conceivable. The injection of hypertonic saline solution caused significant rises in plasma osmolality (from 287 +/- 1.9 to 292 +/- 1.6 mmol/kg, p < 0.05) and in plasma vasopressin levels (from 1.13 +/- 0.29 to 2.86 +/- 0.52 pg/ml, p < 0.05). These results suggest that vasopressin release in patients with cirrhosis is normally responsive to osmotic and non-osmotic stimuli, although our results show a lower theoretical osmolar threshold for suppression of vasopressin release in non-excretors than in excretors (276 vs 284 mmol/kg).

Improvement in identification of multivessel disease after acute myocardial infarction following stress-recovery analysis of ST depression in the heart rate domain during exercise

The demonstration of extensive coronary artery disease (CAD) after acute myocardial infarction (AMI) has important prognostic implications. Exercise-induced ST segment depression is commonly used for detecting the presence of CAD and evaluating its extension. However, even though there have been many attempts to increase its diagnostic yield, the accuracy of the electrocardiographic signal for identifying multivessel disease (MVD) is relatively low, particularly in post-MI patients. The aim of this study was to evaluate the ability of a simple index, combining information on the amount and kinetics of ST depression in the heart rate domain during exercise and recovery, to identify MVD after AMI. Seventy patients (mean age 53.4 years) underwent a bicycle, symptom-limited exercise stress test and coronary angiography 2-3 weeks and 6 weeks respectively, after uncomplicated AMI while cardioactive therapy was discontinued. After obtaining a computer-derived measurement of ST levels based on incremental averaging of normal complexes, the area subtended to baseline and limited by the ST trend against heart rate during both exercise (A1) and recovery (A2) was calculated. The difference (A1-A2) was defined as the 'Stress-Recovery Index' (SRI) and dichotomized, by means of receiver-operating characteristics curve analysis, at 5 mm x beats.min-1 to define an increased risk of MVD. The SRI of patients with MVD was significantly lower than that of patients with single vessel disease. The sensitivity of SRI < -5 mm x beats.min-1 (65%) for predicting MVD was significantly higher than that obtained by other conventional parameters, without appreciable loss of specificity (81%).(ABSTRACT TRUNCATED AT 250 WORDS)