Sexually Transmitted Infections in Adolescents and Young Adults: A Cross Section of Public Health

INTRODUCTION

Sexually transmitted infections (STIs) can be caused by a number of microorganisms that vary greatly in size, life cycle, clinical manifestations, and sensitivity to available treatments. Transmission of STIs can occur during unprotected (or condomless) sexual contact and through the exchange of body fluids during any type of activity. The prevalence of sexually transmitted diseases remains high in the world, despite diagnostic and therapeutic improvements for these infectious diseases that rapidly eliminate the contagiousness of patients. Our study determines the prevalence of STI pathogens in adolescents and young adults in the population of the Province of Macerata (Italy). We will analyze data in correspondence to age and gender, and we will compare our results to international studies.

MATERIALS AND METHOD

We analyzed STI test results from the entire database of a Provincial Health Authority for the period 2021-2022. The samples came from the following age groups: 0-12, 13-18, 19-25, and 26-35 from 2021 to 2022. The results came from vaginal and cervical swabs (for females); urethral, rectal, and pharyngeal swabs (for males and females); and seminal fluid (for males) for the following infections: HPV, Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasmas, Gardnerella, Trichomonas vaginalis, Neisseria gonorrhoeae, and Treponema pallidum. The results also came from blood tests for HIV, hepatitis C, hepatitis B, and Treponema pallidum (TPHA, VDRL). In addition, we examined results from urine tests for chlamydia, Neisseria gonorrhoeae, trichomonas, and Treponema pallidum.

CONCLUSIONS

The literature for other countries reports the need for comprehensive, culturally and developmentally sensitive care to address sexuality-related issues in adolescents and young adults, a need that also applies to Italy. These data will be of great importance in adopting evidence-based STI control programs in Marche Region. This study could, indeed, represent a landmark for public health officials and professionals, with the aim of promoting adolescents' access to sexual health services to receive useful information, strengthening preventive measures in younger age groups, and designing sexual education programs.

Medical ethics questions of COVID-19 vaccination in pregnant and lactating women in East Asia and Oceania

Abstract

We aimed to investigate some of the medical ethics issues that characterize the COVID-19 vaccination phase in pregnancy and breast-feeding. A literature search was conducted using PubMed, Scopus, Web of Science, focusing mainly on the countries of East Asia and Oceania. Vaccination during pregnancy and breastfeeding appears to help protect babies from COVID-19 by enabling antibodies to pass from mother to baby. However, individual countries of the same continent may adopt conflicting policy positions. Not only that, indications on the type of vaccine sometimes vary, depending on whether a woman is pregnant or breastfeeding. In this review we have taken into considerationp the policy positions on pregnancy and lactation by country and type of Covid-19 vaccine in East Asia and Oceania. Ten out of the 18 countries considered (representing more than two thirds of the population of East Asia and Oceania) provide different vaccine indications for pregnant and breastfeeding women. Can this diversity of recommendations be seen as a form of optimal protection for women in these categories, or does it suggest that some countries have taken a defensive position to avoid compensation claims in the event of complications? Is it ethically correct to leave questions concerning informed consent open? Misin-formation during a health crisis leaves people without protection and with increased vaccine hesitancy, especially for vulnerable populations in hard-to-reach areas of East Asia and Oceania.

A Systematic Review of Varying Definitions and the Clinical Significance of Fredet's Fascia in the Era of Complete Mesocolic Excision

BACKGROUND

Fredet's fascia represents a crucial landmark for vascular surgical anatomy, especially in minimally invasive complete mesocolic excision (CME) for right-sided colon adenocarcinoma. Fredet's fascia allows access to the gastrocolic trunk of Henle (GCTH), the most critical step in both open and minimally invasive right-sided CME techniques. Despite this, a recent workshop of expert surgeons on the standardization of the laparoscopic right hemicolectomy with CME did not recognize or include the term of Fredet's fascia or area. Hence, we undertook a systematic review of articles that include the terms "Fredet's fascia or area", or synonyms thereof, with special emphasis on the types of articles published, the nationality, and the relevance of this area to surgical treatments.

METHODS

We conducted a systematic review up to 15 July 2022 on PubMed, WOS, SCOPUS, and Google Scholar.

RESULTS

The results of the study revealed that the term "Fredet's fascia" is poorly used in the English language medical literature. In addition, the study found controversial and conflicting data among authors regarding the definition of "Fredet's fascia" and its topographical limits.

CONCLUSIONS

Knowledge of Fredet's fascia's surgical relevance is essential for colorectal surgeons to avoid accidental injuries to the superior mesenteric vascular pedicle during minimally invasive right hemicolectomies with CME. In order to avoid confusion and clarify this fascia for future use, we suggest moving beyond the use of the eponymous term by using a "descriptive term" instead, based on the fascia's anatomic structure. Fredet's fascia could, therefore, be more appropriately renamed "sub-mesocolic pre-duodenopancreatic fascia".

Over-the-counter emergency contraception in Italy: ethical reflections and medico-legal issues

Although more than ten years have passed since the marketing of Ulipristal acetate in Europe, emergency contraception remains a complex issue with many scientific, legal, ethical and social implications. The topic is an example of the differences that can exist between scientific evidence, the certainties on which law is based, and social implications. This paper shows the incompleteness of the scientific reconstruction on the effects of emergency hormonal contraceptives and the dangerousness of the decision to alienate the supply of over-the-counter drugs from the general rules of health care. This report shows the incompleteness of the scientific reconstruction on the effects of emergency hormonal contraceptives and the dangerousness of the decision to alienate the supply of over-the-counter drugs from the general rules of health care. Various ethical and medico-legal issues will be addressed, also focusing attention on underage women whose sexual and reproductive health requires not abandoning them, but actually taking charge of them without medicalizing their choices.

Guidelines for the Treatment of Abdominal Abscesses in Acute Diverticulitis: An Umbrella Review

BACKGROUND

This systematic umbrella review aims to investigate and provide an analysis of guidelines regarding the treatment of diverticular abscesses.

MATERIAL AND METHODS

A systematic literature search was performed using the Cochrane Overviews of Reviews model and the 'Clinical Practice Guidelines'; at the end of initial search, only 12 guidelines were included in this analysis. The quality of the guidelines was assessed by adopting the "Appraisal of Guidelines for Research and Evaluation II" (AGREE II). The comparative analysis of these guidelines has highlighted the presence of some differences regarding the recommendations on the treatment of diverticular abscesses. In particular, there are some controversies about the diameter of abscess to be used in order to decide between medical treatment and percutaneous drainage. Different guidelines propose different abscess diameter cutoffs, such as 3 cm, 4-5 cm, or 4 cm, for distinguishing between small and large abscesses.

CONCLUSIONS

Currently, different scientific societies recommend that diverticular abscesses with diameters larger than 3 cm should be considered for percutaneous drainage whereas abscesses with diameters smaller than 3 cm could be appropriately treated by medical therapy with antibiotics; only a few guidelines suggest the use of percutaneous drainage for abscesses with a diameter greater than 4 cm. The differences among guidelines are the consequence of the different selection of scientific evidence. In conclusion, our evaluation has revealed the importance of seeking new scientific evidence with higher quality to either confirm, reinforce or potentially weaken the existing recommendations from different societies.

Systematic Review and Meta-Analysis of the Variants of the Obturatory Artery

BACKGROUND

Knowledge of vascular anatomy and its possible variations is essential for performing embolization or revascularization procedures and complex surgery in the pelvis. The obturator artery (OA) is a branch of the anterior division of the internal iliac artery (IIA), and it has the highest frequency of variation among branches of the internal iliac artery. Possible anomalies of the origin of the obturator artery (OA) should be known when performing pelvic and groin surgery, where its control or ligation may be required. The purpose of this systematic review and meta-analysis, based on Sanudo's classification, is to analyze the origin of the obturator artery (OA) and its variants.

METHODS

Thirteen articles published between 1952 and 2020 were included.

RESULTS

The obturator artery (OA) was present in almost all cases (99.8%): the pooled prevalence estimate for the origin from the IIA axis was 77.7% (95% CI 71.8-83.1%) vs. 22.3% (95% CI 16.9-28.2%) for the origin from EIA axis. In most cases, the obturator artery (OA) originated from the anterior division trunk of the internal iliac artery (IIA) (61.6%).

CONCLUSIONS

Performing preoperative radiological examination to determine the pelvic vascular pattern and having the awareness to evaluate possible changes in the obturator artery can reduce the risk of iatrogenic injury and complications.

Legal medicine aspects of female sterilization: our experience

Introduction

The most frequent sterilization procedures include postpartum tubal ligation, laparoscopic tubal disruption or salpingectomy, and hysteroscopic tubal occlusion. It may be performed via laparoscopy, mini-laparotomy, or hysteroscopy. Safety, efficacy, short-term complications, long-term complications, and non-contraceptive benefits of sterilization are different for each procedure. Female sterilization has become an important professional liability problem in obstetrics and gynecology.

Materials and methods

We analyzed 6 cases of surgical sterilization that have been the subject of civil proceedings. We review indications, contraindications, and complications associated with each sterilization procedure.

Results

In our small number of cases, women who have undergone sterilization performed negligently are entitled to recover damages for wrongful conception, negligence, and wrongful birth. We also consider the issue of female sterilization of minors.

Discussion

Tubal sterilization can be performed with different techniques, chosen in light of the various situations involved, with the goal of reducing as many as possible any failures. Thorough and complete communication of information is of primary importance.

Conclusion

Sterilization is the most widely used birth control method around the world. The procedure is generally safe and highly effective. As reported in the literature, the decision concerning method depends on the setting, the surgeon's experience, the country's economic development, and the woman's preference, but we think that some techniques present a greater risk of failure and expose the surgeon to malpractice litigation.

Artificial Intelligence in Evaluation of Permanent Impairment: New Operational Frontiers

Artificial intelligence (AI) and machine learning (ML) span multiple disciplines, including the medico-legal sciences, also with reference to the concept of disease and disability. In this context, the International Classification of Diseases, Injuries, and Causes of Death (ICD) is a standard for the classification of diseases and related problems developed by the World Health Organization (WHO), and it represents a valid tool for statistical and epidemiological studies. Indeed, the International Classification of Functioning, Disability, and Health (ICF) is outlined as a classification that aims to describe the state of health of people in relation to their existential spheres (social, family, work). This paper lays the foundations for proposing an operating model for the use of AI in the assessment of impairments with the aim of making the information system as homogeneous as possible, starting from the main coding systems of the reference pathologies and functional damages. Providing a scientific basis for the understanding and study of health, as well as establishing a common language for the assessment of disability in its various meanings through AI systems, will allow for the improvement and standardization of communication between the various expert users.

The State of Play on COVID-19 Vaccination in Pregnant and Breastfeeding Women: Recommendations, Legal Protection, Ethical Issues and Controversies in Italy

To date, extensive research has been conducted on vaccination against COVID-19 during pregnancy to verify the safety and efficacy of the vaccines, despite the fact that pregnant women were excluded from the initial clinical trials. The ever-increasing number of scientific publications has confirmed the absence of biological mechanisms associating mRNA vaccines with adverse effects in pregnancy and breastfeeding, although few studies have been carried out on their effect on fertility. While the Italian legal system provides for maternity protection measures and indemnity for vaccination damages pursuant to law no. 210/1992, it is not exempt from controversy. This contribution describes the state of play on COVID-19 vaccination in pregnant and lactating women, including: current recommendations for pregnant and lactating women; ethical issues related to vaccination hesitancy among pregnant women; the legislative paradox whereby sanctions may be imposed on women in certain professional categories who refuse vaccination because they are pregnant; and the possible legal consequences in the event of harm to the unborn child due to vaccination. All of this is considered in accordance with the principles of medical ethics, taking into account the national legislation.

Artificial intelligence and digital medicine for integrated home care services in Italy: Opportunities and limits

Home healthcare in the Italian health system has proven to be an essential factor in adequately responding to the health needs of an increasingly aging population. The opportunities offered by digitization and new technologies, such as artificial intelligence (AI) and robotics, are a lever for making home care services more effective and efficient on the one hand, and on the other for improving remote patient monitoring. Telemedicine devices have enormous potential for telemonitoring and telerehabilitation of patients suffering from chronic disabling diseases; in particular, AI systems can now provide very useful managerial and decision-making support in numerous clinical areas. AI combined with digitalization, could also allow for the remote monitoring of patients' health conditions. In this paper authors describe some digital and healthcare tools or system of AI, such as the Connected Care model, the Home Care Premium (HCP) project, The Resilia App and some professional service robotics. In this context, to optimize potential and concrete healthcare improvements, some limits need to be overcome: gaps in health information systems and digital tools at all levels of the Italian National Health Service, the slow dissemination of the computerized medical record, issues of digital literacy, the high cost of devices, the poor protection of data privacy. The danger of over-reliance on such systems should also be examined. Therefore the legal systems of the various countries, including Italy, should indicate clear decision-making paths for the patient.

The Network of Services for COVID-19 Vaccination in Persons With Mental Disorders: The Italian Social Health System, Its Organization, and Bioethical Issues

The adoption of restrictive measures aimed at curtailing the spread of SARS-CoV2 has had a harmful impact on socio-affective relationships, while limiting the scope of interventions and activities to promote social inclusion, with considerable negative repercussions for patients with mental disorders. Vaccination has been and will continue to be a valid tool to overcome the barriers of social isolation and to protect the health of this category of patients. In this paper we present an overview of the Italian network of social and healthcare services for COVID-19 vaccination among patients with mental disorders. Some aspects of medical ethics are discussed in order to share good practices for improving the health of this vulnerable group of people. We then consider the measures implemented by the health system in Italy to deal with the phenomenon of vaccine hesitancy before addressing the issue of autonomy and restricted access to vaccination points. Finally, we illustrate some of the perspectives already adopted by the Italian system, which may be useful to the global scientific community.

Informed Consent and Protection of Personal Data in Genetic Research on COVID-19

The particular characteristics of COVID-19 demand the careful biomedical study of samples from patients who have shown different symptomatology, in order to understand the genetic foundations of its phenotypic expression. Research on genetic material from COVID-19 patients is indispensable for understanding the biological bases for its varied clinical manifestations. The issue of “informed consent” constitutes the crux of the problem in regulating research biobanks, because it concerns the relationship between the person and the parts separated from the body. There are several consensus models that can be adopted, varying from quite restricted models of specific informed consent to forms that allow very broad authorization (open consent). Our current understanding of COVID-19 is incomplete. Thus, we cannot plan, with precision, the research to be conducted on biological samples that have been, or will be, collected from patients infected by the novel coronavirus. Therefore, we suggest utilizing the “participation pact” between researchers and donors, based on a new form of participation in research, which offers a choice based on the principles of solidarity and reciprocity, which represent the communication of “values”. In the last part of this paper, the general data protection regulation concerning the matter is discussed. The treatment of personal data must be performed with explicit goals, and donors must be provided with a clear, transparent explanation of the methods, goals and time of storage. The data must not be provided to unauthorized subjects. In conclusion, open informed consent forms will be necessary for research on individual patients and on populations.

The "Magnificent Seven Errors" in Forensic Autopsy Practice: The Italian Context

According to the Italian legal system, forensic autopsies are performed by a medical doctor specialized in legal medicine, otherwise known as a medicolegal expert (MLE), who has a range of very complex responsibilities. Indeed, the quality of forensic autopsy activity is always questioned in courts of law; incorrect assessments are dangerous because they can jeopardize the validity of a criminal investigation and thus affect the outcome so that a real culprit may be acquitted or an innocent person convicted. Nonconformities also discredit the professionalism of the specialist who performs the autopsy. The work of a MLE implies a series of assignments and duties that should be given constant consideration, but when certain aspects of this activity are underestimated or overlooked, this can lead the expert to make mistakes with irreparable consequences for the judicial investigation. In this article, for the first time, we present a summary of seven known errors related to autopsy activity following death by unnatural causes, with the purpose of alerting MLEs who work under the Italian judicial system to the potential dangers of such errors. These relate to: oversights in autopsy technique, incorrect collection of photographic and video material, unauthorized attendance at the autopsy, missing/mistaken reporting at any stage of the forensic activity, failure to notify the party forensic consultant, using histological or toxicological nonaccredited laboratories for forensic activities, and lack of observance of the chain of custody.

A new analytical cut-off point for determining 18 years of age using MRI on medial clavicular epiphysis

Evaluation of the ossification of the medial clavicular epiphysis plays a key role in forensic age estimation. The purpose of the present study was to assess a new numerical cut-off at the age of 18 years, taking into consideration Magnetic Resonance (MR) images of the medial clavicular epiphysis. We analyzed 163 MR scans of Italian subjects aged between 14 and 25 years. Using the data obtained we calculated two ratios: REM-1 (ratio between the length of the whole epiphysis and the length of the metaphysis) and REM-2 (ratio between the length of epiphyseal-metaphyseal fusion and the length of the metaphysis). In 68 out of 163 cases it was not possible to measure REM-2. The reproducibility was demonstrated using the Intraclass Correlation Coefficient (ICC) (Cronbach's alpha > 0.80). REM-1 and REM-2 were compared in each category of age (adult and minor) by the Wilcoxon signed-rank test. The cut-off points for measurements of REM-1 and REM-2 were determined by logistic regression. For REM-1, the cut-off scores were 0.83 for all individuals (accuracy = 94.77%) and males (accuracy = 96.05%), and 0.86 for females (accuracy = 92.30%). For REM-2, the cut-off values were 0.40 for all individuals and males (accuracy = 100.00%), and 0.41 for females (accuracy = 100.00%). Finally, receiver operating characteristic (ROC) curves for age classification based on REM-1 and REM-2 were constructed, showing that REM-2 had the highest discriminative power. Thus, a new cut-off model for predicting the age of majority has been introduced, conducting a quantitative analysis thanks to the use of a high-resolution imaging tool.

Analysis of the Different Lymphatic Drainage Patterns during Sentinel Lymph Node Biopsy for Skin Melanoma

In the last two decades, studies of lymphoscintigraphy imaging in lymphatic mapping reported an extreme heterogeneity of skin lymphatic drainage of some skin area, in contrast with the previous scientific literature. The aim of this study was to investigate the presence of any correlations between the topographical location of cutaneous melanoma and the topographical location of sentinel lymph nodes. Data from 165 patients undergoing sentinel lymph node biopsy between January 2013 and May 2021 were analyzed, demonstrating that melanomas in the Lumbar region presented a significant more heterogeneous drainage by site than those in the Scapular region (p < 0.01) and that melanomas in the Subscapular region were significantly more heterogeneous by laterality (unilateral vs. bilateral) than those in the Scapular region (p < 0.05). Results of this study supported the evidence of multiple lymphatic drainage as regards the sentinel node biopsy performed in skin melanoma located on the dorsal subscapular region and lumbar region. For this reason, the association of preoperative lymphoscintigraphy with another imaging evaluation is needed in these critical cutaneous areas. Recent technical developments enabling fluorescence lymphography together with indocyanine green have significantly improved the visualization of lymphatic drainage patterns at a microscopic level. In the preoperative phase, any doubt can be resolved by associating the SPET-CT scan to lymphoscintigraphy, while during the intraoperative phase, an additional evaluation with indocyanine green can be performed in doubtful cases. The aim of the duplex lymphatic mapping (pre and/or intraoperative) is an accurate search of sentinel nodes, in order to reduce the rate of false negatives.

Injuries during Laparoscopic Cholecystectomy: A Scoping Review of the Claims and Civil Action Judgements

Background. To define what type of injuries are more frequently related to medicolegal claims and civil action judgments. Methods. We performed a scoping review on 14 studies and 2406 patients, analyzing medicolegal claims related to laparoscopic cholecystectomy injuries. We have focalized on three phases associated with claims: phase of care, location of injuries, type of injuries. Results. The most common phase of care associated with litigation was the improper intraoperative surgical performance (47.6% ± 28.3%), related to a “poor” visualization, and the improper post-operative management (29.3% ± 31.6%). The highest rate of defense verdicts was reported for the improper post-operative management of the injury (69.3% ± 23%). A lower rate was reported in the incorrect presurgical assessment (39.7% ± 24.4%) and in the improper intraoperative surgical performance (21.39% ± 21.09%). A defense verdict was more common in cystic duct injuries (100%), lower in hepatic bile duct (42.9%) and common bile duct (10%) injuries. Conclusions. During laparoscopic cholecystectomy, the most common cause of claims, associated with lower rate of defense verdict, was the improper intraoperative surgical performance. The decision to take legal action was determined often for poor communication after the original incident.

Nursing Home and Vaccination Consent: The Italian Perspective

Since the beginning of the Covid-19 pandemic, many countries have begun vaccination campaigns, with different methods and timelines, with the goal of vaccinating over 75% of the population and thus achieving herd immunity. Initially it was necessary to identity the categories of citizens who should be the first to receive the vaccines, on the basis of scientific evidence. On the basis of this information, elderly residents in nursing homes and the staff who care for them should be the highest priority subjects for vaccination. In this context, obtaining informed consent to Covid-19 vaccination presents a considerable challenge, as the advanced age and frequent comorbidities of a significant number of the residents may mean that they are incapable of expressing consent themselves. The legislation of various Western nations substantially agrees on the general principle that those capable of judgement must be asked for their consent for healthcare services, and that even those with psychological weaknesses that limit their full ability to decide must be involved in these decision-making processes. The article can help systematize the processes to be implemented to protect the health of individuals as members of a close and fragile community.

Perspectives of Italian pregnant women on pregnancy examinations and pregnancy care: is the caregiver more important than the care?

AIM

Assessing awareness of Italian low-risk pregnant patients on low-risk pregnancy care and what do they feel about their own pregnancy.

METHODS

A questionnaire was administered to 382 low-risk pregnant women. This questionnaire assessed general knowledge of low-risk pregnancy, low-risk pregnancy care, and how much patients rated ten topics of low-risk pregnancy care. It would be expected that the knowledge of each topic would associates with the patient's perceived importance of that topic.

RESULTS

Poor knowledge of pregnancy care was proven. Patients seem to incorrectly overrate vaginal examinations and obstetric and gynecologist-led care, while they attribute appropriate importance to midwife-led care. The more examinations performed (vaginal examinations, sonographic checks, cardiotocographies), the higher their rating.

CONCLUSIONS

In Italy, expectations of pregnant women about their own pregnancy are incorrectly trusted in the obstetrics and gynecologists. Both poor knowledge of pregnancy care and cultural perspectives on the birth process amongst Italian people explain the finding. Referring low-risk pregnant women to midwives would help them to rate more the care than the caregiver.

Safety and effectiveness of a somatropin biosimilar in children requiring growth hormone treatment: second analysis of the PATRO Children study Italian cohort

PURPOSE

To investigate the long-term safety (primary endpoint) and effectiveness (secondary endpoint) of the somatropin biosimilar Omnitrope^®.

METHODS

PATRO Children is an ongoing, multicenter, observational, post-marketing surveillance study. Children who received Omnitrope^® for any indication were included. Adverse events (AEs) were evaluated in all study participants. Auxological data, including height standard deviation scores (HSDS) and height velocity standard deviation scores (HVSDS), were used to assess effectiveness. In this snapshot analysis, data from the Italian subpopulation up to August 2017 were reported.

RESULTS

A total of 291 patients (mean age 10.0 years, 56.0% male) were enrolled at 19 sites in Italy. The mean duration of Omnitrope^® treatment was 33.1 ± 21.7 months. There were 48 AEs with a suspected relationship to the study drug (as reported by the investigator) that occurred in 35 (12.0%) patients, most commonly headache, pyrexia, arthralgia, insulin-like growth factor above normal range, abdominal pain, pain in extremity and acute gastroenteritis. There were no confirmed cases of type 1 or type 2 diabetes; however, two patients (0.7%) had impaired glucose tolerance that was considered Omnitrope^® related. The mean HSDS increased from - 2.41 ± 0.73 at baseline (n = 238) to - 0.91 ± 0.68 at 6.5 years (n = 10). The mean HVSDS increased from - 1.77 ± 1.38 at baseline (n = 136) to 0.96 ± 1.13 at 6.5 years (n = 10).

CONCLUSIONS

In this sub-analysis of PATRO Children, Omnitrope^® appeared to have acceptable safety and effectiveness in the treatment of in Italian children, which was consistent with the earlier findings from controlled clinical trials.

Ilioinguinal Nerve Neurectomy is better than Preservation in Lichtenstein Hernia Repair: A Systematic Literature Review and Meta-analysis

OBJECTIVE

This study aimed to evaluate the incidence of chronic groin pain (primary outcome) and alterations of sensitivity (secondary outcome) after Lichtenstein inguinal hernia repair, comparing neurectomy with ilioinguinal nerve preservation surgery. The exact cause of chronic groin postoperative pain after mesh inguinal hernia repair is usually unclear. Section of the ilioinguinal nerve (neurectomy) may reduce postoperative chronic pain.

METHODS

We followed PRISMA guidelines to identify randomized studies reporting comparative outcomes of neurectomy versus ilioinguinal nerve preservation surgery during Lichtenstein hernia repairs. Studies were identified by searching in PubMed, Scopus, and Web of Science from April 2020. The protocol for this systematic review and meta-analysis was submitted and accepted from PROSPERO: CRD420201610.

RESULTS

In this systematic review and meta-analysis, 16 RCTs were included and 1550 patients were evaluated: 756 patients underwent neurectomy (neurectomy group) vs 794 patients underwent ilioinguinal nerve preservation surgery (nerve preservation group). All included studies analyzed Lichtenstein hernia repair. The majority of the new studies and data comes from a relatively narrow geographic region; other bias of this meta-analysis is the suitability of pooling data for many of these studies. A statistically significant percentage of patients with prosthetic inguinal hernia repair had reduced groin pain at 6 months after surgery at 8.94% (38/425) in the neurectomy group versus 25.11% (113/450) in the nerve preservation group [relative risk (RR) 0.39, 95% confidence interval (CI) 0.28-0.54; Z = 5.60 (P < 0.00001)]. Neurectomy did not significantly increase the groin paresthesia 6 months after surgery at 8.5% (30/353) in the neurectomy group versus 4.5% (17/373) in the nerve preservation group [RR 1.62, 95% CI 0.94-2.80; Z = 1.74 (P = 0.08)]. At 12 months after surgery, there is no advantage of neurectomy over chronic groin pain; no significant differences were found in the 12-month postoperative groin pain rate at 9% (9/100) in the neurectomy group versus 17.85% (20/112) in the inguinal nerve preservation group [RR 0.50, 95% CI 0.24-1.05; Z = 1.83 (P = 0.07)]. One study (115 patients) reported data about paresthesia at 12 months after surgery (7.27%, 4/55 in neurectomy group vs. 5%, 3/60 in nerve preservation group) and results were not significantly different between the two groups [RR 1.45, 95% CI 0.34, 6.21;Z = 0.51 (P = 0.61)]. The subgroup analysis of the studies that identified the IIN showed a significant reduction of the 6th month evaluation of pain in both groups and confirmed the same trend in favor of neurectomy reported in the previous overall analysis: statistically significant reduction of pain 6 months after surgery at 3.79% (6/158) in the neurectomy group versus 14.6% (26/178) in the nerve preservation group [RR 0.28, 95% CI 0.13-0.63; Z = 3.10 (P = 0.002)].

CONCLUSION

Ilioinguinal nerve identification in Lichtenstein inguinal hernia repair is the fundamental step to reduce or avoid postoperative pain. Prophylactic ilioinguinal nerve neurectomy seems to offer some advantages concerning pain in the first 6th month postoperative period, although it might be possible that the small number of cases contributed to the insignificancy regarding paresthesia and hypoesthesia. Nowadays, prudent surgeons should discuss with patients and their families the uncertain benefits and the potential risks of neurectomy before performing the hernioplasty.

The COVID-19 Epidemic and the Prison System in Italy

On March 7 and 8, 2020, revolts erupted in numerous Italian prisons after the announcement of regulations to contain the spread of COVID-19 in prisons. On April 2, 2020, the first prisoner died of COVID-19, and as of April 9, 58 prisoners and 178 penitentiary police officers have tested positive for the virus. The situation in Italy is made all the more dramatic because of endemic overcrowding: As of April 3, 2020, there were 56,830 prisoners in institutions meant for a maximum of 47,000 people, that is, an occupancy level of 121.75%. The Ministry of Justice and that of Health have established two strategies to limit the spread of COVID-19 in prisons: progressive isolation from the external world and adoption of practices to identify possible cases and to treat infected subjects. The legislation has significantly reduced individual rights in order to protect public health, but in the prison context, the limitations imposed do not guarantee the achievement of the goal of the entire legislation, which is to interrupt the chain of transmission of contagion. A prison cannot be entirely cut off, because its operations depend on people who come and go daily, The effects of these strategy are discussed critically.

Safety and effectiveness of Omnitrope® in patients with growth hormone deficiency: snapshot analysis of PATRO Adults study in the Italian population

PURPOSE

PATRO adults is an ongoing, multicenter, observational, post-marketing surveillance study aimed at investigating the long-term safety (primary endpoint) and effectiveness (secondary endpoint) of the recombinant human growth hormone (rhGH) Omnitrope® during routine clinical practice. This report describes data from Italian participants in PATRO Adults with growth hormone deficiency (GHD), up to August 2017.

METHODS

Participants were adults (aged > 18 years) with GHD requiring rhGH therapy and were prescribed Omnitrope®, including those who had previously received another rhGH product. Adverse events (AEs) were evaluated in all study participants. Data were collected on insulin-like growth factor (IGF)-I levels and cardiovascular risk factors, including blood pressure, lipids, and anthropometric parameters.

RESULTS

From September 2007 to August 2017, 88 patients (mean age 48.9 years, 58.0% male) were enrolled at 8 sites in Italy. The mean treatment duration with Omnitrope® was 51.5 ± 37 months. AEs occurred in 54 patients; the most common were asthenia (20.5%), headache (14.8%), and arthralgia (13.6%). Serious AEs occurred in 22 patients (25%), including pneumonia (n = 2) and renal failure (n = 2). Neoplasms (2 benign and 1 malignant) developed in three patients, but none were considered to be drug-related. There were no significant changes in fasting glucose or glycosylated hemoglobin (HbA1c) during the study period. Long-term Omnitrope® therapy showed slight positive effects on lipid profile, while no significant changes were observed in body weight and BMI during the study.

CONCLUSION

This snapshot analysis of Italian participants in PATRO Adults confirmed the long-term safety and effectiveness of Omnitrope® in adults with GHD.

Surgical anatomy of sigmoid arteries: A systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to determine the prevalence of the number of sigmoid arteries (SA) and variations in their origins.

METHODS

A thorough systematic search of literature through February 2020 was conducted on major electronic databases to identify eligible studies. Data were extracted and pooled into a meta-analysis using Metafor package in R. The primary outcome was the variations in the SA origin (according to modified Zebrowski classification), and the secondary outcome was the prevalence of the number of SA.

RESULTS

A total of 22 studies (n = 2653 patients) were included. Type 1 modified Zebrowski (separated origins or common trunk of the SA originating from descending recto-sigmoid trunk (DRST)) was the most common origin type of the SA (pooled prevalence estimate (PPE) = 49.67% (95% CI 32. 67- 66.71)), while type 3 (separated origins or common trunk of 1 or 2 SA originating from DRST or superior rectal artery (SRA) and 1 or 2 SA originating from DRST or SRA) was the least common (PPE = 0.18%; 95% CI 0.00-2.82)). Of the Type 1 variants, the not specified (N.S) variant was by far the most prevalent. The number of SA ranged from one to five, with three being the mode (PPE = 42.3%).

CONCLUSION

This is the most comprehensive analysis of arterial vascular anatomy of the sigmoid colon. In light of the highly variable anatomical pattern displayed by the SA, thorough pre-operative knowledge of their anatomy can be crucial in minimizing incidences of iatrogenic injury.

Legal and Ethical Issues Regarding Minors in the Italian Coronavirus Flu Emergency

On February 21, 2020, Italy became one of the countries hit by an epidemic of the new coronavirus that causes "severe acute respiratory syndrome coronavirus 2" (SARS-CoV-2). Even a month before that, however, the Italian government began issuing a series of decrees and ordinances aimed at the containment of the virus in Italy, the first of them on January 25, 2020. The COVID 19 infection has been faced as an epidemic through measures to enforce a high degree of isolation. These regulations hold for minors, as well, with consequent difficulties for this age group. While at the moment young people appear to be the least vulnerable to the severe complications of COVID 19, the psychological problems that may be brought on by pandemic-related restrictions should be taken into serious consideration.

Dermatome Mapping Test in the analysis of anatomo-clinical correlations after inguinal hernia repair

Background

Nerve identification is recommended in inguinal hernia repair to reduce or avoid postoperative pain. The aim of this prospective observational study was to identify nerve prevalence and find a correlation between neuroanatomy and chronic neuropathic postoperative inguinal pain (CPIP) after 6 months.

Material

A total of 115 patients, who underwent inguinal hernia mesh repair (Lichtenstein tension-free mesh repair) between July 2018 and January 2019, were included in this prospective observational study. The mean age and BMI respectively resulted 64 years and 25.8 with minimal inverse distribution of BMI with respect to age. Most of the hernias were direct (59.1%) and of medium dimension (47.8%). Furthermore, these patients were undergoing Dermatome Mapping Test in preoperatively and postoperatively 6 months evaluation.

Results

Identification rates of the iliohypogastric (IH), ilioinguinal (II) and genitofemoral (GF) nerves were 72.2%, 82.6% and 48.7% respectively. In the analysis of nerve prevalence according to BMI, the IH was statistically significant higher in patients with BMI < 25 than BMI ≥ 25 P (< 0.05). After inguinal hernia mesh repair, 8 patients (6.9%) had chronic postoperative neuropathic inguinal pain after 6 months. The CPIP prevailed at II/GF dermatome. The relation between the identification/neurectomy of the II nerve and chronic postoperative inguinal pain after 6 months was not significant (P = 0.542).

Conclusion

The anatomy of inguinal nerve is very heterogeneous and for this reason an accurate knowledge of these variations is needed during the open mesh repair of inguinal hernias. The new results of our analysis is the statistically significant higher IH nerve prevalence in patients with BMI < 25; probably the identification of inguinal nerve is more complex in obese patients. In the chronic postoperative inguinal pain, the II nerve may have a predominant role in determining postoperative long-term symptoms. Dermatome Mapping Test in an easy and safe method for preoperative and postoperative 6 months evaluation of groin pain. The most important evidence of our analysis is that the prevalence of chronic pain is higher when the nerves were not identified.

Analysis of carpal bones on MR images for age estimation: First results of a new forensic approach

Current multifactorial age estimation methods are based on radiography, however, in the forensic field there is growing interest in using magnetic resonance imaging (MRI). With regard to the carpal region, MRI provides more information for defining the individual ossification nuclei and the cartilage surrounding single bones. During the phase of bone growth, the progressive reduction of the cartilage layer is accompanied by the development of a cartilage-bone interface. The aim of our study was to create a new model for age estimation, based on the ratio between the area occupied by the nucleus of ossification (NO) and the surface of growth (SG) of each carpal bone, the latter derived by adding NO to the area of cartilage-bone interface. We analyzed 57 MRI scans of Italian subjects aged between 12 and 20 years, without growth diseases, endocrine disorders or osteodystrophy. Measurements of NO and SG areas were extracted using ImageJ software, and the ratio between the NO and SG of each bone (NOSG) was calculated. A multiple linear regression model was used to estimate the individual's age as a function of the variables: gender and wrist bone measurements. The results showed that the best model was obtained with 6 predictors (nvmax=6): Gender, and the NOSG of the Trapezoid, Trapezium, Scaphoid, Pisiform, and Capitate. The median of the residuals (observed age minus predicted age) was -0.025 years, with an IQR of 0.19 years. Thus a new forensic approach to age assessment using MRI is introduced in this paper, which gives the preliminary results.

Routine drain or no drain after laparoscopic cholecystectomy for acute cholecystitis

BACKGROUND

Laparoscopic cholecystectomy (LC) is considered to be the gold standard in the early management of acute cholecystitis however, recommendations for routine drain insertion in the acute setting are unavailable.

STUDY DESIGN

A systematic review of literature review and metanalysis was conducted. All studies comparing drain versus no drain after LC for acute cholecystitis were included.

RESULTS

Seven studies, with 1274 patients, were included. Postoperative wound infection rates (relative risk (RR) 0.30, 95% confidence interval (CI) 0.10 to 0.88; I2 = 0%) and postoperative abdominal collection requiring drainage (RR 1.20, 95% CI 0.35 to 4.12; I 2 = 0%) were lower in the no-drain group, but this was only significant for wounded infections on subgroup analysis of RCTs. Length of stay hospital (mean difference (MD) -0.49, 95% CI -0.89 to -0.09; I 2 = 69%) and operative time (MD -8.13, 95% CI -13.87 to -2.38; I 2 = 92%) were significantly shorter in the no drain group however this was in the context of significant heterogeneity.

CONCLUSION

The available data suggests that acute cholecystitis is not an indication for routine drain placement after LC. However, these results must be interpreted with caution due to the limitations of the included studies. In effect, the main issue of this meta-analysis lies on the limitations of the included studies themselves, because of a considerable heterogeneity among the included works, particularly for the inclusion criteria of patients and reported severity of acute cholecystitis. Further work is required to produce evidence which will definitively alter clinical practice.

LEVEL OF EVIDENCE

Level 2a (systematic review of cohort studies). Oxford CEBM levels of evidence.

Total parenteral nutrition-induced Wernicke's encephalopathy after oncologic gastrointestinal surgery

Carl Wernicke described the disease bearing his name in 1881 and reported three cases characterized by the presence of mental confusion, ataxia, and ophthalmoplegia. Wernicke’s disease is mainly observed in alcoholic patients, due to decreased vitamin intake as a consequence of an unbalanced diet, and a reduction of absorption due to the effects of alcohol. Likewise, inadequate vitamin intake is prevalent in older patients. Wernicke’s encephalopathy due to inappropriate total parenteral nutrition (TPN) occurs infrequently; recently, there is an increase in the literature concerning Wernicke’s encephalopathy in patients after general and bariatric surgeries. We present two cases of Wernicke’s encephalopathy after oncologic gastrointestinal surgery by failure to administer vitamin B1 during TPN; to our knowledge, these are the first two cases of Wernicke’s encephalopathy after colorectal surgery for cancer. In our opinion, timely diagnosis and treatment are mandatory to avoid nonfunctional recovery and consequent malpractice legal actions as well as an increase in the health-care costs correlated with the prolonged hospital stay and with the nonfunctional recovery.

Medico-legal assessment of personal damage in older people: report from a multidisciplinary consensus conference

Ageing of the global population represents a challenge for national healthcare systems and healthcare professionals, including medico-legal experts, who assess personal damage in an increasing number of older people. Personal damage evaluation in older people is complex, and the scarcity of evidence is hindering the development of formal guidelines on the subject. The main objectives of the first multidisciplinary Consensus Conference on Medico-Legal Assessment of Personal Damage in Older People were to increase knowledge on the subject and establish standard procedures in this field. The conference, organized according to the guidelines issued by the Italian National Institute of Health (ISS), was held in Bologna (Italy) on June 8, 2019 with the support of national scientific societies, professional organizations, and stakeholders. The Scientific Technical Committee prepared 16 questions on 4 thematic areas: (1) differences in injury outcomes in older people compared to younger people and their relevance in personal damage assessment; (2) pre-existing status reconstruction and evaluation; (3) medico-legal examination procedures; (4) multidimensional assessment and scales. The Scientific Secretariat reviewed relevant literature and documents, rated their quality, and summarized evidence. During conference plenary public sessions, 4 pairs of experts reported on each thematic area. After the last session, a multidisciplinary Jury Panel (15 members) drafted the consensus statements. The present report describes Conference methods and results, including a summary of evidence supporting each statement, and areas requiring further investigation. The methodological recommendations issued during the Conference may be useful in several contexts of damage assessment, or to other medico-legal evaluation fields.

The COVID-19 Epidemic and the Prison System in Italy

The Italian Ministry of Justice and that of Health have established two strategies to limit the spread of COVID-19 in prisons: progressive isolation from the external world and adoption of practices to identify possible cases and to treat infected subjects. After the announcement of regulations revolts erupted in numerous Italian prisons. The motivations and effects of these strategy are discussed critically into the search for a balance between the right to health and other rights of prisoners in Italian prisons with the problem of an occupancy level of 121.75%.

Histopathology of COVID-19 pneumonia in two non-oncological, non-hospitalised cases as a reliable diagnostic benchmark

In lung cancer patients infected with COVID-19, pathological features are not easy to distinguish. This report presents detailed histopathological findings in two non-neoplastic subjects whose out-of-hospital deaths were caused by COVID-19 infection. These ‘pure’ cases differ in the time of presentation of symptoms, the phase of lung anatomopathological patterns (acute lung injury versus diffuse alveolar damage) and the mechanism of death. The results provide a valid diagnostic benchmark for evaluating the evolution of COVID-19 pneumonia.

The will of young minors in the terminal stage of sickness: A case report

INTRODUCTION

In Italy, both parents have parental responsibility, so they have the power to give or withhold consent to medical procedures on their children.

METHODS

The present work reports the case of a 5-year-old boy diagnosed with neuroblastoma in the right adrenal loggia, who underwent several chemotherapy treatments that prolonged his life until the age of 10. Informed consent for treatments was requested exclusively of the parents, without taking into consideration the minor's will, not even when he asked for increased pain relief medication instead of other palliative treatments.

RESULTS

The authors thought it interesting to examine the case in the light of new Italian legislation on informed consent and to verify whether it promotes greater participation of minors in healthcare choices, given that the issue of acquisition of informed consent is becoming increasingly broad and complex.

CONCLUSION

The case examined here indicates that current Italian legislation, even including the modifications introduced, does not allow for concrete and active participation of minors, especially those under the age of 12, in the discussion of choices about their health, not even in choices regarding the end of life, and not even when the minor manifests a mature capacity for discernment.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR-A Proposal for a Decision-Making Algorithm

Background and Objectives: The present study aims to assess the effectiveness and current evidence of the treatment of perirectal bleeding after stapled haemorrhoidopexy. Materials and methods: A systematic literature review was performed that combined the published and the obtained original data after a search of PubMed, Web of Science, and SCOPUS. Results: The present systematic review includes 16 articles with 37 patients. Twelve papers report perirectal and six report intra-abdominal bleeding. Stapled hemorrhoidopexy (SH) was performed in 57% of cases (3 PPH 01 and 15 PPH 03), stapled transanal rectal resection (STARR) in 13%, and for 30% information was not available. The median age was 49 years (±11.43). The sign and symptoms of perirectal bleeding were abdominal pain (43%), pelvic discomfort without rectal bleeding (36%), urinary retention (14%), and external rectal bleeding (21%). The median time to bleeding was 1 day (±1.53 postoperative days), with median hemoglobin at diagnosis 8.8 ± 1.04 g/dL. Unstable hemodynamic was reported in 19%. Computed tomography scan (CT) was the first examination in 77%. Only two cases underwent the abdominal US, but subsequently, a CT scan was also conducted. Non-operative management was performed in 38% (n = 14) with selective arteriography and percutaneous angioembolization in two cases. A surgical treatment was performed in 23 cases - transabdominal surgery (3 colostomies, 1 Hartmann' procedure, 1 low anterior resection of the rectum, 1 bilateral ligation of internal iliac artery and 1 ligation of vessels located at the rectal wall), transanal surgery (n = 13), a perineal incision in one, and CT-guided paracoccygeal drainage in one. Conclusions: Because of the rarity and lack of experience, no uniform tactic for the treatment of perirectal hematomas exists in the literature. We propose an algorithm similar to the approach in pelvic trauma, based on two main pillars -hemodynamic stability and the finding of contrast CT.

Regulation of Biobanks in Italy

In Italy, a biobank is "a non-profit organization that must be officially recognized by the appropriate healthcare authority in the member states and must guarantee the treatment, distribution and conservation of biological material according to standards of quality and professionalism," but must not conserve material already regulated by specific laws, as is the case for organs for transplants, blood for transfusions, as well as embryos and gametes for medically assisted reproduction. The concept of biobank includes not only biological samples, but also the related database of clinical and personal information, from which the subject's lifestyle can be deduced. Unfortunately, at the moment, Italian law does not offer specific itineraries for achieving this legal status.

Correlations between the proportion of type III female genital mutilations in the series and adverse obstetric outcomes: a short meta-analysis

Background: Authors have reported that evidence on health harms of female genital mutilation is poor.Aim: Meta-analyzing prospective studies on adverse obstetric outcomes according to the severity of female genital mutilation.Method: Prospective studies were already acknowledged in previous meta-analyses and used for calculations. The proportions of type III female genital mutilation were extracted by full-texts, along with the proportions of adverse obstetric outcomes. Assuming random models, the proportions were encoded for meta-analysis and weighted for the inverse of the variance. Nonparametric correlations among weighted proportions of type III female genital mutilation and weighted proportions of obstetric outcomes were built. Analyzable obstetric outcome were: cesarean section, instrumental delivery, episiotomy, post-partum hemorrhage, low Apgar score - need of resuscitation.Results: Meta-analyzable series are few and heterogeneous. There is a trend of direct correlation among the proportion of type III female genital mutilations in the series and the proportion of cesarean section, instrumental deliveries, post-partum hemorrhage and low Apgar scores at birth or need of neonatal resuscitation. The significance was reached for the post-partum hemorrhage and for the fetal adverse outcome.Conclusion: It should be retained that type III female genital mutilation is likely to be a serious concern for birth.

Genetic Risk in Insurance Field

The risk-delimiting tools available to insurance companies are therefore substantial and it is also possible to argue that a margin of uncertainty is a natural component of the insurance contract. Despite this, businesses look at the potential of predictive medicine, and in particular the growing understanding of genetic mechanisms that support many common diseases. In particular, the rapid development of genetics has led many insurance companies to glimpse in the predictive diagnosis of disease by genetic testing the possibility of extending the calculation of the individual risk of developing a particular disease to appropriate premiums or even denying insurance coverage.

Genetic Testing and Professional Responsibility: The Italian Experience

Responsibility means responding to the damaging consequences of technical work and in this binding perspective the general principles of guilt in genetic diagnostics and related activities are not different from any other medical performance.

Performing a genetic test however, especially when it has predictive characteristics, offers absolutely peculiar technical deontological issues. It is not and should not be considered as a mere habitual laboratory test but as a complex set of interactions that presupposes adequate information as a valid consensus to formalize absolutely in written form.

Genetic Testing: Ethical Aspects

The aim of this article is to provide an analysis of the main issues related to the application of predictive medicine by analysing the most significant ethical implications. Genetic medicine is indeed a multidisciplinary matter that covers broad contexts, sometimes transversely. Its extreme complexity, coupled with possible perceived repercussions on an individual's life, involves important issues in the ethical, deontological and legal medical field. The aspects related to the execution of genetic testing have to be addressed at different levels, starting with the correct information about the "cognitive" meaning they intend (by forcefully disassociating it from the strange "preventive aspect") to the legal medical issues that can be aroused in the field of forensic pathology, medical responsibility and insurance. There is no doubt that in recent years, from the decoding of the human genome, genetic research has exponentially expanded with an equally exponential increase in its use in clinical practice and the ethical and social evolution of it.

Piercing and Tattoos in Adolescents: Legal and Medico-legal Implications

Non-therapeutic body modification interventions are permitted within the limits of the use of one’s own body that can be specified in the legal system. The authors take into consideration Italian regulation on tattooing and piercing, in particular in relation to adolescents.

Aesthetic Dental Procedures: Legal and Medico-legal Implications

Dental treatments, as well as simple anatomical and functional repair work, can also be for aesthetic purposes. This is because the anatomical area concerned, i.e. the oral cavity, has a great power of attraction. Aesthetic treatments in general - in particular dental treatments - have been on the rise in recent years, and this has also meant an increase in claims due to patient dissatisfaction with the results obtained. Numerous laws have been introduced that emphasise the need for comprehensive prior information in order to acquire valid consent. This has resulted in the elimination of the distinction between the obligation of means and obligation of result, with achievement of the normally expected result required in any case.

Ethical and Legal Issues in Gestational Surrogacy

This study originated from events that occurred in 2014 in an Italian hospital, where the embryos of a couple, obtained by means of homologous insemination, were mistakenly implanted into the uterus of another woman who, along with her husband, underwent the same treatment.

Faced with this serious adverse circumstance, that gives rise to ethical and legal issues, the authors conducted a comparative examination of how to consider the division of maternity (between biological mother and uterine mother) and the related division of paternity (between genetic father and legal father, husband or partner of the gestational mother).

Some preliminary observations are made concerning parenthood and filiation within the context of currently applicable Italian law.

The following is a detailed analysis of the arguments in favour of the parental figures involved (gestational mother/genetic mother).

The Central Importance of Information in Cosmetic Surgery and Treatments

The increase in the number of people who choose to have medical procedures done to improve their appearance may be due to changed social and cultural factors in modern society, as well to the ease of access and affordable costs of these cosmetic treatments. Today, two elements legitimate recourse to this type of treatment: the broad definition of health accepted by the law and the scientific community, and the provision of meticulous information to the entitled party previous to obtaining his or her consent. In Italy, while current case-law views treatments exclusively for cosmetic purposes as unnecessary, if not even superfluous, it nonetheless demands that providers inform clients about the actual improvement that can be expected, as well as the risks of worsening their current esthetic conditions.

Blood Transfusion in Children: The Refusal of Jehovah's Witness Parents'

In Italy, both parents have parental responsibility; as a general principle they have the power to give or withhold consent to medical procedures on their children, including consent for blood transfusion; however these rights are not absolute and exist only to promote the welfare of children.

METHODS

The Authors discuss ethical and legal framework for Jehovah's Witness parents' refusal of blood transfusion in Italy. They searched national judgments concerning Jehovah's Witness parents' refusal of blood transfusion - and related comments - in national legal databases and national legal journals, and literature on medical literature databases.

RESULTS

In the case of Jehovah's Witness parents' refusal of blood transfusion for their child, Italian Courts adopt measures that prevents the parents from exercise their parental responsibility not in the child's best interest.

DISCUSSION

In the event that refusal by the parents, outside of emergency situations, exposes the child's health to serious risk, health workers must proceed by notifying the competent authority, according also to the Italian Code of Medical Ethics.

CONCLUSION

When the patient is a minor, the child's best interest always come first.

Hydrogen peroxide-related colitis (previously known as "pseudolipomatosis"): a series of cases occurring in an epidemic pattern

We report several cases of hydrogen peroxide-related colitis that occurred in an epidemic pattern in our gastrointestinal endoscopy center during a 2-month period in early 2007. During colonoscopy using sterilized endoscopes that had been flushed with hydrogen peroxide after the peracetic acid cycle, instantaneous effervescence and blanching (the "snow white sign") were observed on the intestinal mucosa when the water button was depressed. Biopsy specimens revealed features resembling a clinical condition which used to be known as "pseudolipomatosis." At follow-up, no patient was found to have suffered morbidity associated with this peroxide colitis. Endoscopists should consider hydrogen peroxide colitis when they see a snow white sign during colonoscopy which cannot be attributed to active inflammation or organic disease of the digestive tract.

The influence of endoscopic biliary stents on the accuracy of endoscopic ultrasound for pancreatic head cancer staging

BACKGROUND AND STUDY AIMS

Biliary stents have been found to interfere with endoscopic ultrasound (EUS) tumor (T) and nodal (N) staging in patients with periampullary cancer. Our aim was to determine whether this also occurs in patients with pancreatic head cancer.

PATIENTS AND METHODS

We studied a consecutive series of patients who were undergoing preoperative EUS for diagnosis and staging of suspected pancreatic cancer, some of whom had biliary stents in situ and some of whom did not. The main end point was the uni- and multivariate association of biliary stenting with T and N mis-staging by EUS. The surgical T and N stages were used as gold standards.

RESULTS

A total of 65 patients were identified (19 with biliary stents in situ and 46 without). Surgical stage T4 was found more frequently in patients with stents (53% vs. 22%, P = 0.014). The T stage by EUS was correct in 85% of the patients without biliary stents and in 47% of the patients with stents. The frequency of mis-staging by EUS was significant only among patients with a biliary stent. The distribution by EUS N stage did not differ significantly from the surgical N-stage distribution in the two groups of patients. According to the multivariate analysis, patients with stents were 6.55 times more likely to be incorrectly T staged (95% confidence interval [CI] 1.69-25.49) and 3.71 times more likely to be incorrectly N staged (95% CI 1.11-12.45) than patients without stents.

CONCLUSIONS

The results add support to the recommendation that EUS staging of pancreatic head neoplasms should be performed prior to stent placement.

Growth hormone in inflammatory bowel disease

Crohn's disease and ulcerative colitis are inflammatory diseases of the gastrointestinal tract characterized by chronic relapsing inflammation and catabolism. Growth hormone/insulin-like growth factor-I axis is important in inflammatory bowel disease, because of the effects on epithelial cell kinetics, collagen deposition and immunomodulation. The potential of growth hormone as a therapeutic option in inflammatory bowel disease has been proven in various clinical settings. Acquired growth hormone resistance in inflammatory bowel disease seems to be mediated by a combination of undernutrition and active inflammation. In particular, proinflammatory cytokines, such as TNF-a and interleukin-6, have been implicated as potential mediators of growth hormone resistance. The introduction of anti-TNF-alpha monoclonal antibodies has proven very efficacious in patients with inflammatory bowel disease. By reducing cytokines levels in inflammatory cells of intestinal mucosa, infliximab could interfere with cytokine-induced growth hormone resistance. Recent in vivo data have shown that acquired growth hormone resistance in patients with inflammatory bowel disease may be reversed after the administration of anti-TNF-alpha therapy.

Infliximab in the treatment of steroid-dependent ulcerative colitis

BACKGROUND AND OBJECTIVES

Infliximab has proven efficacious in the treatment of Crohn's disease. Limited and contrasting data are available on effectiveness of anti-TNF alpha therapy in ulcerative colitis. We evaluated the efficacy of infliximab in the management of steroid-dependent ulcerative colitis.

METHODS

We report preliminary data from a randomized, open-label, methylprednisolone-controlled trial of infliximab in the induction and maintenance of remission of patients with moderate to severe steroid-dependent ulcerative colitis. Twenty patients received either three infusion of infliximab (5 mg/kg) at 0, 2 and 6 weeks and thereafter every 8 weeks (group A) or methylprednisolone (0,7-1 mg/kg) daily for one week followed by a tapering regimen up to the minimal dose to maintain a symptom-free condition (group B). Clinical remission was defined as a DAI score less than 3.

RESULTS

Ten patients in group A (DAI: 8.9+/-1.4) achieved remission after the first infusion (DAI: 1.6+/-0,7; p = 0.005) and steroids were progressively discontinued. At present (mean follow-up: 9.8+/-1.1 months), 9 out of 10 patients maintain clinical remission, while one patient relapsed at 3 months. Ten patients in group B (DAI: 8.7+/-1.4) reached clinical remission at one week (DAI: 1.9+/-0.3; p = 0.005). Eight out of 10 patients were maintained at a minimal steroid dosage without any relapse at 9.7+/-1.0 months follow-up. Two patients relapsed at 6 and 8 months, respectively.

CONCLUSIONS

Infliximab seems to be as effective as steroids in the management of moderate to severe steroid-dependent ulcerative colitis. These preliminary data suggest the potential efficacy of repeated treatment with infliximab for short-term maintenance of remission and steroid withdrawal in glucocorticoid-dependent ulcerative colitis.

High prevalence of hyperplastic colonic polyps in acromegalic subjects

We evaluated the prevalence and features of colonic polyps in a population of acromegalic subjects, compared to a control group of patients with irritable bowel syndrome (IBS). Colonic polyps were found in 30 acromegalic subjects (40%) and in 10 controls (13%) (P < 0.0001). Among the acromegalic patients, polyps were of the hyperplastic type in 27 subjects (90%) and adenomatous in 3 (10%). In the control group, polyps were hyperplastic in nine subjects (90%) and adenomatous in one (10%). We also observed a significant association (P < 0.0001) between the presence of hyperplastic polyps and the older age in both the acromegalic and the control groups. There were no differences between the two groups regarding sex, site, size, or macroscopic and histological types of polyps. Acromegalic patients have a higher prevalence of colonic hyperplastic polyps than IBS subjects, while the prevalence of adenomatous polyps is similar in the two groups.