The challenge of clinical reasoning in chronic multimorbidity: time and interactions in the Health Issues Network model.

The increasing prevalence of multimorbidity requires new theoretical models and educational approaches to develop physicians' ability to manage multimorbidity patients. The Health Issues Network (HIN) is an educational approach based on a graphical depiction of the evolutions over time of the concurrent health issues of a patient and of their interactions. From a theoretical point of view, the HIN approach is rooted in Prigogine's vision of the "becoming" of the events and in the concept of knowledge organization, intended as the process of storing and structuring of information in a learner's mind.

Cesarean section and hernia repair: simultaneous approach.

Aim: Hernias of the abdominal wall occurring during pregnancy are usually treated a few weeks after delivery. The aim of this study was to retrospectively evaluate the clinical outcome of inguinal or umbilical hernioplasty performed at the time of the cesarean section, and to compare the outcome of this group with a control population, who received a cesarean section alone.

Material & Methods: We reviewed 28 women who developed an inguinal or umbilical hernia during pregnancy from January 1, 2000 to December 31, 2007 and who received a combined cesarean section and hernia repair, and we compared this group with 100 women (controls) who only received a cesarean section.

Treatment of hydatid bronchobiliary fistulas: 30 years of experience.

Background: Bronchobiliary fistula (BBF) is an uncommon but severe complication of hydatid disease of the liver. Operation is considered the treatment of choice but the most appropriate operation is uncertain. The aim of this study was to evaluate the early and long-term outcomes following different surgical procedures.

Cyanoacrylate glue in the treatment of ano-rectal fistulas.

Background And Aims: The management of anal fistula is debatable. Although several procedures have been described, none of them is free from complications, such as anal incontinence and anal pain. The purpose of this study was to evaluate the employment of a glue composed of N-butil-2-cyanoacrylate and methacryloxysulfolane (Glubran 2) to treat fistula-in-ano.

Stromal tumors of the small bowel causing unexplained melena: report of two cases.

Gastrointestinal stromal tumors (GISTs) of the small bowel are relatively rare and, therefore, both difficult to diagnose and treat. The authors present two cases of such tumors and review the various options for diagnosis and treatment.

Surgical treatment of pancreatic head carcinoma in elderly patients.

Hypothesis: The treatment of cancer in elderly patients has become a global clinical issue, considering the increasingly longer life expectancy. Three quarters of patients with pancreatic adenocarcinoma are older than 60 years. Surgical resection is the only chance of cure, and early outcome of pancreaticoduodenectomy in elderly patients is comparable with that obtained in a younger population.

Characterization of tumoral lesions of the breast: preliminary experience with multislice spiral CT.

The aim of the present study was to validate low dose Multislice Spiral Computed Tomography (MSCT) in the diagnosis of breast lesions. Fourteen patients with mammographic and ultrasound findings suspect of malignant neoplasm underwent dynamic MSCT of the breast under basal conditions and 1, 3, and 6 minutes after intravenous injection of iodinated contrast medium. Both enhancement of the lesion >100% without further increase after 6 minutes, and irregular margins of the lesion were considered signs of malignancy.

Treatment of giant intramuscular hemangioma: a multistep approach in three patients.

Background: Giant intramuscular hemangioma (GIH) is a rare, progressively enlarging benign tumor, characterized by variable presentation and usually initially diagnosed in childhood. Large volume, rapid enlargement and particular radiologic imaging create suspicion of malignancy. Radiologic investigations and needle or small excisional biopsy are not always reliable for an accurate diagnosis; therefore, histology on a large surgical specimen is often requested.

Hepatic resection in stage IV colorectal cancer: prognostic predictors of outcome.

Background And Aims: Hepatic resection has been proposed as an effective way to treat metastatic colorectal carcinoma. The aim of the study was to determine if contemporary resection of intestinal primary tumor and hepatic metastases is effective in the treatment of patients with metastases that are recognized at the initial clinical presentation of the primary tumor.

Methods: In a retrospective study, univariate and multivariate models were used to analyze the effect of patient demographics, tumor characteristics, and treatment factors on early and long-term outcome of patients submitted to synchronous intestinal and hepatic resection for colorectal liver metastases.

Clinical significance of serum gastrin levels in patients with colorectal cancer.

Aims: An association between elevated serum gastrin levels and the presence of human colorectal cancer has been reported, and gastrin has been shown to stimulate the growth of experimentally induced colon neoplasia. The aim of this study was to determine the preoperative and postoperative concentrations of serum gastrin in 53 patients with colorectal cancer and to assess the correlation between gastrin levels and tumor characteristics and prognosis.

Materials And Methods: A prospective study was performed over a six-year period during which 53 patients received potentially curative surgery for colorectal cancer.

Subcutaneous emphysema after associated colonoscopy and transanal excision of rectal adenoma.

Non-traumatic subcutaneous emphysema (NSE) is a rare complication of procedures of the digestive tract. To the best of our knowledge, it has never been reported to occur after transanal surgery. Herein we present the first known case of NSE accompanied by retropneumoperitoneum and pneumomediastinum to develop after colonoscopy and full-thickness transanal removal of a rectal polyp.

Adenocarcinoma of the third and fourth portions of the duodenum: results of surgical treatment.

Hypothesis: To verify the adequacy of duodenal segmentectomy after intestinal derotation in the treatment of primary adenocarcinoma of the third and fourth portions of the duodenum.

Design: A retrospective review of the surgical management of patients who underwent derotation of the third and fourth portions of the duodenum was undertaken to determine long-term outcome.

Setting: Departments of surgery in 3 university hospitals.

Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease.

Background: Preservation of the inferior mesenteric artery (IMA) and consequential blood flow to the rectum would reduce the risk of leakage of a colorectal anastomosis.

Methods: One hundred and sixty-three patients undergoing left colectomy for complicated diverticular disease of the colon were randomly placed into two groups: A, n = 86; and B, n = 77. In group A, the integrity of the IMA was preserved by artery skeletization (IMAS); in group B, the IMA was divided at its origin.

Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients.

Objective: To evaluate the correlation between biliary-enteric surgical drainage and the late development of cholangiocarcinoma of the biliary tract.

Summary Background Data: In patients with biliary-enteric drainage, reflux of intestinal contents into the bile duct may occur and cause cholangitis, which is regarded as the most serious complication of these procedures. Lithiasis of the biliary tract and a previous biliary-enteric anastomosis have both been suggested to favor the late onset of cholangiocarcinoma.

Preoperative lymphoscintigraphy and sentinel lymph node biopsy in papillary thyroid cancer. A pilot study.

Background And Objectives: Lymphadenectomy for papillary thyroid cancer is a matter of debate. After showing its usefulness as a prognostic factor in both melanoma and breast cancer, the concept of sentinel lymph node biopsy was also recently applied to differentiated thyroid cancer. To date, all attempts to locate and remove the sentinel node were based on the intraoperative injection of a vital dye.

Prospective evaluation of total parathyroidectomy and autotransplantation for the treatment of secondary hyperparathyroidism.

Objective: To evaluate the clinical effectiveness of total parathyroidectomy with autotransplantation for the treatment of hyperparathyroidism and the recurrence rate of hyperparathyroidism after this procedure.

Design: A prospective study of total parathyroidectomy and autotransplantation in 19 consecutive patients with severe secondary (renal) hyperparathyroidism.

Setting: University hospital department of surgery.

Laparoscopic management of volvulated Meckel's diverticulum.

Laparoscopy in the emergency setting is a logical extension of this technique. Open laparoscopy is particularly useful in the management of the acute abdomen. In our institution, after a sequential work-out that includes physical examination, laboratory data, plain abdominal roentgenograms and ultrasonography, diagnostic laparoscopy is advocated.

Food allergy in children: diagnosis and treatment with sodium cromoglycate.

Food allergy (FA) is a very important problem affecting numbers of infants and children with protean manifestations which are frequent challenges to the pediatrician and other specialists working with children. Adverse reactions to food are very complex, frequently mediated bu IgE mechanisms, and often by other mechanisms. To make the correct diagnosis and to arrive at a proper therapeutic approach requires all the skill a physician can gather.