University Of Insubria Research Articles

Robotic Thyroid Surgery: Need for Initial Stricter Patient Selection Criteria

Department of Surgical Sciences University of Insubria (Como–Varese) Ospedale di Circolo–Polo Universitario Varese, Italy Commentary to the paper by Lee KE, Rao J, Youn YK. “Endoscopic thyroidectomy with the da Vinci robot system using the bilateral axillary breast approach (BABA) technique: our initial experience. Surg Laparosc Endosc Percutan Tech. 2009;19:e71-e75.”

EFFECTS OF UNIVERSITY NAMING ON PREFERENCES, CREDIBILITY, IMAGE AND ENROLMENT INTENTION OF ITALIAN STUDENTS

This research focused on city-of-location vs. region-of-location naming strategies and showed that university naming is a tool for influencing its perceived credibility, image and enrolment intention. An experimental study was carried out on a sample of 200 students at an untested Italian university, who were recruited as potential users living outside of the tested areas of three different existing Italian universities with a region-of-location-based name (i.e., the University of Insubria, the University of Sannio, and the University of Tuscia). These were paired with as many experimentally manipulated fictitious city-of-location-based university names (i.e., the University of Varese and Como, the University of Benevento, and the University of Viterbo, respectively). A close-ended questionnaire was developed for each university, containing two dichotomic measures regarding the recognition of the university location and the name preference, respectively. For each of the six experimental conditions (three universities × two naming strategies), the questionnaire also contained: a three-item seven-point perceived credibility scale, based on Ohanian’s (1990) approach; a ten-item university perceived personality scale, based on the Five-Factor Model (cf. Digman 1990); a composite measure of enrolment intention; and a 12-item seven-point “place-of-origin” image scale, developed from Pisharodi and Parameswaran’s (1994) study. Results showed that experimental subjects were more able to recognise investigated universities and their locations when their names integrate the city rather than the corresponding geographical region where such institutions are located. They also showed that potential users prefer a city-of-location-based name to a region-of-location-based one. Perceived credibility levels of the investigated universities were found to be higher when their names integrate the city of location rather than the corresponding geographical region. Results of a repeated-measure ANOVA carried out on perceived personality scores showed significant effects of university naming strategy on image profile. Both the “place-of-origin” image and the enrolment intention were also found to be higher when university names integrate the city of location rather than the corresponding regional context. Both theoretical and operational implications are discussed.

Natural history of cervical intraepithelial neoplasia during pregnancy

It is uncertain whether pregnancy influences the natural history of cervical intraepithelial neoplasia (CIN). Our aim was to evaluate the evolution of CIN in pregnant women. Prospective study. Department of Obstetrics and Gynaecology, University of Insubria, Italy. Women with histological CIN during pregnancy. Between 2003 and 2007, women with an abnormal Pap-smear during pregnancy underwent colposcopy. Patients with histological CIN were followed during pregnancy with colposcopy every 8 weeks and post-partum evaluation was scheduled 3-6 months after delivery. Women with post-partum histological diagnosis of CIN 2-3 underwent conization. To understand the impact of pregnancy on the evolution of CIN, women with CIN 1 discovered during pregnancy were compared to a group of non-pregnant fertile patients with first diagnosis of CIN 1. A total of 78 women were included: 36 (46.2%) with CIN 2-3 and 42 (53.8%) with CIN 1. In women with CIN 2-3, no invasion was suspected during pregnancy and at post-partum evaluation, no invasive or microinvasive cancer, and 19 (52.7%) persistent CIN 2-3, and 17 (47.3%) regressions were diagnosed. In the group of CIN 1, we recorded six (14.3%) progressions to CIN 2-3, seven (16.6%) persistent CIN 1 and 29 (69%) regressions. The control group of non-pregnant women had a lower regression rate (37/76: 48.7%) in comparison to pregnant women (p=0.03). Expectant management for CIN 2-3 diagnosed during gestation is safe. When discovered during pregnancy, CIN 1 has a significantly higher tendency to spontaneous regression in comparison to non-pregnant condition.

Failure of dual radius hydroxyapatite-coated acetabular cups

IntroductionMany kind of hydroxyapatite-coated cups were used, with favorable results in short term studies; it was supposed that its use could improve osteointegration of the cup, enhancing thus stability and survivorship. The purpose of this study is to analyze the long term behavior of the hemispheric HA coated, Dual Radius Osteonics cup and to discuss the way of failure through the exam of the revised components and of both periacetabular and osteolysis tissue.Materials and MethodsBetween 1994 and 1997, at the Department of Orthopedic Sciences of the Insubria University, using the posterolateral approach, were implanted 276 Dual Radius Osteonics® in 256 patients, with mean age of 63 years.ResultsAt a mean follow-up of 10 years (range 8–12 years), 183 cups in 165 patients, were available for clinical and radiographical evaluation. 22 Cups among the 183 were revised (11%). The cause of revision was aseptic loosening in 17 cases, septic loosening in one case, periprosthetic fracture in another case, osteolysis and polyethylene wear in two cases and, finally, recurrent dislocations in the last one. In the remaining patients, mean HHS increased from a preoperative value of 50,15 to a postoperative value of 92,69. The mean polyethylene wear was 1,25 mm (min. 0,08, max. 3,9 mm), with a mean annual wear of 0,17 mm. The mean acetabular migration on the two axis was 1,6 mm and 1,8 mm. Peri-acetabular osteolysis were recorded in 89% of the implants (163 cases). The cumulative survivorship (revision as endpoint) at the time was 88,9%.ConclusionOur study confirms the bad behavior of this type of cup probably related to the design, to the method of HA fixation. The observations carried out on the revised cup confirm these hypotheses but did not clarify if the third body wear could be a further problem. Another interesting aspect is the high incidence of osteolysis, which are often asymptomatic becoming a problem for the surgeon as the patient refuses the possibility of a revision.

Identifying factors contributing to reduced breast tumor size: A longitudinal study

Aim This study examines the trends and outcomes of breast cancer patients who have undergone surgical procedures at the Department of Surgical Sciences, University of Insubria, Varese, Italy. It also identifies the factors that contributed to the reduction of the breast tumor size over a 13-year period at a tertiary referral center. Methods All breast cancer operations performed at the Department of Surgical Sciences, University of Insubria, Varese, Italy, from January 1992 to June 2005 were examined and data from their surgical pathology reports were also analyzed, using a prospective database. A longitudinal study was performed to compare and analyze the pathological data during three consecutive time periods. The periods were from 1992 to 1996, 1997 to 1999, and 2000 to 2005. Surgical and pathological outcomes included age of the patient at the time of the diagnosis, partial breast resections, mastectomies, axillary lymphadenectomies, tumor size, histological type and stage, and lymph node status. Results The study group was comprised of 3050 patients who underwent breast resection between 1992 and 2005. Quadrantectomy was the preferred surgical approach in 1759 patients (58%). Throughout the longitudinal study, the tumors measuring less than 1 cm increased from 13.4% to 15.4%; the number of tumors diagnosed at stage I increased from 44.1% to 56.8%; the most frequent histological type was ductal carcinoma; the number of ductal carcinomas in situ (DCIS) increased from 4% to 6%; and the incidence of lymphadenectomies decreased from 71.6% to 52.5%. Perioperative factors that correlated with the decreased size of the tumor over time were: screening, improvement of diagnostic and therapeutic techniques, and the increased operative use of sentinel lymph node biopsy (SLNB). Conclusions There has been an evolving refinement in surgical technique and perioperative management of breast cancer patients undergoing surgical resection at the Department of Surgical Sciences, University of Insubria, Varese, Italy, during the past decades. The present longitudinal study on 3050 surgical breast cancer patients confirmed the progressive reduction of tumor size at the time of the diagnosis. Perioperative factors that correlated with the decreased tumor size over time were mammography screening, improvement of diagnostic and therapeutic techniques, and the use of SLNB. Furthermore, the study showed that the progressive reduced number of useless axillary lymphadenectomies was mainly due to the increased intraoperative use of axillary SLNB.

79: Expansion of uterine incision at cesarean delivery: A randomized comparison of two techniques

COMPARISON OF TWO TECHNIQUES ANTONELLA CROMI, EDOARDO DI NARO, GABRIELE SIESTO, STEFANO UCCELLA, ANNAMARIA CARINGELLA, VALERIA UBOLDI, FABIO GHEZZI, University of Insubria, Varese, Italy, University of Bari, Italy OBJECTIVE: Since anatomical studies suggest that oblique and circular running muscle fibers dominate the region toward the isthmus of the uterus, we speculated that blunt extension of the uterine incision in a cephalad-caudad direction would minimize uterine wall trauma at the time of cesarean delivery. We therefore designed a study to investigate whether this method of expanding the uterine incision was associated with lower risk of unintended extensions and associated complications than the conventional expansion from medial to lateral. STUDY DESIGN: Consecutive women undergoing low segment transverse cesarean delivery were randomly assigned to cephalad-caudad or transversal expansion groups. Cephalad-caudad expansion was accomplished by separating the forefingers in a cephalad-caudad direction after the fingers are inserted into the small, midline uterine incision. An extension was defined as any unintended defect observed outside the limits of the original incision. Extensions that involved the uterine vessels and cervical extensions were recorded. Power calculation was based on a previous study in which the unintended extension rate was 12.4%.With 0.05 and 0.20, 403 patients in each arm were required to demonstrate a difference of 6% between groups. RESULTS: The cephalad-caudad (n 405) and transversal (n 406) expansion groups were similar with regard to patients characteristics, indication to surgery, and proportion of emergency procedures. No difference in duration of surgery (40.4 11.8 vs. 38.9 11.9 minutes, P 0.15), type of anesthesia (regional anesthesia: 90.1% vs. 87.9%, P 0.27), need for transfusions (0.7% vs, 0.7%, P 1.0) or estimated blood loss (440 341 vs. 398 242 mL, P 0.09) was noted. The incidence of unintended extension was significantly higher in the transversal expansion group than in the cephalad-caudad group (7.4% vs. 3.7%, P 0.03). CONCLUSION: Since it is associated with less risk of unintended extension, cephalad-caudad expansion should be preferred to transversal expansion of the uterine incision when performing cesarean delivery

Correlación entre la medición ecográfica del cordón umbilical y la edad gestacional, su relación con la biometría fetal y los resultados perinatales

Aim (a) To evaluate the umbilical cord in normal pregnancies using ultrasonography in the third trimester with a view to obtaining gestational age values according to reference tables. (b) To compare umbilical cord measurements with fetal biometry, length, weight and perinatal outcomes to determine whether this type of correlation exists in our population and whether it could be used to establish values of normality that would help to diagnose abnormalities. Material and methods From Juny 2001 to June 2002 we studied 48 pregnat women that have been controlled by ultrasound from week 28 to 38 of gestation. We just included patients with normal and controlled pregnancies, without any associated pathology. We obtain biparietal diameter, abdominal circumference, femoral long measurement, and umbilical cord diameter through a transversal cut of the umbilical area. Gestational age was obtain by last menstruation and by ultrasound according with biometry. measurement of the umbilical cord was compared with a nomogram of the gestational age (GA) performed by the Obstetric and Gynaecology Department of the Insubria University in Italy. We registered the type of birth the GA at birth, APGAR score length, weight, cephalic diameter, and eventually complications. For calculate the normal umbilical cord area according to the gestational age by last menstruation we use the Raio et al equations to construct the corresponding nomogram. It was apply statistics methods with an alfa of 5%. Results LMP-based gestational age was highly correlated with ultrasound measurements. Theoretical UCA was not correlated with observed UCA. Only 54.2% of UCAs were found to be within the 5th and 95th percentiles (P =0.001), and consequently only two-thirds of the patients were within the parameters of normality. No correlation was found between UCA and gestational age, when attempting to construct a nomogram for our population ( P=.99). No association was found between UCA and fetal biometry parameters. No significant correlation was found with weight, length, head circumference or gestational age at delivery. Apgar score was favorable and stable in all neonates; Apgar score was thus considered a constant and was not correlated with UCA. UCA was significantly lower in women who underwent cesarean section than in those with normal deliveries ( P<.05). Conclusion UCA was not correlated with gestational age, fetal biometry or perinatal outcomes. Values in our population cannot be extrapolated to existing nomograms.

Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: Single center experience

Background and aim Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects. Materials and methods Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present. Results All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800 ml/day (range 400–1600 ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20–2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis. Conclusions After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.

Open up and keep the lymphatics open: They are the hydraulics of the body!*

Department of Intensive Care, Ziekenhuis Netwerk Antwerpen, Campus Stuivenberg, Antwerpen, Belgium (Malbrain) Department of Ambient, Health and Safety, University of Insubria, Varese, Italy (Pelosi) Dr. Malbrain has received honoraria and a patent from Pulsion Medical Systems. He also owns stock in the company and is a member of the medical advisory board. He has received honoraria from KCI and MSD and in 2003 received the ESICM Chris Stouten Beek grant. He has received royalties from Spiegelberg and Holtech Medical. Dr. Pelosi has not disclosed any potential conflicts of interest.

The cold side of life

Barren land covered with huge ice shelves, swept by merciless winds and entrapped by deadly cold seas: that is a common perception of the polar regions. However, this picture could not be more wrong, as both the Arctic and Antarctic are teeming with life that is extraordinarily adapted to the harsh conditions and which often exists at the edge of survival (Fig 1,Fig 2,Fig 3,Fig 4). There has been a growing interest in these psychrophilic organisms, and how they evolved to grow and proliferate at permanently cold temperatures (D'Amico et al , 2006). Yet, it is not only the life sciences that can gain important insights from studying biological communities at the poles. Understanding how polar ecosystems respond to rapid climate change is of global significance; there is evidence that organisms, oceans and the atmosphere in the polar regions interact strongly, influencing each other in complex ways and with potentially major consequences for climate. Figure 1. A jellyfish offshore of McMurdo Station, Ross Island. Photograph by Steve Clabuesch/US National Science Foundation. Figure 2. Chinstrap penguins are about 68 cm (27 inches) tall and weigh about 4 kg (9 pounds). They are social animals and number about 5 million. Photograph by Zee Evans/US National Science Foundation. Figure 3. A crab‐eater seal lounges on an ice floe near the Antarctic Peninsula. Crab‐eaters are the most numerous seals in the world, with a population of more than 15 million. Although they do not eat crabs, they do eat krill and other crustaceans. They will reach a length of over 8 ft (2.44 m) and a weight of up to 500 lb (227 kg). Photograph by Jeffrey Kietzmann/US National Science Foundation. Figure 4. A snailfish, Paraliparis devriesi . Common inhabitants of deeper Antarctic waters, snailfish are characterized by a layer of jelly between the muscle and the …

Choking Hypoxia-Inducible Factor 1α: A Novel Mechanism for Connective Tissue Growth Factor Inhibition of Angiogenesis

Journal of the National Cancer Institute, Vol. 98, No. 14, July 19, 2006 Among the driving forces that orchestrate oncogenic transformation, aberrant tumor angiogenesis has evolved as a process assured by the conscription of various signaling pathways with redundant functions. These pathways converge on the same task: to produce more vessels, without ensuring correct structural constraints and proper function. Different cellular components in tissues are equipped with proangiogenic molecular machinery, as demonstrated by studies on the role of infl ammatory cells in tumor promotion that have driven the development of new therapies for cancer prevention and treatment ( 1 , 2 ) . Transcriptional reprogramming controlled by dysregulated signaling pathways is one of the mechanisms that are the basis for the cellular adaptations necessary for cancer establishment. In particular, one master regulator, the hypoxia-inducible transcription factor 1 (HIF-1) complex, which controls tissue homeostasis, seems to take center stage as a pervasive instigator of transformation for almost all cellular compartments in tissues. HIF-1, primarily recognized as a mediator of adaptive responses to tissue oxygenation, integrates diverse information related to energy status, glucose, and iron metabolism, as well as growth factor signaling in normoxia and hypoxia ( 3 , 4 ) . Furthermore, recent evidence indicates that HIF-1 – activated metabolic responses are essential for the recruitment and infi ltration of myeloid cells at early stages of infl ammation ( 5 ) . The decision to constitutively activate HIF-1 α as a means for coping with stressful or threatening local conditions in the microenvironment carries the high cost of increased risk of neoplastic transformation. HIF-1 also contributes to defi ne an invasive, lethal cancer phenotype by elevating the metabolic resources of cells through increased glucose uptake, glycolysis, and angiogenesis ( 6 ) . The HIF-1 α subunit of the heterodimeric transcriptional complex HIF-1 is the labile regulatory element destined to ubiquitination and default destruction in the absence of alerting signals from the microenvironment. Proteins of the von Hippel-Lindau (pVHL) – ubiquitin – proteasome pathway, isoforms of prolyl hydroxylases (PHDs), and the acetyltransferase ARD1 eliminate necessary HIF-1 α under normoxia in normal cells. Hydroxylation of HIF-1 α at proline residues 402 and 564 in the oxygendependent degradation (ODD) domain by PHDs targets HIF-1 α Affi liations of authors: Molecular Oncology Laboratory, National Cancer Research Institute, Genoa, Italy (FT, AA); University of Insubria, Varese, Italy (DMN). Correspondence to: Adriana Albini, PhD, Ist. Nazionale per la Ricerca sul Cancro, Molecular Oncology, Largo Rosanna Benzi, 10, Genova 16132, Italy (e-mail: adriana.albini@istge.it ).

Prospective Study of Infection Risk Factors in 988 Lung Resections

To evaluate the incidence of surgical site infections (SSI), as related to risk factors, in patients undergoing lung resections (LR). We evaluated 988 consecutive patients prospectively who underwent LR between 1996 and 2005 at the Center for Thoracic Surgery of the University of Insubria, Varese, Italy. Patients were divided into four groups: Pneumonectomy (n=104), lobectomy/bi-lobectomy (n=438), wedge resection by thoracotomy (n=155), and wedge resection by video-thoracoscopy (VATS) (n=291). The recorded risk factors for SSI were hemoglobin concentration, serum albumin concentration, lymphocyte count, percentage of predicted forced expiratory volume in 1 sec (FEV1), duration of surgery, blood transfusion, age>70 years, and comorbidity. The postoperative SSIs (superficial and deep incisional SSI, pneumonia, empyema) were recorded in they occurred within 30 days, and the final outcome was recorded. Postoperative infections were found in 141 patients (14.3%) and included 166 thoracic infections, among them 32 incisional SSIs (3.2%), 103 cases of pneumonia (10.4%); and 24 empyemas (2.4%). The overall incidence of SSI was significantly lower in patients having wedge resections by VATS (5.5%) than in the other three groups (17.9%) (p<0.001). The overall mortality rate was 1.2% (12/988), of which six deaths (0.6%) were caused by complications of infection. The infection rate correlated with duration of surgery>180 min, age>70 years, serum albumin<3.5 g/dL, and the presence of any comorbidity. Moreover, 18% of patients with FEV1>70% had postoperative pneumonia, a significant increase (p<0.01) compared with patients with FEV1>or=70%. In this prospective study, the SSI rate after LR was 14.3%, and the 30-day operative mortality rate was 1.2%, with most of the deaths caused by pneumonia. After VATS LR procedures, the incidence of SSI was lower at 5.5%. Finally, SSI correlated with the duration of surgery, serum albumin, concurrent comorbidity, age, and FEV1.

Long-Term Results and Quality of Life of Patients Undergoing Sequential Surgical Treatment for Severe Acute Pancreatitis Complicated by Infected Pancreatic Necrosis

Infected pancreatic necrosis (IPN) is one of the most severe complications of acute pancreatitis (AP). Sequential surgical debridement represents one of the most effective treatments in terms of morbidity and mortality. The aim of this paper is to describe the quality of life and long-term results (e.g., nutritional, muscular, and pancreatic function) of patients treated by sequential necrosectomy at the Department of Surgery of the University of Insubria (Varese, Italy). Data were collected on patients undergoing sequential surgical debridement as treatment for IPN. The severity of AP was evaluated using the Ranson criteria, the Acute Physiology and Chronic Health Evaluation (APACHE II) Score, and the Sepsis Score, as well as the extent of necrosis. The surgical approach was through a midline or subcostal laparotomy, followed by exploration of the peritoneal cavity, wide debridement, and peritoneal lavage. The abdomen was either left open or closed partially with a surgical zipper, with multiple re-laparotomies scheduled until debridement of necrotic tissue was complete. The long-term evaluation focused on late morbidity, performance status, and abdominal wall function. In the majority of patients (68%), mixed flora were isolated. Pseudomonas aeruginosa was the microorganism identified most commonly (59%), often associated with Candida albicans or C. glabrata. The mean total hospital stay was 71+/-38 days (range 13-146 days), of which 24+/-19 days (range 0-66 days) were in the intensive care unit. Eight patients died, the deaths being caused by multiple organ dysfunction syndrome in seven patients and hemorrhage from the splenic artery in one. Normal exocrine and endocrine pancreatic function was observed in 28 patients (88%). At discharge, four patients had steatorrhea, which was temporary. Eight patients (23%) developed pancreatic pseudocysts, and in six, cystogastostomy was performed. Most patients (29/32, 91%) developed a post-operative hernia, but only five required surgical repair. All patients had a Short Form (SF)-36 score>60%, and 20 of the 32 patients (68%) had scores>70-80% (good quality of life). The worst scores were related to alcoholic pancreatitis. The degree of pancreatic failure (exocrine and endocrine function) is not related to the amount of pancreatic necrosis. Even with a need for repeated laparotomy and multiple surgical procedures, the abdominal wall capacity as well as long-term quality of life remain excellent.

Characterization of a thinned back illuminated MIMOSA V sensor as a visible light camera

This paper reports the measurements that have been performed both in the Silicon Detector Laboratory at the University of Insubria (Como, Italy) and at the Instituto Ricerche SOlari Locarno (IRSOL) to characterize a CMOS pixel particle detector as a visible light camera. The CMOS sensor has been studied in terms of Quantum Efficiency in the visible spectrum, image blooming and reset inefficiency in saturation condition. The main goal of these measurements is to prove that this kind of particle detector can also be used as an ultra fast, 100% fill factor visible light camera in solar physics experiments.

Surgical resection for gastrointestinal stromal tumors (GIST): experience on 25 patients.

BackgroundGastrointestinal stromal tumors (GIST) are infrequent and diagnosis and prognosis could be troublesome. We present short and long term results of surgical resection for GIST at the Department of Surgery, University of Insubria, during a period of 17 years.Materials and methodsAll patients' data, tumor characteristics, surgical procedure and survival data were analyzed retrospectively. Tumors were divided in risk classes using the classification proposed by Fletcher, based on tumor size and number of mitosis.ResultsBetween 1987 and 2004, 25 patients underwent surgical resection for GIST. Stomach was the most common site of localization. Complete resection was achieved in 88% cases, while in 12% radical resection was not possible. The mean tumor size was 9.2 cm (1.2 – 30 cm): <5 cm diameter in 14/25 cases (56%), 5–10 cm in 5/25 (20%) and >10 cm in 6/25 (24%). Mitotic count was <10/50 HPF in 68% (17/25) and >10/50 in 32% (8/25). Using Fletcher's classification, tumors were divided in very low (11/25, 44%), low (4/25, 16%), intermediate (6/25, 24%) and high-risk (4/25, 16%) groups. The 5-year overall survival was 65% and 34% respectively with a statistically significant difference between tumors <5 cm and >10 cm in diameter and between complete and incomplete resection. High-risk tumors had a significantly shorter survival than low or very low risk.ConclusionOur experience confirms that GIST's are uncommon and aggressive cancers. The prognosis is strictly related to tumor size and number of mitosis. Although significant advances on new chemotherapeutic regimes have been made, to date, only radical surgery offers the chance of long-term survival.

Videothoracoscopic (VTS) finger palpation and resection of indeterminate lung nodules ≤1.5 cm. Evaluation of histology by size groups: Dominioni L, Imperatori A, Pericelli A, Antonini C, Rotolo N, Paolucci M (Center for Thoracic Surgery, University of Insubria, Varese, Italy; Radiology Unit, Ospedale S. Antonio Abate, Gallarate, Italy

Videothoracoscopic (VTS) finger palpation and resection of indeterminate lung nodules ≤1.5 cm. Evaluation of histology by size groups: Dominioni L, Imperatori A, Pericelli A, Antonini C, Rotolo N, Paolucci M (Center for Thoracic Surgery, University of Insubria, Varese, Italy; Radiology Unit, Ospedale S. Antonio Abate, Gallarate, Italy

New Antithrombotic Drugs

For many decades, heparin and oral anticoagulants have been the antithrombotic drugs of choice in the prevention and treatment of both venous and arterial thromboembolism. The efficacy and the relative safety of these compounds have been consistently proven by a large number of clinical studies that have also progressively contributed to improve their management. However, these drugs have limitations. Unfractionated heparin (UFH) acts by catalyzing the effect of antithrombin III, a natural anticoagulant able to inactivate factors IIa, IXa, and Xa, and also by inhibiting the activation of factors V and VIII by thrombin. The anticoagulant effect of UFH is unpredictable and varies considerably among patients, depending upon age, gender, body weight, smoking status, and renal function. This wide variability is caused by heparin binding to phase reactant proteins; the level of which varies among normal individuals and among disease states. Before therapeutic plasma levels are achieved, the binding to plasma proteins as well as to receptor sites on endothelium must be saturated. Unfractionated heparin must be given parenterally and it requires careful laboratory monitoring to ensure the anticoagulant response is therapeutic.1 Low molecular weight heparin (LMWH) also acts by catalyzing antithrombin III, but because of the reduced number of saccharide units, its antithrombotic activity is more selective and it is mainly based on inactivation of factor Xa because of a reduced ability to inactivate factor IIa. Low molecular weight heparin does not bind to the endothelium and have a lower affinity for plasma proteins. This results in a more predictable bioavailability, in a substantially longer half-life, and in a stable dose response when injected subcutaneously. Therefore, LMWH has a more predictable anticoagulant response that has overcome the need for laboratory monitoring. However, it also needs to be administered parenterally and thus has limited indications for long-term use.2 Characteristics and pharmacokinetics of UFH and LMWH are summarized in T1 and T2. In the last years, new antithrombotic agents have been developed to overcome some of heparin and warfarin limitations. One of the main goals was the search for a greater selectivity in the pharmacologic action of the new compounds. Direct factor Xa inhibitors (DTI) and direct thrombin inhibitors recently underwent extensive evaluation in the prevention and treatment of both venous and arterial thromboembolism. science [coagulation and hematology] New Antithrombotic Drugs Walter Ageno,1 Alexander G.G. Turpie2 1Department of Internal Medicine, University of Insubria, Varese, Italy, 2Department of Internal Medicine, McMaster University, Hamilton, Canada

Non-point source critical area analysis in the Gisselö watershed using GIS

In the southeast in Norrköping, Sweden, is a small fjord-like bay called Slätbaken. The water quality in Slätbaken—with its narrow outlet to the Baltic Sea—depends highly on the water quality of the streams that flow in it. While point pollution sources can be identified easily in general, the non-point sources are harder to find. The most important sources for non-point pollution are agricultural areas, and the pollutants are mostly nutrients like phosphorus, which come from the fertilisation of the fields. One important catchment area for Slätbaken is the 57.7 km 2 Gisselö river basin (part of the topographic map 8GNO), which contains large agricultural areas. The transport of water pollutants is based on the same hydrological processes as erosion and sediment transport. The implementation of such a model in a GIS allows the analysis of a large area with a high resolution. When choosing the model, special attention was paid to the possibility of using a verified model that is easy to implement in a commercial GIS without the need of too much expert knowledge. This may allow its widespread use in many administrative applications that need non-point source information. A feasibility test for an enhanced GIS USLE model was done in the Gisselö drainage basin before it was implemented for all river basins in the whole administrative area of Norrköpings kommun. It is possible to use the suggested simplified USLE model to estimate the load of both pollutants and sediments, and it is able to show the areas that are critical for the water quality at the outlet of the water basin. The model has been evaluated in three studies [Int. J. Geogr. Inf. Syst. 2 (4) (1988) 365; A GIS to target critical areas for non point source management, in: Proceedings of the International Non Point Source Management Symposium, Austin, TX, November 7, 1989; Vatten 48 (1992) 117]. Then, implemented in a very simple GIS that allowed only rough estimates of terrain models and distances, the model was able to estimate the total suspended solids (TSS) and total phosphorus (TP) loads in the Svartå river basin of 1539 km 2 in the same region as Gisselö and the Bornsjö river basin outside Stockholm. Besides an estimated R 2 of 0.91–0.98 (verified by a more than one year measurement from manual and automated sampling stations in the whole river basin), the benefit with the GIS implemented USLE was the possibility to identify the risk areas with high spatial accuracy. During the last decade, both available databases and software have changed the possibilities to identify areas at risk of nutrient leakage. Schein [GIS Methods for Monitoring Sustainable Development by Analysis of Land-use and Land Cover Changes in the Surroundings of Linköping (Sweden), Institut für Photogrammetrie und Fernerkundung, Technische Universität Dresden, Germany] and Schein and Sivertun [Method and models for sustainable development monitoring and analyses in GIS, in: Proceedings of the International Workshop on Geo-Spatial Knowledge Processing for Natural Resource Management, University of Insubria, Varese, Italy, June 28–29, 2001] show that the enhanced land use data available through the European Union agricultural support program can be used together with remote sensing data to fine tune the modified GIS USLE model. The problems with the new 50×50 m digital elevation data now available are also pointed out here. Obvious errors in the data and possibilities to enhance the model by introducing a better terrain model were two important suggestions in these works. In this article, two modifications to the original model are suggested. One is enhancement of the digital terrain model by using height curves from the digital 1:50 000 scale topographic map, and the other is a smooth distance function that better reflects the impact of nutrients on water bodies. Because of its easy implementation on standard low cost systems, the GIS USLE model is suitable for analysing huge areas for critical places. The results can lead to more detailed studies in the risk areas thus identified or to investigations on the effect of land use changes, or can be used simply for taking care in the use of fertilisers and other chemicals in the critical agricultural areas.

Outcome and long term results of surgical resection for gastrointestinal stromal tumors (GIST).

Gastrointestinal Stromal Tumors (GIST) are rare; diagnosis and prognosis of these tumors are often complex. We present short and long term results of surgical resection for GIST at the Department of Surgery, University of Insubria, during a period of 14 years. All patients' data, tumor characteristics, surgical procedure and survival data were analyzed retrospectively. Tumors were divided in risk classes using a new classification proposed by Fletcher, based on tumor size and number of mitosis. From 1987 to 2001 19 patients underwent surgical resection for GIST. Stomach was the most common site of localization. Complete resection was achieved in 78.9 % cases, while in 21.1% radical resection was not possible. The mean tumor size was 8.4 cm (1.2-30 cm): < 5 cm diameter in 11/19 cases (58%), 5-10 cm in 4/19 (21%) and > 10 cm in 4/19 (21%). Mitotic count was < 10/50 HPF in 68.5 % (13/19) and > 10/50 in 31.5 % (6/19). Using Fletcher's classification, tumors were divided in very low (8/19, 42.2 %), low (3/19, 15.8 %), intermediate (4/19, 21%) and high risk (4/19, 21%). The 5 years overall survival was 63 % and 34 % respectively with a statistically significant difference between tumors < 5cm and > 10 cm in diameter and between complete and incomplete resection. High risk tumors have a significantly shorter survival than low or very low risk. Our experience confirms that GIST are uncommon and aggressive cancers which prognosis is strictly related to tumor size and number of mitosis. Although significant advances on new chemotherapic regimes have been made, to date, radical surgical removal is the only chance of long term survival.

Amiodarone-induced thyrotoxicosis: a difficult diagnostic and therapeutic challenge.

Clinical EndocrinologyVolume 56, Issue 1 p. 23-24 Amiodarone-induced thyrotoxicosis: a difficult diagnostic and therapeutic challenge* Luigi Bartalena, Corresponding Author Luigi Bartalena University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalyProfessor Luigi Bartalena, University of Insubria, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy. Tel./Fax: +39 332 278561; E-mail: l.bartalena@libero.itSearch for more papers by this authorFausto Bogazzi, Fausto Bogazzi University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalySearch for more papers by this author 1 * Enio Martino, Enio Martino University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalySearch for more papers by this author 1 Luigi Bartalena, Corresponding Author Luigi Bartalena University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalyProfessor Luigi Bartalena, University of Insubria, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy. Tel./Fax: +39 332 278561; E-mail: l.bartalena@libero.itSearch for more papers by this authorFausto Bogazzi, Fausto Bogazzi University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalySearch for more papers by this author 1 * Enio Martino, Enio Martino University of Insubria, Varese, Italy and *Department of Endocrinology, University of Pisa, Pisa, ItalySearch for more papers by this author 1 First published: 11 January 2002 https://doi.org/10.1046/j.0300-0664.2001.01458.xCitations: 40 * See page 33. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume56, Issue1January 2002Pages 23-24 RelatedInformation