Role of bronchoscopy in critically ill patients managed in intermediate care units - indications and complications: A narrative review

Flexible bronchoscopy(FB)has become a standard of care for the triad of inspection,sampling,and treatment in critical care patients.It is an invaluable tool for diagnostic and therapeutic purposes in critically ill patients in intensive care unit(ICU).Less is known about its role outside the ICU,particularly in the intermediate care unit(IMCU),a specialized environment,where an intermediate grade of intensive care and monitoring between standard care unit and ICU is provided.In the IMCU,the leading indications for a diagnostic work-up are:To visualize airway system/obstructions,perform investigations to detect respiratory infections,and identify potential sources of hemoptysis.The main procedures for therapeutic purposes are secretion aspiration,mucus plug removal to solve atelectasis(total or lobar),and blood aspiration during hemoptysis.The decision to perform FB might depend on the balance between potential benefits and risks due to frailty of critically ill patients.Serious adverse events related to FB are relatively uncommon,but they may be due to lack of expertise or appropriate precautions.Finally,nowadays,during dramatic recent coronavirus disease 2019(COVID-19)pandemic,the exact role of FB in COVID-19 patients admitted to IMCU has yet to be clearly defined.Hence,we provide a concise review on the role of FB in an IMCU setting,focusing on its indications,technical aspects and complications.

The Use of a“Rewarding System”for Healthcare Personnel

This work aims to identify a method by the coordinator of the OU(operational unit)for the training of gratified personnel through the use of a rewarding system.The continuous transformations that concern the Italian healthcare scene lead the operators to face always new needs and problems.Professionals can not only be considered as workers but bearers of qualified intellectual,professional and cultural skills.Individual coordinators are required to be real leaders within their operational units and to use their managerial skills in achieving company objectives and in evaluating the personnel they manage.The main factor to which difficulties in the management of staff are related concerns the motivation,defined as a state of mind together with aspirations,needs,orientations,that pushes people to act and to use a behavior characterized by commitment,perseverance and determination.The need to better rationalize the resources available,to promote high quality health care,improving safety,efficiency and appropriateness has led the general management and coordinator of the OU to use the reward systems.With the introduction of this procedure aimed at enhancing the merit and encouraging virtuous behavior during the provision of health services,the public employment reform participates in the evolution of the regulatory framework and it turns on the change that is taking place in the world of work.

Sickness, Pain, and Suffering: Reflections on Doctors Dealing With Painful Diseases and the Death of Their Patients

Medicine consists first of all in taking care,also in those cases when it is impossible to cure the patients and to restore their good health.In fact,healthcare workers and doctors are increasingly faced with painful diseases and end-of-life situations.In these difficult circumstances,it becomes necessary for the doctor to recover a more global vision of the person of the patient,and to understand that the present illness can be read as a metaphor of his/her own existence-since the experience of an entire life manifests and redefines itself in the disease.Empathy and compassion constitute a guide to authentic and effective caring that manifests itself in the language used and in attitudes that become externalized as appropriate behaviours.The doctor must do all he/she can in order to alleviate the patient’s physical and psychological pain,using the tools of caregiving and palliative care.

Femoral artery blowout syndrome after inguinal lymphadenectomy for penile cancer

Dear Editor,Inguinal lymphadenectomy represents a crucial step in both staging and treatment of penile cancer and can be curative in some patients.Nevertheless,severe morbidity can be high in up to 50%of cases.The most-reported complications are skin necrosis,wound infection,lymphoedema,and lymphocele[1].In this setting,artery blowout syndrome(ABS)is a complication rarely described,presenting with vessels exposure through wound dehiscence,leading to arterial wall rupture with potentially life-threatening bleeding(Type III ABS).Reports have been described following radiation treatment of the groins or the neck[2,3].We present the first case of femoral artery wall rupture with severe hemorrhage after iliac and inguinal lymphadenectomy for penile cancer in a patient without previous radiation treatment.Written consent for case publication was obtained.

Heterogeneity of the intrahepatic biliary epithelium

这评论的目的是在 apoptotic，增生的和分泌活动与变化构画出与胆汁的上皮的词法异质和对肝胃肠激素和肽和肝损伤的不同大小的胆汁管的异构的 pathophysiological 回答有关的最近的调查结果。因为胆汁的上皮细胞(cholangiocytes ) 是人的 cholangiopathies 的目标的识别，胆汁的功能的知识很快正在增加，它被胆汁管的增长 / 损坏在尺寸的一个小范围以内描绘。胆汁的上皮的唯一的解剖，形态学，神经分布和血管形成与在胆汁的树的不同区域以内的 cholangiocytes 的功能一致。在活体内模型[例如，胆汁管结扎( BDL )，部分肝切除术，胆汁酸，四氯化碳( CCl4 )或 alpha-naphthylisothiocyanate ( ANIT )喂]并且在活体内试验性的工具[例如，刚孤立小、大的 cholangiocytes 或肝内胆汁管单位( IBDU )和小、大的鼠科的 cholangiocytes 的主要文化]允许我们表明肝内的胆汁的上皮的词法、功能的异质。这些模型表明了微分分泌活动和异构的 apoptotic 和不同的大小的管的增生的回答。类似于限制为特定的大小的管的 cholangiocyte 增长 / 损害的动物模型，在人的肝疾病，胆汁管损坏支配特定的大小的胆汁管。与肝内的胆汁的上皮的功能的异质有关的未来研究可以与 cholangiopathies 为病人揭示新 pathophysiological 治疗。

Anaesthetic perioperative management of patients with pancreatic cancer

Pancreatic cancer remains a significant and unresolved therapeutic challenge.Currently,the only curative treatment for pancreatic cancer is surgical resection.Pancreatic surgery represents a technically demanding major abdominal procedure that can occasionally lead to a number of pathophysiological alterations resulting in increased morbidity and mortality.Systemic,rather than surgical complications,cause the majority of deaths.Because patients are increasingly referred to surgery with at advanced ages and because pancreatic surgery is extremely complex,anaesthesiologists and surgeons play a crucial role in preoperative evaluations and diagnoses for surgical intervention.The anaesthetist plays a key role in perioperative management and can significantly influence patient outcome.To optimise overall care,patients should be appropriately referred to tertiary centres,where multidisciplinary teams(surgical,medical,radiation oncologists,gastroenterologists,interventional radiologists and anaesthetists)work together and where close cooperation between surgeons and anaesthesiologists promotes the safe performance of major gastrointestinal surgeries with acceptable morbidity and mortality rates.In this review,we sought to provide simple daily recommendations to the clinicians who manage pancreatic surgery patients to make their work easier and suggest a joint approach between surgeons and anaesthesiologists in daily decision making.

BRCA mutations and gastrointestinal cancers:When to expect the unexpected?

BRCA1/2 pathogenic variants are widely known as major risk factors mainly for breast and ovarian cancer,while their role in gastrointestinal(GI)malignancies such as colorectal cancer(CRC),gastric cancer and oesophageal cancer(OeC)is still not well established.The main objective of this review is to summarise the available evidence on this matter.The studies included in the review were selected from PubMed/GoogleScholar/ScienceDirect databases to identify published articles where BRCA1/2 pathogenic variants were assessed either as a risk factor or a prognostic/predictive factor in these malignancies.Our review suggests that BRCA1/2 might have a role as a risk factor for colorectal,gastric and OeC,albeit with differences among these diseases:In particular BRCA1 seems to be much more frequently mutated in CRC whereas BRCA2 appears to be much more closely associated with gastric and OeC.Early-onset cancer seems to be also associated with BRCA1/2 mutations and a few studies suggest a positive prognostic role of these mutations.The assessment of a potentially predictive role of these mutations is hampered by the fact that most patients with these diseases have been treated with platinum compounds,where it is expected that a higher probability of response should be seen.A few clinical trials focused on poly(ADPribose)polymerase inhibitors use in GI cancers are currently ongoing.

Functional roles of gut bacteria imbalance in cholangiopathies

Cholangiopathies are caused by bile duct damage or inflammation followed by cholestasis leading to liver fibrosis.Bile duct epithelial cells,cholangiocytes,are a primary target for cholangiopathies.Ductular reaction is often observed in cholangiopathies and the proliferation of cholangiocytes is associated with ductular reaction and liver fibrogenesis.Accumulating evidence suggests that patients with chol-angiopathies have different gut bacterial profiles from healthy individuals,indicating the association between gut microbiota and cholangiopathies.Bile acids are produced by hepatocytes and modified by gut bacteria.Bile acids regulate cholangiocyte proliferation but effects vary depending on the type of bile acids.Recent studies suggest that therapies targeting gut bacteria,such as antibiotics administration and gut bacteria depletion or therapies using gut bacteria-associated bile acids,such as ursodeoxycholic acid(UDCA)administration,may be useful for treatments of cholangiopathies,although data are contro-versial depending on animal models or cohorts.This review summarizes current understandings of functional roles of gut bacterial imbalance and strategies for treatments of cholangiopathies targeting gut bacteria.

Immunotherapy in colorectal cancer treatment: actual landscape and future perspectives

Colorectal cancer(CRC)represents the second most common cancer in Europe with marked differences in prognosis and response to treatments.In the past years research showed emerging interest in genomic and immunologic fields.The clinical heterogeneity,that occurs during the pathogenesis of CRC,is driven by chromosomal alterations and defective function of DNA mismatch repair genes.CRC is classified in four consensus molecular subtypes(CMS)with different immunogenic characteristics and prognosis.CMS1 microsatellite instable(MSI)-like and CMS4,both characterized by high levels of immune infiltration,are recognized as the most immunogenic subtypes,even though functional characteristic leading to different prognosis are reported.In particular,MSI tumors have been identified as the best candidates for immunotherapy treatment and a number of studies have evaluated the efficacy of anti-programmed cell death ligand-1(PDL-1)and anti-cytotoxic T-lymphocyte-associated protein 4(CTLA4)in this setting.However,literature data show that the majority of patients with CRC have microsatellite stable(MSS)tumors and this status seems related to lower response to PDL-1/programmed cell death-1 or CTLA4 blockade.The aim of this paper is to investigate the role of immunotherapy in MSI and MSS CRC.