Background The inability to comply with enhanced recovery protocols (ERp) after pancreaticoduodenectomy (PD) is a real but understated issue. Our goal is to report our experience and a potential tool to predict ERp failure in order to better characterize this problem. Methods From January 1, 2014, to January 31, 2016, 205 consecutive patients underwent PD in our center and were managed according to an ERp. Failure to comply with postoperative protocol items was defined as any of: no active ambulation on postoperative day 1 (POD1); less than 4 h out of bed on POD2; removal of nasogastric tube and bladder catheter after POD1 and POD3, respectively; reintroduction of oral feeding after POD4; and continuation of intravenous infusions after POD4. Data were collected in a prospective database. Results Taking in consideration the number of failed items and the length of stay, we defined failure of the ERp as no compliance to two or more items. A total of 116 patients (56.6%) met this definition of failure. We created a predictive model consisting of age, BMI, operative time, and pancreatic stump consistency. These variables were independent predictors of failure (OR 1.03 [1.001–1.06] p = 0.01; OR 1.11 [1.01–1.22] p = 0.03; OR 1.004 [1.001–1.009] p = 0.02 and OR 2.89 [1.48–5.67] p = 0.002, respectively). Patient final score predicted the failure of the ERp with an area under the ROC curve of 0.747. Conclusions It seems to be possible to predict ERp failure after PD. Patients at high risk of failure may benefit more from a specific ERp.

Introduction: Though metastatic disease is a common presentation of pancreatic adenocarcinoma, localization to the penis is an extremely rare event despite its abundant vascularization. Primary cancers responsible for penile metastases usually occur in prostate and rectum and are often associated with disseminated malignancy and poor prognosis. Case description: A 66-year-old man was diagnosed with adenocarcinoma of the tail of the pancreas after the onset of thrombosis of the dorsal vein of the penis; pubis ultrasound and total body computed tomography scan were negative for metastases at other sites. The patient was submitted to distal pancreatectomy with splenectomy for a pT3 N1 G4 pancreatic ductal adenocarcinoma. Three weeks after discharge, the patient returned to the outpatient clinic complaining of a painful permanent turgidity of the penis shaft. Ultrasound revealed a complete replacement of the cavernosal bodies by multiple nodular masses and a penile biopsy confirmed metastases from the primary pancreatic cancer. The patient started chemotherapy with NAB-paclitaxel and gemcitabine, with excellent control of symptoms. However, the disease progressed to bone and liver and the patient died 9 months after surgery. Conclusions: Penile localization is an extremely rare event and a standard of care has not been elaborated. Treatments are palliative and mainly aimed at pain relief and can comprise chemotherapy, radiotherapy, and surgery. Identification of venous thrombosis as an early sign of involvement could potentially offer patients an earlier diagnosis and a better treatment option.

The Marlowe-Crowne Social Desirability Scale (MCSDS) is commonly used to validate other self-report measures within social and health research. Concerns over the scale's length (33 items) have repeatedly been raised. Nevertheless, prior efforts to develop psychometrically sound short forms of the MCSDS have not led to consistent findings. The purpose of this study was to develop a short form of the MCSDS, in accordance with guidelines for best practices in short form and scale development. Information on item properties, obtained with item response theory (IRT) and cognitive interviews (CogI), were used to eliminate items with poor properties and select items for a short form to be administered via the Internet. The IRT analyses were based on responses from 536 Internet panel members and the CogI sample consisted of 40 interviewees. Ten items were dropped due to poor psychometric properties and out of the 23 remaining items a ten item short form was developed.

Background. The appropriate management of the pancreatic remnant following distal pancreatic resection remains a clinically relevant problem. We carried out a retrospective analysis which focused on this issue and compared the two favored techniques of suture and staple closure. Patients and methods. Forty-six patients underwent distal pancreatectomy between October 1999 and January 2006. The patients were retrospectively analysed based on the management of the remaining pancreatic gland. Thirty-seven patients had suture and nine patients had staple closure. The morbidity, mortality, incidence of pancreatic fistula, necessity of secondary surgical intervention, and the duration of hospital stay for the two groups were compared. Pancreatic fistula was considered according to the novel international standard definition (ISGPF). In addition, subgroup analysis of patients receiving octreotide was carried out. Results. Overall, postoperative morbidity due to pancreatic fistula occurred in seven patients (19%) after suture and in one patient (11%) after staple closure (p = 0.54), with no deaths. The number of patients with surgical revision related to pancreatic leakage was two (5%) after suture closure vs no revision after staple closure (p= 0.65). The median number of total hospital days for the suture group was 19 (range 7–78 days) vs 21 (range 12–96 days) for the stapler group (p= 0.21). No significant benefit for the octreotide application could be determined. Conclusion. According to the data, no significant difference for either suture or stapler closure was observed, with the tendency for staple closure to be superior.

Enucleation (EN) and middle pancreatectomy (MP) have been proposed as a treatment for G1 and G2 pancreatic neuroendocrine tumors (PNET). The aim of this study is to analyze the outcomes of parenchyma-sparing surgery (PSS) for PNET in an Italian high-volume center. All patients with a histological diagnosis of PNET who underwent surgical resection in our center between January 2010 and January 2016 were included in the study. Demographic, perioperative, and discharge data were collected in a prospective database. Follow-up was considered until March 31, 2016. 99 patients were included. PSS was performed in 22 cases (22.2 %), 18 EN (82 %), and 4 MP (18 %). 89.8 % patients were staged with CT scan, 69.6 % with endoscopic ultrasonography, 48.4 % with MRI, and 47.4 % with 68Ga-PET. Pre-operative histological diagnosis was obtained in 68.6 %. Most of PSS tumors were G1 (n = 15; 68 %) and there were no G3. Nodal sampling was performed in every PSS. Only two patients showed nodal metastatic disease. The median post-operative length of stay was 7 days after PSS. Eleven (50 %) of these patients developed a complication; two (18.2 %) were major complications. Pancreatic fistula developed in ten patients (45.5 %); two (20 %) were type B. There were no type C fistula and no re-operations after PSS. Readmission rate was 9 %. All patients submitted to PSS are alive and free of recurrence. PSS is a safe technique for G1 and G2 PNETs, but it has to be conducted in experienced centers and an extensive nodal sampling and a long follow-up are required for the best oncologic outcome.

This paper describes an R package, named SPATCLUS that implements a method recently proposed for spatial cluster detection of case event data. This method is based on a data transformation. This transformation is achieved by the definition of a trajectory, which allows to attribute to each point a selection order and the distance to its nearest neighbour. The nearest point is searched among the points which have not yet been selected in the trajectory. Due to the trajectory effects, the distance is weighted by the expected distance under the uniform distribution hypothesis. Potential clusters are located by using multiple structural change models and a dynamic programming algorithm. The double maximum test allows to select the best model. The significativity of potential clusters is determined by Monte Carlo simulations. This method makes it possible the detection of multiple clusters of any shape.

In order to construct efficient and motivational learning environments for the primary school, this paper proposes a design model for geometry-based simulation games. It is structured on the basis of the isomorphism found in the didactic process among three simulation games purposely conceived, designed, and developed: Cardland on the isometries, Similand on the similarities and Angleland on the angles.The paper presents and compares Cardland, Similand and Angleland, and highlights their structural characteristics and the isomorphism in the didactic process, that is invariant in respect to the content of each simulation game. The references take into account the theoretical framework and methodological choices, drawn from the recent research findings on the literature of the simulation games, and on the theory of learning, on the basis of which the simulation games are designed.On the basis of observed analogies, the paper describes the important elements of the design model developed, and explains the conceptual diagram, the design and assessment criteria, that have been assessed and validated in previous research carried out with Cardland.

Comparar el bloqueo con la radiofrecuencia térmica bipolar para el dolor de la articulación sacroilíaca.Estudio prospectivo, aleatorizado y experimental en 60 pacientes, seleccionados en 9 meses en 2 centros, con dolor intenso (escala visual analógica [EVA] > 6) de > 3 meses de duración. Fueron divididos en 3 grupos (n = 20). Grupo A: pacientes a los que se les realizaron 2 bloqueos intraarticulares, con control ecográfico en 7 días. Grupo B: radiofrecuencia bipolar «palisade» utilizando 6 agujas perpendiculares a la zona dorsal del sacro, a una distancia de 1 cm, para producir lesiones contiguas entre los forámenes S1-S2-S3 y la línea articular. Grupo C: radiofrecuencia bipolar «palisade» modificada (distancia entre agujas > 1 cm). Los pacientes fueron evaluados al mes, a los 3 y a los 12 meses del tratamiento. Se valoraron los datos demográficos (en la visita basal), la eficacia analgésica y los efectos secundarios (en el resto).Al mes, la reducción del dolor en los 3 grupos fue > 50% (p ≤ 0,001). A los 3 y 12 meses el grupo A no refirió disminución significativa del dolor. El grupo B, a los 3 meses, alivio cercano al 50% (p = 0,03), y < 25% (23,8) a los 12 meses (p = 0,01). En el grupo C, alivio próximo al 50% a los 3 y 12 meses (p < 0,001) respecto al basal. Todos los pacientes finalizaron el estudio.La radiofrecuencia bipolar «palisade», especialmente aumentando la distancia entre las agujas, ha sido eficaz, a más largo plazo, que el bloqueo con anestésicos y corticoides en el alivio del dolor de la articulación sacroilíaca.To compare the analgesic effects between the blockade and bipolar thermal radiofrequency in the treatment of sacroiliac joint pain.Prospective, randomised and experimental study conducted on 60 patients selected in the two hospitals over a period of nine months, who had intense sacroiliac joint pain (Visual Analogue Scale [VAS] > 6) that lasted more than 3 months. Patients were randomised into three groups (n = 20): Group A (two intra-articular sacroiliac injections of local anaesthetic/corticosteroid guided by ultrasound in 7 days). Group B: conventional bipolar radiofrequency «palisade». Target points were the lateral branch nerves of S1, S2, and S3, distance needles 1 cm. Group C: modified bipolar radiofrequency «palisade» (needle distance > 1 cm). Patients were evaluated at one month, three months, and one year. Demographic data, VAS reduction, and side effects of the techniques were assessed.One month after the treatment, pain reduction was > 50% in the three groups P < .001. Three and 12 months after the technique, the patients of the group A did not have a significant reduction in pain. At 3 months, almost 50% patients of the group B referred to improvement of the pain (P = .03), and < 25% at 12 months, and those results were statistically significant (P = .01) compared to the baseline. Group C showed an improvement of 50% at 3 and 12 months (P < .001). All patients completed the study.Bipolar radiofrequency «palisade», especially when the distance between the needles was increased, was more effective and lasted longer, compared to join block and steroids, in relieving pain sacroiliac joint.

To report the severe metabolic acidosis identified in a group of 11 healthy mules anaesthetized with halothane for castration.Data generated from a prospective study.Eleven mules aged 2.5–8 years, weighing 230–315 kg and 11 horses aged 1.5–3.5 years, weighing 315–480 kg.Animals were anaesthetized for castration as part of an electroencephalographic study. Preanaesthetic medication was acepromazine (0.03 mg kg−1) administered through a preplaced jugular venous catheter. Anaesthesia was induced 30–90 minutes later with intravenous thiopental (10 mg kg−1). After orotracheal intubation, anaesthesia was maintained with halothane vaporised in oxygen. The animals’ lungs were ventilated to maintain the end-tidal CO2 concentration between 3.9 and 4.5 kPa (29–34 mmHg). Anaesthetic monitoring included invasive blood pressure measurement via the auricular artery (mules) and submandibular branch of the facial artery (horses). Arterial blood gas samples were drawn from these catheters at three time points during surgery and pH, PaCO2, base excess (ecf) and HCO3− were measured. Values were compared between groups using a Mann–Whitney test. p was taken as <0.05. Results are reported as median (range).PaCO2 did not differ between groups but pH was significantly lower in mules [7.178 (7.00–7.29)] compared to horses [7.367 (7.24–7.43)] (p = 0.0002). HCO3− values were significantly lower in the mules [16.6 (13.0–22.3) mM] compared to horses [23.7 (20.9–23.7) mM] (p = 0.0001), whilst base excess (ecf) was significantly more negative in the mules [−11.4 (−1.27 to −16) mM] compared to horses [−1.3 (−5.8 to +2.4) mM] (p = 0.0004).This study demonstrated severe metabolic acidosis in healthy mules, which may have prompted intervention with drug therapies in a clinical arena. It is probable that the acidosis existed prior to anaesthesia and caused by diet, but other possible causes are considered.

Introduction. Pancreatic surgery is challenging and associated with high morbidity, mainly represented by postoperative pancreatic fistula (POPF) and its further consequences. Identification of risk factors for POPF is essential for proper postoperative management. Aim of the Study. Evaluation of the role of morphological and histological features of pancreatic stump, other than main pancreatic duct diameter and glandular texture, in POPF occurrence after pancreaticoduodenectomy. Patients and Methods. Between March 2011 and April 2013, we performed 145 consecutive pancreaticoduodenectomies. We intraoperatively recorded morphological features of pancreatic stump and collected data about postoperative morbidity. Our dedicated pathologist designed a score to quantify fibrosis and inflammation of pancreatic tissue. Results. Overall morbidity was 59,3%. Mortality was 4,1%. POPF rate was 28,3%, while clinically significant POPF were 15,8%. Male sex (P = 0.009), BMI ≥ 25 (P = 0.002), prolonged surgery (P = 0.001), soft pancreatic texture (P < 0.001), small pancreatic duct (P < 0.001), pancreatic duct decentralization on stump anteroposterior axis, especially if close to the posterior margin (P = 0.031), large stump area (P = 0.001), and extended stump mobilization (P = 0.001) were related to higher POPF rate. Our fibrosis-and-inflammation score is strongly associated with POPF (P = 0.001). Discussion and Conclusions. Pancreatic stump features evaluation, including histology, can help the surgeon in fitting postoperative management to patient individual risk after pancreaticoduodenectomy.