Prognosis of patients with metastatic melanoma is poor (Ketcham and Balch, 1985;Tafra et al, 1995), with an annual risk of death of about 20% during the first 3 years (Slingluff et al, 1992). The second most common site for metastatic spread is the lung (Balch and Milton, 1985), and the annual probability of developing pulmonary metastases increases progressively from 10% at 5 years to 17% at 15 years. Overall long-term survival for such patients is poor, with only 4% of patients alive at 4 years (Harpole et al, 1992).As effective chemotherapy for metastatic melanoma is not available, surgery can represent the only prospect of cure for highly selected patients (Wong et al, 1993;Karakousis et al, 1994). However only 10-12% of cases are suitable for surgery with curative intent (Cahan, 1973;Mountain et al, 1984;Thayer and Overholt, 1985;Pogrebniak et al, 1988;Gorenstein et al, 1991). Moreover, surgical results are still controversial as the majority of published studies are based on a small number of cases with relatively short follow-up.Two large series have already confirmed the prognostic value of factors such as radicality, number of resected metastases and disease-free interval (DFI) after pulmonary metastasectomy (Harpole et al, 1992;Tafra et al, 1995) but it remains unclear how these data can be used for preoperative patient selection.The purpose of this study is to evaluate the long-term results of surgery in melanoma pulmonary metastases from the International Registry of Lung Metastases (IRLM) data, with the aim of defining the subset of patients that really benefit from surgery. PATIENTS AND METHODSOf the 5206 patients recorded in the International Registry of Lung Metastases in the period 1945-1995, 328 (6.3%) had operations for pulmonary stage IV melanoma. The aims of the Registry, methodology of data collection and analysis have been published previously (Pastorino et al, 1997). In summary, all patients who had undergone resection of pulmonary metastases with curative intent were eligible for inclusion if their primary tumour, as well as metastases in other organs, had been effectively treated. Eighteen major centres from Europe, the USA and Canada took part in the project. Data analysisSurvival time was calculated from first metastasectomy to the last date of follow-up, by means of the Kaplan-Meier estimate. Mean follow-up of patients alive was 42 months.The impact on survival of the following variables was tested: age, sex, radicality of metastasectomy, time to pulmonary metastases (time from surgery of primary melanoma to diagnosis of pulmonary metastases, TPM), number of pathologically confirmed metastases, resection volume, nodal involvement, delay of surgery from diagnosis of metastases to metastasectomy, chemotherapy, Lung metastases from melanoma: when is surgical treatment warranted? Summary Surgical treatment of lung metastases from melanoma is highly controversial as the expected outcome is much poorer than for other primary tumours and a reliable system for selecting patients is lacking. ...

Additional post-operative NP measurement enhanced risk stratification for the composite outcomes of death or nonfatal myocardial infarction at 30 days and ≥180 days after noncardiac surgery compared with a pre-operative NP measurement alone.

Increased postoperative BNPs are independently associated with adverse cardiac events after noncardiac surgery.

BackgroundTo evaluate the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis in comparison with other imaging modalities.MethodsThe authors performed a search of the Medline/ PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the accuracy of ultrasonography in the diagnosis of acute calculous cholecystitis. The search design utilized a single or combination of the following terms : (1) acute cholecystitis, (2) ultrasonography, (3) computed tomography, (4) magnetic resonance cholangiopancreatography and (5) cholescintigraphy. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 198 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 31 papers was reviewed.ResultsSonography is still used as the initial imaging technique for evaluating patients with suspected acute calculous cholecystitis because of its high sensitivity at the detection of GB stones, its real-time character, and its speed and portability. Cholescintigraphy still has the highest sensitivity and specificity in patients who are suspected of having acute cholecystitis. However, due to a combination of reasons including logistic drawbacks, broad imaging capability and clinician referral pattern the use of cholescintigraphy is limited in clinical practice. CT is particularly useful for evaluating the many complications of acute calculous cholecystitis. The lack of widespread availability of MRI and the relatively high cost prohibits its primary use in patients with acute calculous cholecystitis.ConclusionsUS is currently considered the preferred initial imaging technique for patients who are clinically suspected of having acute calculous cholecystitis.

IntroductionThe goal of non-operative management (NOM) for blunt splenic trauma (BST) is to preserve the spleen. The advantages of NOM for minor splenic trauma have been extensively reported, whereas its value for the more severe splenic injuries is still debated. The aim of this systematic review was to evaluate the available published evidence on NOM in patients with splenic trauma and to compare it with the operative management (OM) in terms of mortality, morbidity and duration of hospital stay.MethodsFor this systematic review we followed the "Preferred Reporting Items for Systematic Reviews and Meta-analyses" statement. A systematic search was performed on PubMed for studies published from January 2000 to December 2011, without language restrictions, which compared NOM vs. OM for splenic trauma injuries and which at least 10 patients with BST.ResultsWe identified 21 non randomized studies: 1 Clinical Controlled Trial and 20 retrospective cohort studies analyzing a total of 16,940 patients with BST. NOM represents the gold standard treatment for minor splenic trauma and is associated with decreased mortality in severe splenic trauma (4.78% vs. 13.5% in NOM and OM, respectively), according to the literature. Of note, in BST treated operatively, concurrent injuries accounted for the higher mortality. In addition, it was not possible to determine post-treatment morbidity in major splenic trauma. The definition of hemodynamic stability varied greatly in the literature depending on the surgeon and the trauma team, representing a further bias. Moreover, data on the remaining analyzed outcomes (hospital stay, number of blood transfusions, abdominal abscesses, overwhelming post-splenectomy infection) were not reported in all included studies or were not comparable, precluding the possibility to perform a meaningful cumulative analysis and comparison.ConclusionsNOM of BST, preserving the spleen, is the treatment of choice for the American Association for the Surgery of Trauma grades I and II. Conclusions are more difficult to outline for higher grades of splenic injury, because of the substantial heterogeneity of expertise among different hospitals, and potentially inappropriate comparison groups.

Acute abdomen is a medical emergency, in which there is sudden and severe pain in abdomen of recent onset with accompanying signs and symptoms that focus on an abdominal involvement. It can represent a wide spectrum of conditions, ranging from a benign and self-limiting disease to a surgical emergency. Nevertheless, only one quarter of patients who have previously been classified with an acute abdomen actually receive surgical treatment, so the clinical dilemma is if the patients need surgical treatment or not and, furthermore, in which cases the surgical option needs to be urgently adopted. Due to this reason a thorough and logical approach to the diagnosis of abdominal pain is necessary. Some Authors assert that the location of pain is a useful starting point and will guide a further evaluation. However some causes are more frequent in the paediatric population (like appendicitis or adenomesenteritis) or are strictly related to the gender (i.e. gynaechologic causes). It is also important to consider special populations such as the elderly or oncologic patients, who may present with atypical symptoms of a disease. These considerations also reflect a different diagnostic approach. Today, surely the integrated imaging, and in particular the use of multidetector Computed Tomography (MDCT) has revolutionised the clinical approach to this condition, simplyfing the diagnosis but burdening the radiologists with the problems related to the clinical management. However although CT emerging as a modality of choice for evaluation of the acute abdomen, ultrasonography (US) remains the primary imaging technique in the majority of cases, especially in young and female patients, when the limitation of the radiation exposure should be mandatory, limiting the use of CT in cases of nondiagnostic US and in all cases where there is a discrepancy between the clinical symptoms and negative imaging at US.

The mTOR staining provides a new biomarker for poor outcome in early stage NSCLC and could enable resected stage IA patients to be selected for novel therapies possibly with an mTOR inhibitor.

In the assessment of polytrauma patient, an accurate diagnostic study protocol with high sensitivity and specificity is necessary. Computed Tomography (CT) is the standard reference in the emergency for evaluating the patients with abdominal trauma. Ultrasonography (US) has a high sensitivity in detecting free fluid in the peritoneum, but it does not show as much sensitivity for traumatic parenchymal lesions. The use of Contrast-Enhanced Ultrasound (CEUS) improves the accuracy of the method in the diagnosis and assessment of the extent of parenchymal lesions. Although the CEUS is not feasible as a method of first level in the diagnosis and management of the polytrauma patient, it can be used in the follow-up of traumatic injuries of abdominal parenchymal organs (liver, spleen and kidneys), especially in young people or children.