Thèses sur le sujet « Chirurgia pediatrica »

Le caratteristiche istologiche, immunologiche e fisiologiche della cute in età pediatrica sono responsabili di quadri dermatologici differenti nel bambino rispetto all’adulto, per cui la dermatologia pediatrica sta acquisendo sempre maggiore importanza come branca specifica nell’ambito sia della dermatologia generale che della pediatria. Il problema cruciale che si incontra nel management delle dermatosi pediatriche è legato alle difficoltà diagnostiche incontrate, che comportano spesso la necessità di eseguire una biopsia cutanea. Mentre gli studi epidemiologici relativi alla frequenza delle patologie dermatologiche pediatriche siano ampiamente riportati in letteratura, i dati e le revisioni relative alla chirurgia pediatrica dermatologica, nell’ambito dei servizi di Dermatologia Pediatrica, sono ridotti. Nell’arco dei tre anni di dottorato, la mia attività è stata finalizzata a valutare la possibilità di organizzare un servizio ambulatoriale per i prelievi bioptici in età pediatrica, con il solo ausilio di anestetici topici e locali. Durante i tre anni di Dottorato di Ricerca sono stati eseguiti 296 prelievi. Le biopsie eseguite sono state suddivise in 3 gruppi: biopsie diagnostiche su patologie dermatologiche (108 pz, 36%), biopsie su neoformazioni cutanee (174 pz, 59 %) e biopsie su lesioni follicolari ( 14 pz, 5%). Di ciascun gruppo sono state valutate le patologie riscontrate, l’età, il sesso, l’impiego di anestetico topico associato ad anestetico locale. In 180 (61%) pazienti dopo la biopsia si è proceduto all’applicazione di punti di sutura. Si sono valutati inoltre i vantaggi e gli svantaggi di tale attività ambulatoriale rispetto ai prelievi eseguiti avvalendosi di una sedazione profonda.
The skin of the child has histological, immunological and physiological characteristics responsible for different dermatological manifestations in children than adults, so the pediatric dermatology is gaining increasing importance as a specific branch in the general dermatology and pediatrician. An important problem which is encountered in the management of pediatric dermatosis is related to diagnostic difficulties, which often involve the need to perform a skin biopsy. As epidemiological studies relating to the frequency of pediatric dermatological diseases are widely reported in the literature, the data and revisions to the pediatric dermatological surgery are reduced. During the three years of research, my intent was aimed at assessing the possibility of organizing an outpatient service for biopsies in children, with only the aid of topical and local anesthetics. In particular 296 samples were performed. The biopsies were divided into 3 groups: diagnostic biopsies of skin diseases (108 pcs, 36%), biopsies of skin tumors (174 pcs, 59%) and biopsies of follicular lesions (14 pcs, 5%). Of each group were evaluated pathologies, age, sex, the use of topical anesthetic associated with local anesthetic. In 180 (61%) patients were applied stitches. We have evaluated the advantages and disadvantages of ambulatory activity compared to samples taken using deep sedation / general anesthesia.

Le caratteristiche istologiche, immunologiche e fisiologiche della cute in età pediatrica sono responsabili di quadri dermatologici differenti nel bambino rispetto all’adulto, per cui la dermatologia pediatrica sta acquisendo sempre maggiore importanza come branca specifica nell’ambito sia della dermatologia generale che della pediatria. Il problema cruciale che si incontra nel management delle dermatosi pediatriche è legato alle difficoltà diagnostiche incontrate, che comportano spesso la necessità di eseguire una biopsia cutanea. Mentre gli studi epidemiologici relativi alla frequenza delle patologie dermatologiche pediatriche siano ampiamente riportati in letteratura, i dati e le revisioni relative alla chirurgia pediatrica dermatologica, nell’ambito dei servizi di Dermatologia Pediatrica, sono ridotti. Nell’arco dei tre anni di dottorato, la mia attività è stata finalizzata a valutare la possibilità di organizzare un servizio ambulatoriale per i prelievi bioptici in età pediatrica, con il solo ausilio di anestetici topici e locali. Durante i tre anni di Dottorato di Ricerca sono stati eseguiti 296 prelievi. Le biopsie eseguite sono state suddivise in 3 gruppi: biopsie diagnostiche su patologie dermatologiche (108 pz, 36%), biopsie su neoformazioni cutanee (174 pz, 59 %) e biopsie su lesioni follicolari ( 14 pz, 5%). Di ciascun gruppo sono state valutate le patologie riscontrate, l’età, il sesso, l’impiego di anestetico topico associato ad anestetico locale. In 180 (61%) pazienti dopo la biopsia si è proceduto all’applicazione di punti di sutura. Si sono valutati inoltre i vantaggi e gli svantaggi di tale attività ambulatoriale rispetto ai prelievi eseguiti avvalendosi di una sedazione profonda.
The skin of the child has histological, immunological and physiological characteristics responsible for different dermatological manifestations in children than adults, so the pediatric dermatology is gaining increasing importance as a specific branch in the general dermatology and pediatrician. An important problem which is encountered in the management of pediatric dermatosis is related to diagnostic difficulties, which often involve the need to perform a skin biopsy. As epidemiological studies relating to the frequency of pediatric dermatological diseases are widely reported in the literature, the data and revisions to the pediatric dermatological surgery are reduced. During the three years of research, my intent was aimed at assessing the possibility of organizing an outpatient service for biopsies in children, with only the aid of topical and local anesthetics. In particular 296 samples were performed. The biopsies were divided into 3 groups: diagnostic biopsies of skin diseases (108 pcs, 36%), biopsies of skin tumors (174 pcs, 59%) and biopsies of follicular lesions (14 pcs, 5%). Of each group were evaluated pathologies, age, sex, the use of topical anesthetic associated with local anesthetic. In 180 (61%) patients were applied stitches. We have evaluated the advantages and disadvantages of ambulatory activity compared to samples taken using deep sedation / general anesthesia.

2015 - 2016
BACKGROUND. Lo sviluppo di sistemi medicali sempre più avanzati per l’acquisizione delle immagini finalizzati all’estrazione di informazioni tridimensionali sugli organi del corpo umano tramite metodi non invasivi, hanno portato all’affermazione di una nuova disciplina scientifica nota come medical imaging. L’innovazione degli ultimi anni, dalla quale nasce il mio progetto di ricerca, è lo sviluppo di programmi informatici che creano immagini con risoluzione 3D, avendo come substrato le immagini 2D generate con gli esami TC (Tomografia Computerizzata) e RM (Risonanza Magnetica) in pazienti con patologia tumorale o malformativa. Le ricostruzioni 3D trovano la loro applicazione principale nel supporto della diagnosi, considerando che le immagini possono essere trasmesse ad esperti in tutto il mondo per consultazioni in tempo reale (tele-medicina), e nella pianificazione del trattamento chirurgico in termini di tipo di approccio, scelta del materiale, scelta della tecnica più idonea, salvaguardia di strutture vicine. CASISTICA. Durante i 3 anni di dottorato, sono stati inclusi nello studio 40 pazienti, 13 femmine e 27 maschi, con un’età compresa tra 6 mesi e 17 anni. Sono stati suddivisi in 3 gruppi sulla base della patologia: malformativa (29/40), tumorale (7/40) e altro (4/40). Tutti i pazienti hanno eseguito TC o RM dalle cui immagini è stata eseguita la ricostruzione 3D con il programma Vr Render 0.81. Tutti i 40 bambini sono stati sottoposti ad intervento chirurgico. Per ognuno di loro le immagini ricostruite sono state discusse tra il chirurgo pediatrico e il radiologo-per pianificare al meglio la strategia chirurgica. Non riportiamo complicanze intraoperatorie né discrepanze tra la ricostruzione 3D e la reale anatomia del paziente. CONCLUSIONI. Dall’analisi retrospettiva del nostro studio è emerso che la ricostruzione 3D permette una buona e migliore pianificazione chirurgica delle patologie tumorali e malformative. L’immagine sviluppata dal programma Vr Render garantisce una definizione corretta della dimensione della patologia, della sua localizzazione e i suoi rapporti con le strutture circostanti. Importante e necessaria è stata la collaborazione tra il Chirurgo Pediatra e il Radiologo, emblema della multidisciplinarietà, ormai tipica, del management di patologie complesse. Il futuro della renderizzazione 3D è certamente una sempre maggiore applicazione nella pianificazione chirurgica e nel training e formazione dei giovani chirurghi. [a cura dell'autore]
BACKGROUND. The development of advanced medical imaging systems led to a new scientific discipline known as medical imaging. the main gol of this branch is to obtain three-dimensional information on human body organs through non-invasive methods. In tha last 10 years, many programs, that create images with 3D resolution following 2D images obtained by TC (Computer Tomography) and MRI (Magnetic Resonance) in patients with cancer or congenital malformation, have been developed. The 3D reconstructions find their main application in diagnose and plan surgical treatment in terms of approach type, choice of material, choice of the most suitable technique, safeguarding nearby structures. MATERIALS and METHODS. During the 3-year of study, 40 patients, 13 females and 27 males, aged 6 months to 17, were included in the study. They were subdivided into 3 groups based on the pathology: malformative (29/40), tumor (7/40) and others (4/40). All patients underwent TC or MRI. Based on CT or MRI images, 3D reconstruction was carried out with the Vr Render 0.81 program. All 40 children underwent surgery. All imaging have been discussed between pediatric surgeon and radiologist to plan surgical strategy. We do not report intraoperative complications or discrepancies between the 3D reconstruction and the real anatomy of the patient. CONCLUSION. After retrospective analysis of our study, we can conclude that 3D reconstruction allows to better plan surgery of tumor and malformative pathologies. The Vr Render program guarantees to have a correct definition of the size of the pathology, its location and its relationships with nearby structures. The multidisciplinary team (Pediatric Surgeon and the Radiologist) has been Important for the management of complex pathologies. The future of 3D rendering is certainly a major application in surgical planning and training of young surgeons. [edited by author]
XXIX n.s.

Short Bowel Syndrome (SBS) in children is a condition of intestinal malabsorption and dysmotility, caused by rare congenital malformations or acquired diseases, requiring extensive bowel surgical resection which in severe cases can lead to irreversible intestinal failure. Nowadays, the management of pediatric patients affected by SBS is multidisciplinary, involving different possible strategies of treatment: total parenteral nutrition, surgical intestinal lengthening up to intestinal transplantation. The main aim of all these approaches is to promote bowel absorption, but none of them is free from complications that may impair children quality of life. Based on these considerations, this Research Project aims to identify new options to manage and treat SBS. Hence, two aspects were considered: a clinical and an experimental one. As known, the management of SBS patients requires a careful follow-up by a multispecialistic team, able to survey their possible short- and long-term complications and their progressive weaning from parenteral support. Considered this, the clinical part of this Research Project focused on the evaluation of citrulline as a reliable serum marker of residual bowel function. The goal was to verify the possibility of suggesting it for routine dosage in case of intestinal failure, similarly to creatinine in renal impairment and for transaminases in hepatic failure. Briefly, we identified a sample population consisting of 10 SBS patients, age ≤ 5 years and residual bowel length (after surgery) ≤ 100 cm. Patients followed-up with parenteral and enteral nutrition programs and were subjected to citrulline dosages at least 6 weeks after surgery. At the end of the clinical evaluation, we highlighted that serum values of citrulline are strongly related with both the residual intestinal length and the duration of their dependence on parenteral support (p < 0.01). Likewise, the experimental research turned its attention to Tissue Engineering that is a new medical science which aims to achieve functionally active tissue substitutes by scaffolds, cells and growth factors. The second part of the Research Project focused on the possibility to develop a bio-synthetic scaffold for tissue engineering applications in SBS. We manufactured, according to a protocol we patented, new hydrogels based on polyvinyl alcohol with a degree of oxidation of 1% and 2% respectively. The purpose of the chemical oxidation was to confer to the derived biomaterial a certain biodegradation rate. Hence, oxidized hydrogels obtained via physical cross-linking (freezing-thawing) were compared to native PVA hydrogels for their morpho-mechanical and biological properties by means of ultrastructural analysis with scanning electron microscopy, tensile tests, swelling index analysis, and in vivo biodegradation studies. These investigations showed that the strength and the stiffness of the polymer are significantly related to the chemical modification as they decrease along with the oxidation degree; conversely, the swelling and the biodegradation rate increase along with it. The obtained results led us to identify in scaffolds prepared by using 1% Oxidized PVA the supports with the most adequate morpho-mechanical and biodegradation properties to our purposes. Hereafter, it was set up a composite scaffold in 1% Oxidized PVA cross-linked with decellularized intestinal extracellular matrix (ECM). The combination of the polymer with the bioactive matrix allowed us to obtain a support with good mechanical properties and able to promote cell growth and proliferation. Briefly, the small intestine of adult rats was removed and decellularized according to the detergent-enzymatic protocol by Meezan. After having assessed the effectiveness of the procedure (DAPI staining) the acellular matrix was characterized by histological staining (hemotoxylin/eosin). Thereafter, the extracellular matrix (intact and homogenized) was crosslinked with 1% Oxidized PVA and the ability of the composite scaffold to support cell adhesion and proliferation was investigated using a primary culture of adipose mesenchymal stem cells. After 7 days from seeding, a significant cell growth on the composite scaffolds was observed in comparison with the nude polymeric support. Finally, based on of the TESI (Small Intestine Tissue Engineering) model, the scaffold was implanted in the omentum of adult rats; after 4-weeks, composite scaffolds demonstrated their ability to induce the formation of a composite pseudoepithelial tissue with intestinal-like features.
La sindrome dell'intestino corto o Short Bowel Syndrome (SBS) in età pediatrica è una condizione di malassorbimento e dismotilità intestinali, conseguenza di rare malformazioni congenite o patologie acquisite, che comportino resezioni chirurgiche più o meno estese dell'intestino sino, nei casi più gravi, ad insufficienza intestinale. Allo stato attuale, la gestione dei pazienti affetti da SBS è multidisciplinare; varie le possibili strategie terapeutiche: la nutrizione parenterale totale, la chirurgia di "allungamento intestinale" e, nelle fasi più avanzate della patologia, il trapianto di intestino. L'obiettivo primario di tutti questi approcci è quello di promuovere l'assorbimento intestinale, tuttavia nessuno di essi è scevro da complicanze capaci di inficiare la qualità della vita dei pazienti. Sulla base delle precedenti considerazioni, questo Progetto di Ricerca si propone di identificare nuovi approcci per il management ed il trattamento della SBS. A tal fine, la ricerca si è sviluppata su due versanti: uno clinico e l’altro sperimentale. Come noto, la gestione della SBS necessita di un attento follow-up dei pazienti da parte di un'equipe multispecialistica che sia in grado di monitorare, nel breve e nel lungo termine, le possibili complicanze nonché la svezzabilità del paziente dal supporto parenterale. In tale senso, nella parte di ricerca clinica è stata studiata e valutata l'attendibilità della citrullina come marker sierico della funzionalità intestinale residua; l’obiettivo è di proporne un impiego routinario esattamente come avviene per la creatinina nell'insufficienza renale e per le transaminasi nell'insufficienza epatica. A tale scopo, all’interno del nostro campione di pazienti affetti da SBS e seguiti in follow-up, è stata individuata una sottopopolazione campionaria costituita da 10 pazienti inseriti in un programma di nutrizione parenterale ed enterale domiciliare, con età ≤ 5 anni e lunghezza intestinale residua (dopo chirurgia) ≤ 100 cm, che sono stati sottoposti a dosaggio della citrullinemia ad almeno 6 settimane di distanza dalla chirurgia. I valori della citrullinemia sierica sono risultati essere correlati in maniera statisticamente significativa (p < 0,01) sia con la lunghezza intestinale residua di tali pazienti, che con la durata della loro dipendenza dal supporto parenterale. In parallelo, la Ricerca Sperimentale ha rivolto l’attenzione verso una nuova disciplina medica: l’Ingegneria Tissutale. Quest’ultima è una scienza multidisciplinare che si propone di realizzare in laboratorio sostituti tissutali funzionalmente attivi attraverso l’impiego di scaffold, cellule e fattori di crescita. In particolare, in questa seconda parte del progetto di ricerca è stata investigata la possibilità di sviluppare uno scaffold bio-sintetico per applicazioni di ingegneria tissutale intestinale. Brevemente, sono stati realizzati, secondo un protocollo brevettato dal nostro gruppo di ricerca, dei nuovi idrogeli a base di polivinil alcol con un grado di ossidazione dell’1% e del 2%. L'obiettivo dell’ossidazione chimica è stato quello di conferire al biomateriale caratteristiche di biodegradabilità in confronto alla sua forma non ossidata. Dopo cross-linking fisico mediante freezing-thawing, idrogeli in PVA nativo e PVA ossidato sono stati caratterizzati per le loro proprietà morfo-meccaniche e biologiche, tramite analisi ultrastrutturali di microscopia elettronica a scansione, test di trazione, valutazione dell’indice di rigonfiamento e studio di biodegradazione in vivo. Queste indagini hanno dimostrato che la resistenza meccanica e la rigidità del polimero vengono modulate dalla modifica chimica, diminuendo all’aumentare del grado di ossidazione. Diversamente, l’indice di rigonfiamento e il tasso di biodegradazione sono tanto più elevati quanto più aumenta la percentuale dei gruppi carbonilici derivati dall’ossidazione. I risultati ottenuti hanno consentito di identificare nel PVA ossidato all’1% il polimero con caratteristiche morfo-meccaniche e di biodegradazione congeniali ai nostri scopi. Sulla base di questo, è stato allestito uno scaffold composito, costituito da PVA ossidato all’1% cross-linkato con matrice extracellulare intestinale decellularizzata (intera e omogenizzata): la combinazione del polimero (avente proprietà meccaniche e di biocompatibilità/biodegradazione ottimali) con la matrice bioattiva ha consentito di ottenere un supporto capace di favorire la crescita e la proliferazione cellulare. Brevemente, la realizzazione dello scaffold composito ha previsto l'espianto di intestino tenue da ratto adulto e la successiva decellularizzazione del tessuto con metodo detergente-enzimatico secondo Meezan. Dopo aver valutato l'efficacia della procedura di decellularizzazione (marcatura con DAPI) la matrice acellulare è stata caratterizzata tramite colorazione con ematossilina/eosina. A seguito del cross-linking della matrice extracellulare (intera e liofilizzata) con l’idrogelo in PVA ossidato all’1%, la capacità dello scaffold composito nel sostenere l'adesione e la proliferazione cellulare è stata indagata utilizzando cellule staminali mesenchimali da tessuto adiposo umano. A 7 gg dalla semina è stato possibile riscontrare una crescita cellulare significativa sugli scaffold compositi in confronto al solo supporto polimerico. Infine, sulla scorta del modello TESI (Tissue Engineering Small Intestine), tali scaffold sono stati impiantati in omento di ratti adulti, dimostrando, ad un end-point di 4 settimane, la capacità di generare uno pseudoepitelio composito con caratteristiche di tipo intestinale.

Obiettivi Il COVID-19 è una malattia principalmente respiratoria nell’età adulta; nei bambini, al contrario, i sintomi gastrointestinali sono più frequenti. Inoltre, non si conoscono i meccanismi di infezione in epoca fetale, epoca in cui i pazienti sono raramente colpiti da COVID-19. Gli organoidi sono uno strumento relativamente nuovo per stabilire in vitro colture di lunga durata che assomigliano tridimensionalmente al tessuto di origine e possono sia mantenere la staminalità che differenziarsi completamente in tutti i tipi di cellule. Abbiamo quindi mirato a sviluppare un sistema di coltura per organoidi gastrointestinali (GIO) per studiare l'infezione da SARS-CoV-2 nell'epitelio gastrico lungo tutta la durata della vita. Metodi I GIO sono stati derivati da feti di 8-21 settimane e da tessuti pediatrici e adulti. Sono stati coltivati utilizzando un terreno chimicamente definito, per testare la loro capacità di mantenere la forma e di differenziarsi completamente. GIO sono stati analizzati in correlazione all'ECM circostante. Gli organoidi sono stati quindi indotti a differenziarsi nella forma a polarità cellulare inversa (RP-GO) e quindi incubati con SARS-CoV-2. Tutti gli esperimenti sono stati analizzati mediante qPCR, immunofluorescenza e analisi qualitativa a seconda dei casi. Risultati Gli organoidi gastrointestinali possono essere isolati da tutte le età gestazionali, dimostrando la normale morfologia dell'epitelio gastrico ed esprimendo tipi di cellule mature, comprese le cellule della nicchia, del villo/ghiandola e di tipo enteroendocrino. Queste colture possono essere mantenute indefinitamente in vitro e coltivate in condizioni conformi alle indicazioni GMP. Gli RP-GO mostrano polarità apicale, esponendo ACE2 sulla superficie esterna, ottimizzando le condizioni per l'infezione virale. La nucleoproteina virale è stata dimostrata nelle cellule in fase di apoptosi, con gli RP-GO pediatrici più suscettibili ed infettati in modo efficiente rispetto agli organoidi fetali e adulti. Conclusioni Abbiamo stabilito con successo un efficiente sistema di coltura di organoidi gastrointestinali per tutte le età, dalla vita fetale all'età adulta. La tecnologia basata sugli organoidi può essere utilizzata per modelli di malattie in vitro, test sui farmaci o terapia cellulare. L'applicazione di regole conformi alle GMP rende la traduzione clinica più vicina.
Aims Adult COVID-19 is mainly respiratory illness, but in children GI symptoms are more frequent. Furthermore, fetuses are rarely affected by COVID-19. Organoids are a relatively new tool to in vitro establish long-living culture that three-dimensionally resemble the tissue of origin and may both maintain the stemness and fully differentiate in all cell types. As a proof of concept, we aimed to develop a culture system for gastrointestinal organoids (GIOs) to investigate SARS-CoV-2 infection in gastric epithelium across the lifespan. Methods GIO were derived from 8-21 week fetuses and from pediatric and adult tissues. They were cultured using chemically-defined medium, to test their ability to maintain stemness and to fully differentiate. GIO were analyzed in correlation to the surrounding ECM. Reverse cellular polarity Organoids (RP-GOs) were induced and incubated with SARS-CoV-2. All experiments were analyzed by qPCR, immunofluorescence and qualitative analysis as appropriate. Results Gastrointestinal organoids can be isolated from all gestational ages, demonstrating normal gastric epithelial morphology and expressing mature gastric cell types including, the niche, secretive, and enteroendocrine cells. These cultures may be maintained indefinitely in vitro and cultured in GMP-compliant conditions. RP-GOs exhibit apical-out polarity, exposing ACE2 on the external surface, optimizing conditions for viral infection. Viral nucleoprotein was demonstrated in cells undergoing apoptosis, with pediatric RP-GOs most susceptible and efficiently infected compared to fetal and adult organoids. Conclusions We have successfully established an efficient gastrointestinal organoid culture systems for all ages, from fetal life to adulthood. Organoid-based technology can be used for in vitro disease modelling, drug testing or cell therapy. The application of GMP compliant rules makes the clinical translation closer.

Background and Purpose: Pediatric arterial ischemic stroke (AIS) may underlie an as yet undiagnosed syndrome often characterized by simple Mendelian inheritance. We aimed to establish and validate a targeted gene panel for AIS associated with monogenic disorders, and to determine its diagnostic yield and clinical utility. Methods: Clinical and neuro-radiological data were collected for every patient enrolled in the study. DNA samples were tested by means of a customized gene panel including 15 genes associated with known genetic diseases related with AIS. Results: Thirty-eight patients (23 males, mean age 6.5 years) were selected with heterogeneous AIS phenotypes, mostly multiple and asynchronous and secondary to vasculopathy. Ten out of 38 resulted to carry rare potentially causative mutations in at least one of the 15 genes analyzed. In 4 cases the analyses led to a definite genetic diagnosis while results were either controversial or null in the remaining patients. Conclusions: While the complexity of the different clinical phenotypes associated with AIS is not fully accounted for by the genes tested in the present study, the achieved diagnoses had a great beneficial impact on patient management. A wider gene panel or an unbiased genome wide approach would be better suited to explain a greater proportion of pediatric stroke events.

INTRODUCTION Kidney transplantation has progressively established as the treatment of choice for end stage renal disease (ESRD). The progressive loss of function of the transplanted organ is the leading cause of graft failure. The outcome of graft is influenced by many parameters: one of them is the "delayed graft function" (DGF). Graft damage can be influenced by events occurred during donor reanimation or at the time of brain death. The more recent available studies on this subject are almost exclusively based on an adult population. Assuming that some variables concerning donor resuscitation can influence DGF development and transplant outcome, the main purpose of this project was to understand whether this correlation also exists in the pediatric renal transplantation. MATERIALS AND METHODS We reviewed the data of all patients (<15 years) who underwent a kidney transplantion from 26/12/2003 to 18/04/2011. Donor data were extracted from observations of the intensive care units (ICU) after diagnosis of brain death. We considered: type and volume of plasma expander, transfusions, inotropic drugs, shock episodes, episodes of cardiac arrest, time of stay in ICU , serum creatinine, blood urea and urine output. the recipients data were obtained through the systematic review of medical records. Patients were divided into two Groups: Group 1 (DGF positive) and group 2 (DGF negative). Endpoints of the study were: DGF incidence, graft function and patient survival at 6,12,24 months after transplantation. RESULTS In this period were performed 141 kidney transplants of which 116 with complete donation data. Univariate analysis of donor’s parameters has shown that age, cause of death and donor sex are risk factors for development of DGF. The multivariate logistic regression model confirmed age of the donor as independent risk factor for DGF. CONCLUSIONS Donor age has been revealed as an important independent risk factor for development of DGF. DGF is also an important risk factor for long term loss of graft function, but has no effect on patient’s survival
INTRODUZIONE ED OBIETTIVI Da quando è stato introdotto 40 anni fa, il trapianto di rene si è progressivamente affermato come la terapia di scelta dell'insufficienza renale terminale. La progressiva perdita di funzione dell'organo trapiantato rimane, tuttavia, la principale causa di fallimento del trapianto. L'outcome del graft è influenzato da molteplici parametri: uno di questi è la €"delayed graft function"€ (DGF), ovvero la ritardata ripresa funzionale dell'organo trapiantato. C'è crescente evidenza che il grado di danno dell'organo da trapiantare possa essere influenzato da eventi intercorsi in terapia intensiva o durante il periodo di morte cerebrale. Un punto chiave, quindi, per capire la qualità dell'organo da trapiantare, sembrerebbe essere la gestione rianimatoria del donatore in morte cerebrale. Gli studi disponibili in letteratura sull'argomento sono quasi esclusivamente basati su una popolazione adulta oppure prendono in considerazione un numero ristretto di parametri. Non ci risulta che esistano attualmente studi simili condotti su pazienti pediatrici. Partendo quindi dall'ipotesi, dimostrata nell'adulto, che alcune variabili riguardanti la rianimazione del donatore possano influenzare la DGF e quindi l'outcome del trapianto, scopo principale del presente progetto di ricerca è stato capire se esista questa correlazione anche nell'ambito del trapianto renale pediatrico. SCOPI Analisi della prevalenza di DGF e i suoi fattori di rischio in una popolazione selezionata. Valutazione dell'impatto della DGF sulla funzionalità del trapianto e sulla sopravvivenza del paziente e del graft a 24 mesi dopo il trapianto. MATERIALI E METODI Sono stati presi in considerazione i dati di tutti i pazienti con età inferiore ai 15 anni sottoposti a trapianto di rene presso il nostro Dipartimento di Pediatria (Chirurgia Pediatrica e Nefrologia Pediatrica- Azienda Ospedaliera e Università degli Studi di Padova) ed è quindi stato condotto uno studio retrospettivo su tutti i casi di trapianto di rene da donatore non vivente eseguiti dal 26/12/2003 al 18/04/2011. E'stato escluso il periodo antecedente per la sostanziale differenza nella terapia immunosoppressiva, fatto che avrebbe costituito una notevole fonte di errore nell'analisi dei dati. I dati dei donatori sono stati estratti dalle osservazioni delle unità di terapia intensiva dalla diagnosi di morte cerebrale al prelievo dell'organo. Sono state considerate: tipo e volume di Plasma Expander, trasfusioni, utilizzo di inotropi, episodi di shock ipotensivo, episodi di arresto cardiocircolatorio, ermanenza in terapia intensiva, creatininemia, uremia e diuresi. I dati dei riceventi sono stati ottenuti attraverso la revisione sistematica delle cartelle cliniche dei reparti di Chirurgia Pediatrica e Nefrologia Pediatrica del nostro centro. I criteri di inclusione sono stati:età inferiore ai 18 anni, donatore cadavere in morte cerebrale, follow-up di almeno un anno. I pazienti sono stati divisi in gruppo 1 (11 pz.) con Delayed Graft Function (DGF) e gruppo 2 (105 pz.) senza DGF. Gli endpoints dello studio sono stati: DGF, funzione dell‘organo trapiantato a 6-12-24 mesi dal trapianto e sopravvivenza del paziente a 6-12-24 mesi. RISULTATI Nel periodo di tempo considerato sono stati eseguiti un totale di 141 trapianti di rene, 126 da donatore cadavere, dei quali in 116 bambini i dati relativi alla donazione erano completi. L'analisi univariata dei parametri del donatore in morte cerebrale ha mostrato che l'età , la morte da accidente cerebrovascolare e dil sesso del donatore sono fattori di rischio per lo sviluppo di DGF. Il modello di regressione logistica multivariata haconfermato come fattore di rischio indipendente per DGF l'età del donatore. A 6 mesi di follow-up, il gruppo con DGF ha mostrato una funzionalità renale e un quadro istologico bioptico peggiori rispetto al gruppo senza DGF, ma non abbastanza da raggiungere la significatività . CONSIDERAZIONI CONCLUSIVE L'età del donatore si è rivelata un importante fattore di rischio indipendente per lo sviluppo di DGF, a sottolineare quanto già presente in letteratura di come reni provenienti da donatori pi๠“anziani” siano pi๠suscettibili ad esaurire prima la loro funzionalità . La DGF è risultato inoltre un importante fattore di rischio la perdita di funzione del graft a lungo termine , ma non ha alcun effetto sulla sopravvivenza del paziente

Background The aetiology and the prognostic factors of biliary atresia (BA), a progressive obstructive cholangiopathy of infants, are still not well known. Four different subtypes of BA have been described in relation to the age of the developmental failure during gestational age (i.e. Biliary Atresia Splenic Malformation (BASM), Cystic BA, CMV IgM +ve BA and Isolated BA). We aimed to investigate the relation between the bile duct damage in the porta hepatis and liver and cells with an intestinal phenotype (expressing Cytokeratin 20 (CK-20)) in order to establish if this could be considered a prognostic marker of BA. Methods Samples were orientated intra-operatively then immunostained with anti-cytokeratin 20 (CK20). Sections were then digitised and analysed. Clinical and immunohistochemical data were compared. Data are quoted as median (range). Non-parametric statistical comparisons were made as appropriate. P < 0.05 was regarded as significant. Results 48 consecutive infants were treated with Kasai Portoenterostomy (KPE) or primary liver transplantation in a single-centre between 1999 and 2017. CK20 expression in the liver was not associated with a successful KPE (P = 0.69) or native liver survival (P = 0.91). By contrast, remnant porta hepatis CK20 expression was associated with a successful KPE (P=0.04, HR: 0.49). Diffuse expression (distribution > 50% of slide) was associated with a longer period of native live survival (P=0.01; HR: 0.29). Conclusions CK20 diffuse expression in the porta hepatis is associated with a successful KPE and it is a predictor of native liver survival.

ABSTRACT Background. The diagnosis of pediatric adrenocortical tumors (ACT) is sometimes difficult and it does not always allow to distingush beteween benigna and malignant tumors. Wieneke’s score is useful to classify ACT in benign, indeterminate and malignant tumors but it is based on the evaluation of nine different histological features. The Reticulin Algorithm (RA) has been proved to be reliable and easily reproducible in the classification of adult adrenocortical tumors. Aim of this study is to retrospectively validate the use of RA in a series of pediatric ACT. Materials e methods. Thirty-seven pediatric ACT treated in 3 different european centers were evaluated: according the Wieneke’s score, they were classified as benign in 46% of cases (17), indeterminate in 22% (8) e malignant 32% (12). All cases were reclassified according the RA (malignant if necrosis, vascular invasion and high mitotic count were found associate to an altered reticulin framework). The mitotic index considered was both the adult one (>5/50 HPF; aRA) and the pediatric one (>15/20 HPF; pRA). The reticulin was considered altered with both qualitative and quantitative alterations. Five pathologists revised independently the sections stained for the reticulin framework and a second round was performed in order to obtain a consensus on discordant cases. Results. Reticulin framework was intact in 8 cases (22%), all benign according Wieneke’s score as well. The remaining 29 cases (78%) showed an alteration (quantitative in 16 cases, qualitative in 9 and both in 4). Both Wieneke’s score (p<0.0001) and RA (pRA p=0.0005 e aRA p=0.015) showed an association with the overall outcome. All indeterminate cases according to Wieneke had a favourable clinical course, except for 2 who are alive with disease. aRA distributed these case as follows: 4 in the benign group e 4 in the malignant group; pRA classified 5 as benign and 3 as malignant. Conclusions. RA is a reliable prognostic algorithm to diagnose and stratify pediatric ACT both in its version already described for adult ACT and in the version, described for the first time, here adapted for pediatric ACT.
ABSTRACT Background e obiettivi. La diagnosi istologica dei tumori adrenocorticali (ACT) in età pediatrica è difficoltosa in alcuni casi e non permette sempre agevolmente la distinzione tra forme benigne e forme maligne. Lo score di Wieneke, che permette di classificarli in tumori benigni, tumori indeterminate e tumori maligni, prevede però la valutazione di ben nove parametri istopatologicici. Nei tumori corticosurrenalici dell'adulto, l'algoritmo della reticolino è stato dimostrato essere un metodo affidabile e facilmente riproducibile per la classificazione dei tumori adrenocorticali. Lo scopo di questo studio è di validare retrospettivamente l'applicazione dell'algoritmo della reticolina (RA) ad una casistica di ACT pediatrici. Materiali e metodi. Sono stati analizzati 37 casi di ACT pediatrici trattati da 3 diversi centri europei: questi erano stati classificati come benigni nel 46% (17 casi), indeterminati 22% (8) e maligni 32% (12) secondo lo score di Wieneke. Tutti i casi sono stati riclassificati con il RA (maligni se all'alterazione del reticolo si associava necrosi, invasione vascolare o un'alta conta mitotica). Si è provveduto a considerare sia il cut-off degli adulti (>5/50 HPF; aRA) sia quello pediatrico (>15/20 HPF; pRA). L'alterazione del reticolo considerata era sia qualitativa sia quantitativa. Cinque patologi hanno rivisto le sezioni colorate per il reticolo ed un secondo round di revisione è stato effettuato per raggiungere un consensus sui casi discordanti. Risultati. Il reticolo è risultato intatti in 8 casi (22%) tutti benigni anche secondo il Wieneke index. Gli altri 29 casi (78%) hanno mostrato un'alterazione del network intercellulare (quantitativi in 16 casi, qualitativi in 9 e misti in 4). Sia il Wieneke index (p<0.0001) sia il RA (pRA p=0.0005 e aRA p=0.015) hanno mostrato di associarsi all'outcome clinico. Tutti i casi indeterminati secondo Wieneke sono andati incontro ad un outcome favorevole, tranne 2 casi che risultano vivi con malattia. Il aRA distribuisce questi casi: 4 nel gruppo dei tumori benigni e 4 nel gruppo dei maligni; il pRA li classifica 5 come benigni e 3 come maligni. Conclusioni. Il RA è un valido algoritmo prognostico per diagnosticare e stratificare gli ACT pediatrici sia nella sua versione descritta per i casi dell'adulto sia nella versione, descritta qui per la prima volta, adattata per i casi pedatrici.

ABSTRACT BACKGROUND: Oesophageal Atresia (OA) is a congenital defect that occurs during gestation and prevents the correct oesophagus development in 1 every 3000-4500 ¬births. Tissue Engineering could represent a therapeutic alternative for the most severe cases, where oesophageal replacement becomes necessary. Decellularised matrices are the ideal option because they are derived from tissue-specific extracellular-matrix (ECM) after removing all the cells therefore avoiding the risk of incompatibility and rejection. However, appropriate preservation may significantly affect scaffold behaviour. AIM: here we aim to create a decellularised oesophageal scaffold in a large animal and to establish an innovative method of scaffold storing. METHODS: rabbit oesophagi were decellularised using a detergent-enzymatic treatment (DET) and evaluated at 2 and 4 weeks, 3 and 6 months of storage. Four storage methods were compared: SCM (slow cooling in medium with 10% DMSO at -1°C/min, then stored in liquid nitrogen), SF (snap-freezing in liquid nitrogen, then stored in -80°C), FD (freeze-drying, then stored in -20°C) and 4C (phosphate-buffered saline solution at 4°C). Structural and functional analyses were performed prior to and after each storage condition. RESULTS: efficient decellularisation with preservation of the ECM was achieved after 2 DET cycles as evidenced by histology and DNA quantification. Only the SCM method maintained the architecture and biomechanical properties of the scaffold up to 6 months. On the contrary, all other methodologies failed long-term preservation of the original structure. In particular, SF-oesophagi displayed irreversible tissue collapse, FD-samples were impossible to rehydrate 3 and 6 months post-storage and the 4C option led to a progressive distortion of the tissue architecture. DISCUSSION: scaffolds for oesophageal tissue engineering can be obtained in a large animal using a combination of detergent and enzymatic agents. Efficient storage allows a timely use of decellularised oesophagi, essential for clinical translation. Here we describe for the first time that slow cooling in a DMSO/medium solution and liquid nitrogen leads to reliable long-term storage of decellularised scaffolds.
RIASSUNTO INTRODUZIONE: vi sono patologie nelle quali è necessario procedere a sostituzione totale o parziale dell'esofago. Tra di esse vi è l'atresia esofagea, una malattia dello sviluppo esofageo che colpisce 1 ogni 3000-4500 neonati. Tra le terapie emergenti ed innovative per il trattamento delle forme più gravi si propone l'uso di matrici decellularizzate create mediante tecniche di Tissue Engineering. Queste strutture rappresenterebbero la scelta ideale, in quanto esse mantengono le caratteristiche della matrice extracellulare (ECM) dell'esofago nativo, ma sono private della componente cellulare abbattendo il rischio di incompatibilità e di rigetto. Tuttavia va identificata un'adeguata strategia di conservazione delle matrici prodotte in laboratorio per garantirne la preservazione in modo da renderle disponibili e utilizzabili nella pratica clinica. SCOPI: identificare un metodo efficace di produzione e conservazione delle matrici esofagee decellularizzate in un modello di grande animale. MATERIALI E METODI: esofagi di coniglio sono stati prelevati e decellularizzati utilizzando un metodo che combina l'uso di detergenti ed enzimi (DET). Le matrici sono state analizzare dopo 2-4 settimane e 3-6 mesi dopo averle conservate in 4 modi differenti: SCM (congelate lentamente in medium e conservate in azoto liquido); SF (snap-frozen in azoto liquido e conservate a -80°C), FD (freeze-dryed e poi conservate a -20°C); 4C (in PBS a 4°C). Analisi di struttura e meccanica sono state effettuate ad ognuno dei 4 time-points. RISULTATI: abbiamo raggiunto una decellularizzazione efficace con preservazione dell'ECM dopo 2 cicli DET (come mostrato dalla quantificazione del DNA e dall'istologia). Solo il metodo SCM preserva le caratteristiche strutturali e meccaniche della matrice fino all'ultimo time point dei 6 mesi. Gli altri metodi non sono efficaci, in particolar modo SF porta a collasso della micro-architettura tissutale, i campioni in FD non possono essere reidratati dopo 3 o 6 mesi e la conservazione a 4°C porta a progressiva distorsione delle strutture. DISCUSSIONE: è possibile creare matrici esofagee decellularizzate utilizzando la combinazione di detergenti ed agenti enzimatici. Un metodo di conservazione efficace permette di preservare la matrice esofagea decellularizzata rendendola uno strumento concretamente utilizzabile nella terapia sostitutiva dell'esofago. Abbiamo illustrato come il metodo SCM sia il migliore a tale scopo.

ABSTRACT Introduction and Aim of the Study. Studies devoted to brain dead donor parameters are all based on adult populations. The aim of this study was to analyze the correlation of delayed graft function (DGF) with brain-dead donor variables in a population of 116 consecutive pediatric recipients and to compare the clinical outcomes of non-DGF versus DGF recipients. Patients and Methods. We classified the recipients into two groups: group 0 (No. 11) with DGF and group 1 (No. 105) without DGF. Endpoints of the study were: DGF, 6 months graft function and short-term patient and graft survival. Multivariate analysis was performed to determine independent risk factors of DGF. Results. Monovariate analysis of donor parameters showed that donor age above 15 years, gender combination female donor/male recipients, and vascular cause of donor brain death were risk factors for prolonged DGF. The multivariate logistic regression model confirmed as independent risk factors for DGF donor age > 15 years and gender combination female donor to male recipient. After 6 months follow-up, the DGF group showed worse graft function, as well as a smaller incidence of normal histological pattern at graft biopsies. Conclusions. About parameters associated with brain-death donor resuscitation, except for non-traumatic cause of death, the others did not demonstrate any relationship with DGF. Importantly we show that donor age > 15 years and gender combination female donor to male recipient are clearly major independent risk factors for prolonged DGF in children. Furthermore in our paediatric series DGF revealed an important predictor of poor short-term graft function.
RIASSUNTO Introduzione e scopo dello studio. In pazienti adulti, danni legati allo stato di morte cerebrale e alle manovre rianimatorie possono influenzare la ”delayed graft function” (DGF) e l‟outcome dell‟organo trapiantato. Scopo dello studio è stato valutare, in trapiantati di rene in età pediatrica, la correlazione tra parametri rianimatori del donatore cadavere e l‟outcome dell‟organo trapiantato. Materiali e Metodi. Il campione casistico è consistito in 116 pazienti (età ≤ 16 anni), sottoposti a trapianto di rene da cadavere dal 2004 al 2011. I pazienti sono stati divisi in gruppo 0 (No. 11) con DGF e gruppo 1 (No. 105) senza DGF. Gli “endpoints” dello studio sono stati: DGF, funzione dell‟organo trapiantato a 6 mesi dal trapianto e sopravvivenza del paziente e del rene trapiantato a 6 mesi. Risultati. L‟analisi monovariata dei parametri del donatore in morte cerebrale ha dimostrato che l‟età superiore a 15 anni, la combinazione donatore femmina/ricevente maschio e morte da accidente cerebrovascolare rappresentano fattori di rischio per lo sviluppo di DGF. Il modello di regressione logistica multivariata ha confermato come fattori di rischio indipendente per DGF l‟età del donatore e la combinazione donatore femmina/ricevente maschio. A 6 mesi di follow-up, il gruppo con DGF ha dimostrato una funzionalità renale e un quadro istologico bioptico significativamente peggiori rispetto al gruppo senza DGF. Conclusioni. Ad eccezione della causa di morte non traumatica, nessuna variabile ha influenzato la DGF nei bambini trapiantati. L'età del donatore (>15 anni) e la combinazione donatore femmina/ricevente maschio si sono rivelati importanti fattori di rischio indipendente per lo sviluppo di DGF. Inoltre, la DGF è risultato un fattore predittivo di funzionalità a breve termine dell‟organo trapiantato.

BACKGROUND The etiology and pathogenesis of anorectal malformations (ARM) are multifactorial, poorly understood and controversial. The classification of ARM from a genetic perspective, it is not easy due to the fact that these malformations exist in various forms probably influenced by different factors such as gender and associated anomalies. In the literature, several chromosomal genetic syndromes have been associated with this malformations; the analysis of associated malformations is an important aspect of the genetic study of ARM, because the association of anomalies with mendelian transmission or with a recognized causative gene can be an essential starting point for further investigations. The normal development of the hindgut depends on the proper development of the cloaca and the cloacal membrane, and epithelial-mesenchymal interactions on the correct essential for proper morphogenesis. Sonic Hedgehog (Shh) is an excellent candidate as a mediator in the interaction between endoderm and mesoderm, multiple studies in animal models have shown that the reduced or non-presence of Shh or its downstream signal mediators, are able to cause defects of different anorectal region. AIM OF THE STUDY The first part of the study is for the most part retrospective, and has the purpose of classifying the genetic point of view and clinical the patients suffering from ARM followed at the Department of Pediatric surgery until the year 2011 (period 1991-2011), dividing them into syndromic forms and not , in isolated or familial cases. Another part of the study aims to identify chromosomal abnormalities associated with ARM. The second part is intended to perform a morphological and immunohistochemical staining of tissue taken from the site of the malformation to verify such alteration parietal are present, and assess the expression of Shh in the context of normal and pathological tissue. MATHERIALS AND METHODS The first retrospective of the project has been obtained by re-evaluating the clinical history of all patients followed at the Department of Pediatric Surgery from 1991 until 2011. To achieve the second objective was performed classical and molecular cytogenetic analysis (by FISH: Fuorescence in situ hybridization or array-CGH: array-based comparative genomic hybridization) of the peripheral blood of patients followed since 2000, with possible extension to their parents or other family members. For the morphological study of the material coming from the site of the malformation, was evaluated by light microscopy and subjected to classical staining hematoxylin-eosin, with the aim to evaluate: the type of coating, the presence of erosion and/or ulceration, edema of the lamina own, the structural architecture of the muscularis layer, the presence of the connective tissue and its disposal. Study of some immunohistochemical markers of muscle differentiation and maturation processes (myogenin), stem cell markers (CD34, CD133,) and the possible pathogenetic pathways involved Shh. RESULTS Were identified in the period 1991-2011, 143 patients divided into 56 isolated forms, 82 associated forms with 6 syndromic forms, 4 clinical associations; 5 cases are not classified. In the male are 50 associated forms and 32 with isolated forms, in the female are 32 associated forms and 24 with the isolated forms. Syndromic forms are found: 2 chromosomal syndromes, 4 genetic syndromes. Was not identified familial form. The most interesting observations of histological study relate to the muscularis evaluated both in its internal and external component: in most of the defects is observed an important disarray of muscle fibers with significant fibrosis. The expression of CD133 was evaluated in the different layers of the intestinal wall and it shows there is an intense expression of this marker but to a lesser extent than the CD34 that presents an intense positivity in all the layers, especially in the lamina propria directly to below the epithelium. The myogenin is constantly negative. Regarding Shh levels of signal strength is considerably lower in the muscularis. CONCLUSIONS The results of this work indicate, in agreement with the literature, that 60% of patients with ARM has a defect associated. Rectovescical fistula in 80% of cases are associated with other malformations, followed by: cloaca (78%), rectourethral fistula (71%), vestibular fistula (65%), perineal fistula (49%). From the reduced expression of Shh in the mesodermal tissue can mean that, or an alteration that affects directly Sonic or its downstream mediators, that causes absence of an optimal gradient parietal necessary for a correct shaping of the intestinal wall layers, and hence the changes in the observed in this preliminary study. This down-regulation may provide a molecular support to the hypothesis that the incomplete formation and division of the cloaca results in a wide variety of malformations of the hindgut. To confirm this hypothesis are still needed further studies on the expression of mediators downstream of the Shh signal such as for example Gli2, Bmp-4, Hox genes and the Wnt protein.
PRESUPPOSTI DELLO STUDIO L’eziopatogenesi delle malformazioni anorettali è sconoscosiuta e multifattoriale. La classificazione delle MAR dal punto di vista genetico non è semplice per il fatto che tali malformazioni si presentano sotto differenti forme influenzate probabilmente, da fattori diversi come il genere e le anomalie associate. Sono descritte in letteratura sindromi genetiche e cromosomiche associate a tali malformazioni e per tale motivo risulta importante conoscere il fenotipo con le quali si manifestano ed eseguire un analisi citogenetica classica nei pazienti con MAR al fine di per poterle individuare anomalie cromosomiche che potrebbero essere associate ad una certa ereditarietà. Il normale sviluppo dell’intestino posteriore (hindgut) dipende dal corretto sviluppo della cloaca e della membrana cloacale, nonché dalle corrette interazioni epitelio-mesenchimali indispensabili per una morfogenesi corretta. Sonic Hedgehog (Shh) è un eccellente candidato come mediatore nelle interazione tra endoderma e mesoderma , multipli studi su modelli animali hanno evidenziato come la ridotta o mancata presenza di Shh o dei mediatori a valle del suo segnale, siano in grado di causare difetti diversi nello sviluppo della regione anorettale. SCOPO La prima parte dello studio è per la maggior parte retrospettivo, ed ha lo scopo di classificare dal punto di vista genetico e clinico, i pazienti affetti da MAR seguiti presso il reparto di chirurgia pediatrica fino all’anno 2011 (periodo 1991-2011), suddividendoli in forme sindromiche e non, in casi sporadici o familiari. Un ulteriore parte dello studio ha lo scopo di identificare anomalie cromosomiali associate alle MAR. La seconda parte ha lo scopo di effettuare una caratterizzazione morfologica e immunoistochimica del tessuto prelevato dal sito della malformazione per verificare quali alterazione parietali siano presenti, e valutare l’espressione di Shh nel contesto del tessuto normale e patologico. MATERIALI E METODI La prima parte del lavoro retrospettivo è stato ottenuto rivalutando la storia clinica di tutti i pazienti seguiti presso il reparto di chirurgia Pediatrica dall’anno 1991 fino al 2011. Per il conseguimento del secondo obiettivo è stata effettuata l’analisi citogenetica classica e molecolare (mediante FISH: Fuorescence in situ Hybridization o con array-CGH: array based-comparative genomic Hybridization), del sangue periferico dei pazienti seguiti dall’anno 2000, con eventuale estensione ai genitori o altri familiari. Per lo studio morfologico il materiale proveniente dalla sede della malformazione, è stato valutato al microscopio ottico e sottoposto alla colorazione classica Ematossilina-Eosina, con lo scopo di valutare: il tipo di rivestimento, presenza di erosione e/o di ulcerazione, edema della lamina propria, l’architettura strutturale della tonaca muscolare, la presenza della trama connettivale e della sua disposizione. Per lo studio immunoistochimico sono stati utilizzati di alcuni marcatori dei processi di maturazione e differenziazione muscolare (Miogenina), dei marcatori di staminalità (CD34, CD133,) e delle possibili vie patogenetiche coinvolte (Shh). RISULTATI Sono stati individuati nel periodo 1991-2011, 143 pazienti affetti da MAR suddivisi in forme isolate 56, forme associate 82, con 6 forme sindromiche , 4 associazioni cliniche; 5 casi non sono classificabili. Nel maschio sono 50 le forme associate e 32 le forme isolate; nella femmina sono 32 le forme associate e 24 le forme isolate. Le forme sindromiche riscontrate sono: 2 sindromi cromosomiche, 4 sindromi genetiche. Non è stata identificata nessuna forma familiare Le osservazioni più interessanti dello studio istologico riguardano la tonaca muscolare valutata sia nella sua componente circolare interna che longitudinale esterna: nella maggior parte dei difetti si osserva un importante disarrangiamento delle fibre muscolari con rilevante dissociazione da parte della componente fibrosa. L’espressione di CD133 è stata valutata nei diversi livelli della parete intestinale; vi è un’intensa espressione di tale marker ma in misura minore rispetto il CD34 che presenta un’intensa positività in tutti gli strati, soprattutto nella lamina propria direttamente al di sotto dell’epitelio. La miogenina è costantemente negativa. Per quanto riguarda Shh i livelli di intensità del segnale è notevolmente più basso nella tonaca muscolare. CONCLUSIONI I risultati di questo lavoro indicano, in accordo con la letteratura, che il 60% dei pazienti con MAR ha un difetto associato. La fistola rettovescicale nel 80% dei casi si associa ad altre malformazioni seguita da: cloaca (78%), fistola rettouretrale (71%), fistola rettovestibolare (65%), fistola perineale (49%). Dalla ridotta espressione di Shh a livello del tessuto mesodermico del difetto si può ipottizare che o, ad un alterazione che colpisce direttamente Sonic o i suoi mediatori a valle, porti all’assenza di un ottimale gradiente parietale necessario per un corretto modellamento degli strati parietali intestinali, e quindi alle alterazioni in parte osservate in questo studio preliminare. Questa down-regulation può fornire una supporto molecolare all’ipotesi che l’incompleta formazione e divisione della cloaca determina un’ampia varietà di malformazioni dell’intestino posteriore. Per confermare tale ipotesi sono comunque necessari ulteriori studi sull’espressione dei mediatori a valle del segnale Shh quali per esempio Gli2, Bmp-4, Hox geni e le proteine Wnt.

We consider rare tumors in pediatric age those tumors with an incidence less than 2 cases/1.000.000 children/year, which are not included in treatment protocols of the Associazione Italiana di Emato-Oncologia Pediatrica (AIEOP). These tumors are object of a national project called TREP, aiming to register patients with rare tumors and promote studies of these cancers. We hypothesize that infancy-onset of typically adulthood tumors, extremely rare in pediatric age, could be the expression of an underlying predisposing genetic condition. In fact, the earliest is the age of onset, the least is the exposition to environmental factors. The renal cell carcinoma (RCC) occurs in a sporadic form or as part of genetic diseases, such as Von Hippel-Lindau disease. Likewise, phechromocytoma and paraganglioma occur in a sporadic form or associated with hereditary disorders such as Von Hippel-Lindau disease, Hereditary Paraganglioma-Pheochromocytoma Syndrome, Multiple endocrine neoplasia type 2 (MEN2) syndrome and neurofibromatosis, type 1. AIM We report the preliminary results of a retrospective and prospective study of a TREP project aiming to evaluate the prevalence of main hereditary syndromes associated with renal cell carcinoma and pheochromocytoma in pediatric age. MATERIALS AND METHODS. Patients diagnosed with renal cell carcinoma or pheochromocitoma from January 2000 until May 2009 (age at diagnosis <18 years) and registered in the TREP, alive, with or without disease, were considered for this study. These patients were registered at 18 reference Italian Pediatric Surgery or Oncology centers. Patients were contacted by the Reference Center in order to obtain blood DNA to detect germ-line mutation of the following genes: VHL (Von Hippel-Lindau disease): in renal cell carcinomas and pheochromocytomas RET (MEN2), SDHB, SDHC, SDHD (Hereditary Paraganglioma-Pheochromocytoma Syndrome): in pheochromocytomas only. For patients with renal cell carcinoma, referring clinicians were asked to complete a questionnaire, aimed to enlighten the presence of signs and symptoms suggestive of the possible associated syndromes. Mutation scanning of the VHL gene for identification of point or small size mutations was conducted on the entire coding sequence and intron-exon boundaries, by PCR amplification, DHPLC and direct sequence analysis. Quantitative Real Time PCR for the identification of deletions of part or the entire gene, was performed on genomic DNA fragments representing each VHL exon. Genetic analysis of RET, SDHB, SDHC, SDHD genes was conducted by direct sequencing of coding sequence and intron-exon boundaries. For RET gene, exons 8, 10, 11, 13, 15 and 16 were sequenced. For SDHx genes, all 8 SDHB exons, all 6 SDHC and 4 SDHD exons were entirely sequenced. Rearrangement analysis was conducted by MLPA (Multiple Ligation Probe Assay). Finally we analyzed clinical data in relation to the presence of genetic syndromes. RESULTS Genetic analysis was performed in 13 on 32 eligible patients with renal cell carcinoma. In all cases no mutation were found. In no case the questionnaire, completed in 11 patients, suggested the presence of an underlying genetic syndrome. 14 patients with pheochromocytoma (on 20 eligible) underwent the genetic analysis: we found a germ-line mutation in 7 (2 VHL, 1 SDHD, 4 SDHB) with an overall prevalence of 50%. When possible, genetic analysis was extended to family members: until now we found 9 mutations in SDHB gene and 1 mutation of SDHD. From a clinical point of view our data support the role of a complete surgery of the tumor. Patients with genetic syndrome did not significantly differ from nonsyndromic ones in terms of clinical manifestations and prognosis. CONCLUSIONS As far as renal cell carcinoma is concerned, the limited number of cases analyzed until today does not allow to draw any significant conclusion. Particularly, we could not detect an association with VHL disease. We found an high prevalence (50%) of genetic disorders associated with pheochromocytoma otherwise labeled "sporadics". This prevalence is higher than what reported in adulthood, confirming that the incidence of pheochromocytoma in pediatric age is more frequently associated to an inherited disorder. Our data show that some rare tumors in pediatric age can be the first manifestation of a genetic syndrome. Both renal cell carcinoma and pheochromocytoma clinical outcome strictly depend on completeness of surgery; however these patients need to be considered also from a genetic point of view for the possible implication that a family cancer syndrome can have for the patient and other family members.
Consideriamo "tumori rari in età  pediatrica" quei tumori con un incidenza inferiore ai 2 casi/1.000.000 bambini/anno e che non sono inclusi in protocolli di trattamento dell'Associazione Italiana di Emato-Oncologia Pediatrica (AIEOP). Questi Tumori sono l'oggetto di un progetto nazionale denominato Progetto TREP che si propone fra gli obiettivi la registrazione dei pazienti con tumore raro e l'avvio di studi a loro dedicati. Questo studio si basa sull'ipotesi che l'insorgenza in un bambino di un tumore tipico dell'età  adulta, ma estremamente raro in età  pediatrica possa essere l'espressione di una condizione genetica predisponente. Infatti più è precoce l'età  di insorgenza di un tumore meno è facile che sia avvenuta un' esposizione a fattori ambientali. Il carcinoma renale (CR) può presentarsi in forma sporadica o come parte del quadro clinico di alcune malattie genetiche, tra cui la malattia di Von Hippel-Lindau. Analogamente feocromocitoma e paraganglioma possono presentarsi sia in forma sporadica che associati ad alcune malattie geneticamente trasmissibili tra cui la malattia di Von Hippel-Lindau, la sindrome del feocromocitoma/paraganglioma ereditario, la sindrome da neoplasie endocrine multiple tipo 2 (MEN 2) e la neurofibromatosi tipo 1. SCOPO Nella tesi riportiamo i dati preliminari di uno studio retrospettivo e prospettico condotto nell'ambito del Progetto TREP, che ha lo scopo di valutare la prevalenza delle principali sindromi genetiche associate a carcinoma renale e a feocromocitoma in età  pediatrica. MATERIALI E METODI Sono stati considerati i pazienti con carcinoma renale e con feocromocitoma registrati nel Progetto TREP di età  <18 anni, con diagnosi da gennaio 2000 a maggio 2009 e vivi, con o senza evidenza di malattia, al momento dello svolgimento di questo studio. Questi pazienti sono stati registrati da 18 Centri italiani di Chirurgia o Oncologia Pediatrica. I pazienti, sono stati ricontattati dal medico del centro di riferimento e gli è stato proposto di essere sottoposti a prelievo di sangue periferico per ricerca di alterazioni genetiche. In particolare sono state ricercate: VHL (malattia di Von Hippel-Lindau): sia per i carcinomi renali che per i feocromocitomi RET (MEN2), SDHB, SDHC e SDHD (sindrome del feocromocitoma/paraganglioma familiare): solo per i feocromocitomi. Inoltre per i carcinomi renali è stato compilato dal clinico che aveva in cura il paziente un questionario che cercava di identificare sintomi e segni delle possibili sindromi associate. L'analisi delle mutazioni del gene VHL per l'identificazione di mutazioni puntiformi o di piccola taglia è stata condotta sull'intera sequenza codificante e sulle zone di giunzione introne-esone attraverso amplificazione in PCR, DHPLC e sequenziamento diretto. La PCR Real Time quantitativa è stata utilizzata su frammenti di DNA genomico rappresentanti ogni esone del gene VHL per identificare delezioni di parti o dell'intero gene. L'analisi genetica del gene RET e dei geni SDHB, SDHC ed SDHD è stata condotta mediante sequenziamento diretto delle regioni codificanti e delle regioni introniche fiancheggianti. Per il gene RET sono stati sequenziali gli esoni 8, 10, 11, 13, 15 e 16. Per quanto riguarda i geni SDHx sono stati sequenziati interamente gli 8 esoni di SDHB, i 6 di SDHC e i 4 di SDHD; inoltre è stata condotta l'analisi dei riarrangiamenti mediante MLPA (Multiple Ligation Probe Assay). Abbiamo infine analizzato i risultati del trattamento correlandoli alla presenza di una sindrome genetica. RISULTATI Per quanto riguarda i carcinomi renali sono stati identificati 32 pazienti eligibili al nostro studio. La scheda anamnestica è stata somministrata in 11 pazienti, e non ha posto in nessun paziente il sospetto clinico di una sindrome genetica associata. L'analisi genetica per VHL è stata condotta in 13 pazienti ed in tutti i casi ha dato esito negativo. Clinicamente la prognosi è apparsa correlata con lo stadio e quindi con la chirurgia: i pazienti con tumore localizzato asportato completamente hanno mostrato un' ottima sopravvivenza. Per i feocromocitomi l'analisi genetica è stata condotta in 14 pazienti su 20 eligibili ed ha evidenziato una mutazione germinale in 7 (2 VHL, 1 SDHD, 4 SDHB) con una prevalenza totale del 50%. Ove possibile l'analisi genetica è stata estesa anche ai familiari: finora sono stati identificati 9 familiari con mutazione del gene SDHB e uno con mutazione di SDHD. Dal punto di vista clinico i nostri dati confermano l'importanza di una chirurgia completa del tumore. Non è stata riscontrata una differenza significativa nelle manifestazioni cliniche e nella prognosi dei pazienti sindormici quando confrontati a quelli non sindormici. CONCLUSIONI Per quanto riguarda il carcinoma renale, non siamo riusciti ad evidenziare una associazione con la sindrome di VHL, ma la limitata numerosità del campione esaminato ci permette di trarre solo delle conclusioni preliminari. Nei feocromocitomi abbiamo riscontrato un' elevata prevalenza (50%) di sindromi genetiche associate. Tale frequenza è superiore rispetto a quanto riportato in casistiche di pazienti adulti confermando che l'insorgenza di un feocromocitoma in età  pediatrica è maggiormente associata ad una sindrome genetica. I nostri dati dimostrano che alcuni tumori rari per l'età pediatrica possono rappresentare la prima manifestazione di una sindrome genetica. Il risultato del trattamento è strettamente correlato all' esito della chirurgia sia per i carcinomi renali che per il feocromocitoma. E' però importante sottolineare che oltre le problematiche inerenti al trattamento vanno considerate quelle di tipo genetico per le implicazioni che una family cancer syndrome può avere per la famiglia e il paziente stesso.

Thoracic Non-Rhabdo Soft Tissue Sarcomas (NRSTS) are a rare entity in paediatric age, and are characterized by a dismal prognosis. Being a seldom occurring site, thorax is grouped together with other infrequent localizations, following the classification used for Rhabdomyosarcomas. Inside the thorax, clinicians divide three different sub-localizations: thoracic wall, paraspinal site and intrathoracic region. The most frequent histotype is represented by Ewing Sarcomas (ES)/pPNET, followed by the “adult-type” NRSTS, the Synovial Sarcoma and other histotypes. The aim of the present analysis has been to evaluate the data about patients with thoracic NRSTS enrolled in three subsequent Italian Paediatric Protocols since 1979 to 2005, in order to improve the knowledge on this rare subject. Ninety-nine patients have been considered: 66 were localized in the thoracic wall, 18 were intrathoracic, 15 paraspinal; 58 were ES/pPNET, 29 “adult-type” NRSTS, 5 Synovial Sarcoma and 7 other histotypes. We have identified the prognostic role played by dimensions, local invasiveness, loco-regional lymph nodes involvement and metastatic distant spread; but we have also identified the undoubtful prognostic advantage determined by the initial complete excision, itself correlated to the over mentioned characteristics. These patterns are common to all the localizations and to all histotypes, even if paraspinal tumours present a worst prognosis compared to other sites and ES/pPNET more often are diagnosed with advanced disease and metastatic spread. We are aware of the wide variety of the examined population and of the complexity of this analysis, therefore no definitive conclusions are possible, but this work improves the knowledge on this topic. Thoracic NRSTS represent a challenge in particular for paediatric surgeons, especially from the technical point of view: on one hand the “radicality”, with the aim to remove completely the tumour, on the other side the reconstructive program. The local control is fundamental in order to give good chances to obtain a long-term survival, but a satisfying functional and aesthetic result is equally important in young patients. And thoracic cage presents some peculiar characteristics of resistance and elasticity, therefore being a good subject to research new operative techniques and innovative reconstructing strategies, respecting the radicality and thus avoiding radiotherapy and its long-term sequelae.
I Sarcomi delle Parti Molli non Rabdomiosarcoma (NRSTS) localizzati al torace rappresentano un’entità rara in età pediatrica, caratterizzata da una prognosi infausta. Il torace, proprio per il fatto di essere una sede raramente colpita da questi tumori, viene raggruppato insieme ad altre sedi infrequenti, seguendo quella che è la classificazione applicata ai Rabdomiosarcomi: al suo interno si possono distinguere la parete toracica, la sede paraspinale e la regione intratoracica. L’istotipo più frequentemente rappresentato è il Sarcoma di Ewing (ES)/pPNET, seguito dal gruppo dei NRSTS “adult-type”, dal Sarcoma Sinoviale e da altri istotipi. Scopo della presente analisi è stato quello di analizzare la popolazione di NRSTS toracici registrati nei tre Protocolli Italiani che si sono susseguiti dal 1979 al 2005, al fine di incrementare le conoscenze su questo raro gruppo di neoplasie. Sono stati presi in considerazione 99 pazienti, 66 localizzati a livello della parete toracica, 18 a localizzazione intratoracica, 15 paraspinali; 58 erano ES/pPNET, 29 “adult-type” NRSTS, 5 Sarcomi Sinoviali e 7 altri istotipi. E’ stato riconosciuto il ruolo prognostico giocato da dimensioni, invasività locale, estensione linfonodale loco-regionale e disseminazione metastatica a distanza; ma anche l’indubbio vantaggio prognostico determinato dall’exeresi iniziale completa, che a sua volta è correlata alle caratteristiche summenzionate. Queste caratteristiche sono trasversali a tutte le sottosedi e a tutti gli istotipi, sebbene i tumori paraspinali dimostrino una prognosi più severa rispetto alle altre sedi ed i ES/pPNET si manifestino più frequentemente in una forma avanzata di malattia con metastasi a distanza. Sicuramente l’eterogeneità del campione preso in esame rende difficili delle conclusioni definitive, tuttavia questa analisi apporta un incremento nelle conoscenze su questo argomento, che rappresenta una sfida particolare per il chirurgo pediatra anche dal punto di vista delle difficoltà legate alla chirurgia, sia nella sua parte demolitiva sia nella sua parte ricostruttiva. Infatti, se è pur vero che il controllo locale è fondamentale per dare delle valide possibilità di guarigione, è altrettanto importante garantire un risultato funzionale ed estetico soddisfacente a questi piccoli pazienti, e la gabbia toracica, con le sue caratteristiche di resistenza ed elasticità, costituisce uno stimolo alla ricerca di strategie operatorie e di tecniche ricostruttive innovative, sempre nel rispetto della radicalità che consente di evitare la radioterapia ed i suoi possibili effetti collaterali.

Introduction and purpose Bladder exstrophy (BE) is a rare malformation that involves not only the bladder, urethra and genital organs but also all of the pelvic floor and bones. Its prevalence is about 1/25.000-40.000 born in Italy and about 15 new cases are estimated each year. The disease affects males and females with a ratio of 2:1. The etiology is unknown. The effect of this malformation, affecting the urogenital complex, can be reflected on urinary continence and sexual life. These aspects can influence strongly the social life of patients. We evaluated both psychosexual and psychosocial aspects and sexual dysfunctional in adult with BE using a validated instrument. Materials and methods We conducted a survey using SESAMO (Sexuality Evaluation Schedule Assessment Monitoring). We evaluated a group of patients (cases) and a group of controls. All are invited to complete the male or female, single or partnership version of the instrument. The questionnaires are loaded into the program SESAME-Win and processed by the software SESAME-R. Both cases and the controls are analyzed in general and by sex and by emotional situation (single or partnership). We investigated the Areas found to be significant in the group of cases and not in the corresponding group of controls; in these Areas we analyzed individually every Items, highlighting the percentage of significant responses. We also assessed the state of continence about patients. Results This questionnaire is being distributed to 45 patients with BE, including 30 men (M) and 15 women (W) and 40 controls, 20 M and 20 W. 26 cases (17 M and 9 W), with a response rate of 57.7%, and 35 controls (18 M and 17 W) with a response rate of 87.5%, were finally included in analysis. With regard to the cases 16 (11 M and 5 W), completed the questionnaire as situation of “partnership” and 10 (6 M and 4 W) as "single". In group of controls 26 (14 M and 12 W) completed the questionnaire as situation of "partnership" and 9 (4 M and 5 W) as "single". Median age was 28 years in the Cases group and 30.5 in Controls. Environmental psychology and Lived Body Areas were significant in all groups of Cases (except in Females Total about Lived Body) and never in groups of controls. Desire Area is significant only in females Cases. Pleasure Areas are significant only in the groups of Controls and never in Cases. Remote Masturbation is significant, both in the group of Cases that Controls Females. Previous Experiential and the Sexual and Medical History are significant in all groups (except in the group of females controls about this last Area). Patients had a continence rate of 80, 7%. Conclusions Patients with bladder exstrophy have a tendency toward obsessive-compulsive disorder towards sexuality. They are dissatisfied about their free time, but they reached a satisfactory social position. They have a critical relationship with their parents and especially with mother, certainly more present in the clinical pathway. Especially with female patients, there is a lack of communication about sexuality. They present a difficulty to express and share their experiences, particularly sexuality, which they define like frustration experience. The body perception was very critical, more critical in single cases than in partnership. The areas of the body affected by the malformation are hated by themselves. Sexual dysfunction affects a high percentage of both sexes and the women seem to have more difficulty in having a satisfying sexual relationship. Sexuality appear a pathological experience in both single and partnership group. Singles are not satisfied with their emotional situation and even the frequency of sexual intercourse. Patients who live in a partnership use frequently masturbation not for his own pleasure but as act that substitute a complete sexual intercourse.
Introduzione e scopo dello studio L’Estrofia Vescicale-Epispadia (EV) è una rara patologia congenita caratterizzata da uno sviluppo incompleto della vescica e dell’uretra. La sua prevalenza varia da 1/25.000 a 1/40.000 nati ed in Italia si stima un'incidenza di circa 15 nuovi casi ogni anno. La patologia colpisce maschi e femmine con un rapporto di 2:1. L’etiologia non è nota. La patologia, colpendo l’apparato uro-genitale si riflette su elementi di primaria importanza, vale a dire la continenza urinaria e la vita sessuale. Tali aspetti possono condizionare fortemente la vita di relazione dei soggetti affetti. Scopo dello studio è stato quello di identificare sia gli aspetti psicosessuali e psicosociali che gli aspetti disfunzionali sessuali in soggetti affetti da EV. Materiali e metodi Abbiamo eseguito un’indagine strutturata mediante il questionario SESAMO (Sexuality Evaluation Schedule Assessment Monitoring - Boccadoro, Perillo 1996). Sono stati individuati due gruppi d’indagine: un gruppo di pazienti (casi) e uno di soggetti non portatori della patologia (controlli). Tutti i soggetti sono stati invitati a rispondere alla versione maschile o femminile, single o di coppia del questionario. I questionari sono stati caricati nel programma SESAMO-Win ed elaborati dal software SESAMO-R. Sia i Casi che i controlli sono stati analizzati sia in generale che divisi per sesso e situazione affettiva single/coppia. Sono state indagate le Aree risultate significative nel gruppo dei Casi e non nel corrispettivo gruppo dei Controlli; di tali Aree sono stati analizzati singolarmente i vari Item che le componevano, evidenziando la percentuale di risposte significative. Abbiamo inoltre valutato lo stato di continenza dei pazienti. Risultati Il questionario è stato consegnato a 45 pazienti affetti da EV di cui 30 maschi (M) e 15 femmine (F) e 40 controlli, di cui 20 M e 20 F. Hanno aderito allo studio 26 casi (17 M e 9 F), con un tasso di risposta di 57,7%, e 35 controlli (18 M e 17 F) con un tasso di risposta di 87,5%. In particolare per quanto riguarda i casi, 16 (61,5%) di cui 11 M e 5 F, hanno compilato il questionario come situazione affettiva di “coppia” e 10 (38,5%) di cui 6 M e 4 F come “single”; riguardo i controlli 26 (74,5%) (14 M e 12 F) hanno compilato il questionario come situazione affettiva di “coppia” e 9 (25,5) (4 M e 5 F) come “single”. L’età mediana è stata di 28 anni nel gruppo dei casi e 30,5 nei controlli. Le Aree Relati psicoambientali e Vissuto corporeo sono risultate significative in tutti i gruppi dei Casi (eccetto nei Casi Femmine totali per quanto riguarda il vissuto corporeo) e mai nei gruppi dei Controlli. L’Area Desiderio è significativa solo nei Casi Femmine. Gli Ambiti del piacere sono significativi solo nei gruppi dei Controlli e mai nei Casi. La Masturbazione remota è significativa sia nel gruppo dei Casi che dei Controlli Femmine. L’Esperienziale pregresso e l’ Anamnesi Medica e Sessuale sono significative in tutti i gruppi (eccetto nel gruppo dei Controlli Femmine per quest’ultima Area). I pazienti hanno presentato un tasso di continenza dell’80,7%. Conclusioni I pazienti affetti da estrofia vescicale presentano una spiccata tendenza all’ossessività che si manifesta sia nelle pratiche quotidiane che nei confronti della sessualità. Sono insoddisfatti del loro tempo libero ma circa la metà di essi ha raggiunto una condizione sociale soddisfacente. Presentano un rapporto critico con i propri genitori e in particolar modo con la madre, figura sicuramente più presente nel percorso clinico; specialmente nelle pazienti di sesso femminile si riscontra una carente comunicazione intrafamiliare riguardo alla sessualità. E’ emersa inoltre una difficoltà ad esprimere e raccontare le loro esperienze, in particolare quelle sessuali che definiscono frustranti. L’attenzione rivolta al “se’ corporeo” è risultata molto critica, più nei casi in situazione di coppia che nei single; le zone interessate dalla malattia e di conseguenza coinvolte negli interventi chirurgici sono le più odiate da essi. Le disfunzioni sessuali colpiscono in alta percentuale entrambi i sessi e nel complesso le donne sembrano avere più difficoltà ad avere un rapporto sessuale soddisfacente. La sessualità è vissuta in maniera patologica sia nel gruppo dei pazienti “single” che “coppie”. I pazienti single non sono soddisfatti della loro situazione affettiva e neppure della frequenza dei rapporti sessuali. I pazienti che vivono una situazione di coppia sono spinti ad attuare con maggiore frequenza la masturbazione non per proprio piacere ma come atto sostitutivo al rapporto sessuale completo.

This project rises from the hypothesis of using cell therapy and tissue engineering in the gastrointestinal system. The clinical environment the project borne is the Pediatric Surgery. However the faced topics embrace all age population. In particular we explored the possible correction of sphincter defect by using skeletal muscle precursors. In this view we studied the capability of skeletal muscle precursors (committed stem cells) of integrating into contractile tissue of gut. In vitro and in vivo experiments have been done. The most data have been obtained from the murine model of cryo-injury of gastroesophageal junction. We studied the regeneration after injection of cultured or freshly isolated satellite cell (obtained by the single fibre technique) compared with other cell populations. The candidate personally managed several technique to obtain skeletal muscle precursors, primary cell culture, co-culture between various cell-type; analysis techniques ( conventional histology, immunofluorescent analysis of cryo-sections, western-blotting, cytofluorimetric anlysis, statistical analysis, microscopy imaging). Further micro-surgery techniques have been used in the in vivo experiments on small animals. Results have been presented in international meetings or publications: - Murine Muscle Precursor Cells survived and integrated in a Cryoinjured Gastroesophageal Junction. Fascetti Leon F, Malerba A, Boldrin L, Leone E, Betalli P, Pasut A, Zanon GF, Gamba PG, Vitiello L, DeCoppi P. J Surg Res. Epub 2007 Jun 19 - Muscle precursors injection in the gastroesophageal junction: further experience. Fascetti Leon F, Malerba A, Boldrin L, Zanon GF, Gamba PG, Pierro A, De Coppi P. Oral presentation at the 8th European Congress of Paediatric Surgery (EUPSA) Turin, Italy 2007 In vitro enhancement of muscle precursors cells differentiation enhanced by co-cultures with neurogenic cells. A Malerba, F Fascetti Leon, L Boldrin, C Caldwell, N, Thapar, A Pierro, P De Coppi British Association of Paediatric Surgeons (BAPS) annual meeting Edimburgh, UK 2007 - Further experience with the injection of muscle precursors in the gastroesophageal junction Fascetti Leon F, Malerba A, Boldrin L, Vitello L, Talenti E, Zanon GF, Gamba PG, Pierro A, De Coppi P. presentation at the American Paediatric Surgeons Association (APSA) Orlando, Florida 2007 - Long term integration of muscle precursor cells injected in the lower esophageal sphincter. Fascetti Leon F, Malerba A, Boldrin L, Betalli P, Gamba PG, Vitiello L, A. Pierro, DeCoppi P. submitted. Cell culture have been conduced at the Regenerative Medicine Lab of Della Città della Speranza (c/o Dipartimento di Pediatria e Istituto VIMM). Part of the analyses and the co-culture have been conduced at the Institute of Child Health - Great Ormond Street Hospital of London. The in vivo section have been done at The work allows the conclusion that adult skeletal muscle precursors could be used in the regeneration of digestive tract contractile tissue. In particular good engrafting and data regarding the possible trans-differentiation through smooth muscle lineage led to follow this approach (correction of sphincter defect). Few data have been obtained from the preliminary experiments on anal sphincter. Furthermore, the capability of integrating and interacting in vitro between ganglion derived cells and muscle cells, let us think to the possible wilder application to gastro-intestinal contraction defects.
Il progetto di ricerca nasce dall’ipotesi dell’utilizzo di approcci di terapia cellulare ed ingegneria tissutale nel tratto digerente. L’ambiente clinico da cui nasce lo spunto per questo progetto di ricerca è la Chirurgia Pediatrica. Tuttavia le tematiche affrontate abbracciano trasversalmente ogni fascia di età. Ci si è interessati in particolare alla possibilità di correggere difetti “sfinteriali” tramite l’utilizzo di precursori derivati dal muscolo scheletrico. In tale ottica sono state esplorate le capacità di integrazione nel tessuto contrattile del tubo digerente di precursori cellulari del muscolo scheletrico (cellule staminali committed). Sono stati eseguiti esperimenti in vivo e in vitro. La maggior parte dei dati sono stati ottenuti utilizzando un modello di danno da congelamento a carico della giunzione gastro-esofagea di topo. Sono state esplorate le possibilità di rigenerazione dopo iniezione di cellule satellite coltivate o a fresco ottenute con la tecnica della singola fibra. Il candidato ha personalmente utilizzato diverse tecniche per l’ottenimento di precursori staminali da muscolo scheletrico, colture cellulari primarie, coculture tra vari tipi cellulari, nonché varie tecniche di analisi (istologia convenzionale, analisi d’immunofluorescenza delle criosezioni, western-blotting, citofluorimetria, analisi statistica e d’immagine microscopica). Per gli esperimenti in vivo,inoltre, sono state utilizzate tecniche di microchirurgia sul piccolo animale. Risultati del lavoro svolto sono stati oggetto di presentazioni in congressi nazionali ed internazionali: - Murine Muscle Precursor Cells survived and integrated in a Cryoinjured Gastroesophageal Junction. Fascetti Leon F, Malerba A, Boldrin L, Leone E, Betalli P, Pasut A, Zanon GF, Gamba PG, Vitiello L, DeCoppi P. J Surg Res. Epub 2007 Jun 19 - Muscle precursors injection in the gastroesophageal junction: further experience. Fascetti Leon F, Malerba A, Boldrin L, Zanon GF, Gamba PG, Pierro A, De Coppi P. Oral presentation at the 8th European Congress of Paediatric Surgery (EUPSA) Turin, Italy 2007 In vitro enhancement of muscle precursors cells differentiation enhanced by co-cultures with neurogenic cells. A Malerba, F Fascetti Leon, L Boldrin, C Caldwell, N, Thapar, A Pierro, P De Coppi British Association of Paediatric Surgeons (BAPS) annual meeting Edimburgh, UK 2007 - Further experience with the injection of muscle precursors in the gastroesophageal junction Fascetti Leon F, Malerba A, Boldrin L, Vitello L, Talenti E, Zanon GF, Gamba PG, Pierro A, De Coppi P. presentation at the American Paediatric Surgeons Association (APSA) Orlando, Florida 2007 - Long term integration of muscle precursor cells injected in the lower esophageal sphincter. Fascetti Leon F, Malerba A, Boldrin L, Betalli P, Gamba PG, Vitiello L, A. Pierro, DeCoppi P. submitted. Gli esperimenti “in vivo” e ‘analisi istologica sono stati condotti presso il Centro inter-dipartimentale Vallisneri dell’Unioversità di Padova. Le colture cellulari sono state eseguite presso il Laboratorio di Medicina Rigenerativa Della Città della Speranza (c/o Dipartimento di Pediatria e Istituto VIMM). Parte dell’analisi e delle co-culture sono state eseguite presso l’Institute of Child Health - Great Ormond Street Hospital di Londra. Il lavoro svolto porta alla conclusione che cellule precursori muscolari derivati da tessuto muscolare scheletrico adulto sono potenzialmente utilizzabili nella rigenerazione delle strutture contrattili del tubo digerente. In particolare la buona capacità di integrazione e dati sulla possibile trans-differenziazione verso la linea cellulare muscolare liscia stimolano a proseguire nella direzione di una terapia cellulare dei difetti sfinteriali. Pochi dati sono derivati dagli esperimenti condotti sullo sfintere anale interno, che vanno pertanto considerati preliminari. Inoltre la capacità di integrazione e interazione in vitro tra cellule nervose gangliari e muscolari derivate da muscolo scheletrico fanno pensare ad un più ampio utilizzo nei difetti di contrattilità gastro-intestinali.

Background. Repair of skeletal muscle loss due to trauma, surgical resection or malformations represent a challenge for clinicians. Several attempts to create a bioscaffold to substitute skeletal muscle have been done but no satisfying results were obtained due to lack in regeneration process and functionality of repaired tissue. Some studies on tissue engineering investigated the application of decellularized extracellular matrix (ECM) derived from skeletal muscle observing positive effect towards regeneration. It is becoming relevant the role of tissue-specificity in the field of tissue engineering. This study aims to compare the regenerative effect of both tissue-specific and no tissue-specific scaffolds when applied in a volume of volume muscle loss. Muscle regeneration and macrophagic response are investigated. Material and Methods. Decellularized extracellular scaffold from murine skin, intestine and rhabdomyosarcoma (ARMS) were obtained using a detergent-enzymatic protocol. Scaffolds’ characteristics were investigated. Wild type mice were used as animal model for in vivo implantation on diaphragm and tibialis anterioris muscles. Samples were obtained at sequential timepoints and analysed with Histology, DNA quantification techniques, Immunofluorescence, Real-time PCR. Results. Decellularized ECM scaffold were obtained from each tissue. Moreover, their ECM maintained ultrastructure and composition. Implantation in vivo showed a regeneration of new, centre nucleated myofibers when muscle scaffold was used. No significant regeneration was observed with other scaffolds. With muscle implants, macrophagic response was present and characterized by organized distribution of cells. Conclusions. The decellularization protocol used in this study demonstrated to be effective in maintaining ECM properties even if in absence of cells. Pro-regenerative results obtained only with implantation of muscle-derived scaffolds underline the importance of tissue-specificity in order to obtain the ideal material to repair muscular defects.
Premesse. Il trattamento della perdita di sostanza muscolare dovuta a traumi, resezioni chirurgiche o malformazioni rappresenta ancora una sfida in ambito medico. In passato sono stati creati diversi bioscaffold che potessero sostituire il tessuto muscolare ma i risultati sono stati poco soddisfacenti a causa del mancato stimolo alla rigenerazione tissutale e del mancato recupero funzionale. Alcuni studi hanno hanno esaminato le potenzialità rigenerative di bioscaffold derivati da matrice extracellulare di muscolo scheletrico. In ambito di ingegneria tissutale risulta sempre più importante la specificità tissutale dello scaffold. Questo studio mette a confronto il potenziale rigenerativo di scaffold tessuto-specifici e non in un modello di perdita di sostanza muscolare. In particolare vengono studiati i meccanismi di rigenerazione muscolare e la risposta macrofagica. Materiali e Metodi. Utilizzando un protocollo di decellularizzazione detergente-enzimatico, sono stati ottenuti da modello murino scaffold di matrice extracellulare di cute, intestino, rabdomiosarcoma. Di tali scaffold sono state studiate le caratteristiche intrinseche. Come modello animale è stato utilizzato il topo wild type. Gli scaffold sono stati impiantati chirurgicamente a livello del diaframma e del muscolo tibiale anteriore. I campioni, prelevati a timepoints diversi, sono stati esaminati con istologia, quantificazione del DNA, Immunofluorescenza, Real-Time PCR. Risultati. E' stato possibile ottenere scaffold di matrice extracellulare decellularizzata da ciascun tessuto esaminato. La struttura e la composizione della matrice extracellulare è stata preservata nonostante il trattamento di decellularizzazione. L'applicazione in vivo di scaffold derivati da muscolo ha indotto la rigenerazione di nuove fibre muscolari centro-nucleate. L'applicazione in vivo degli scaffold derivati dagli atri tessuti non ha condotto a rigenerazione tissutale. Una volta applicato lo scaffold derivato dal muscolo la risposta macrofagica è stata significativa e caratterizzata da una distribuzione regolare delle cellule. Conclusioni- Il protocollo di decellularizzazione utilizzato in questo studio è risultato efficace nell'ottenere matrici extracellulari decellularizzate pur preservando le caratteristiche della matrice stessa. Lo stimolo rigenerativo ottenuto solamente mediante impianto di matrice muscolare sottolinea l'importanza della specificità tissutale nell'ottica di ottenere un valido sostituto in caso di danno con perdita di sostanza.

L'obiettivo del presente studio è quello di verificare la sicurezza e l’efficacia della protezione miocardica ottenuta con la soluzione cardioplegica istidina-triptofano- chetoglutarato (HTK) (Custodiol®) in pazienti con peso inferiore a 15 Kg, sottoposti a chiusura isolata di difetto interventricolare.In questo studio retrospettivo sono stati valutati 360 pazienti consecutivi sottoposti a chiusura isolata di difetto interventricolare con peso inferiore a 15 Kg. Sono stati valutati una serie di fattori preoperatori, operatori e postoperatori per valutare l’efficacia della protezione miocardica. E’ stata eseguita una analisi statistica univariata e multivariata per correlare i vari fattori tra di loro ed in rapporto con il tempo di ischemia miocardica e di circolazione extracorporea. I livelli di troponina e creatina chinasi-MB, la funzione ventricolare sinistra e l’attività elettrofisiologica del miocardio sono stati monitorizzati nel periodo postoperatorio.L’utilizzo della soluzione cardioplegica intracellulare cristalloide Custodiol HTK nei pazienti sotto i 15 Kg di peso corporeo, risulta essere sicura ed efficace nel proteggere il miocardio immaturo o in via di transizione anche negli interventi che richiedo tempi di ischemia miocardica non particolarmente prolungati.
The objective of this study is to verify the safety and efficacy of the myocardial protection obtained with the cardioplegic histidine-tryptophan ketoglutarate (HTK) solution (Custodiol®) in patients weighing less than 15 kg, undergoing an isolated closure of interventricular defect. In this retrospective study, 360 consecutive patients undergoing isolated closure of an interventricular defect weighing less than 15 kg were evaluated. A series of preoperative, operative and postoperative factors were assessed to evaluate the effectiveness of myocardial protection. A univariate and multivariate statistical analysis was performed to correlate the various factors with each other and in relation to the time of myocardial ischemia and extracorporeal circulation. Troponin and creatine kinase-MB levels, left ventricular function and electrophysiological activity of the myocardium were monitored in the postoperative period. The use of the Custodiol HTK crystalloid intracellular cardioplegic solution in patients under 15 kg of body weight is safe and effective in protecting the immature or transitioning myocardium even in interventions that require not particularly prolonged myocardial ischemia times.

La planification chirurgicale repose sur l’anatomie du patient, et repose souvent sur l’analyse d’images médicales acquises avant la chirurgie. En particulier, c’est le cas pour les interventions de chirurgie pelvienne en pédiatrie, pour de nombreuses pathologies telles que des tumeurs et des malformations. Dans cette zone anatomique, en raison de sa forte vascularisation et innervation, une bonne planification chirurgicale est extrêmement importante pour éviter des lésions fonctionnelles des organes du patient, qui pourraient nuire a sa qualité de vie. En pratique clinique, la procédure standard repose sur l’analyse visuelle, coupe par coupe, des images de la région pelvienne. Cette tâche, même si elle est facilement accomplie par des radiologues experts, est très complexe et fastidieuse pour les chirurgiens, en raison de la complexité et de la variabilité des structures anatomiques et, par conséquent, de leurs images. De plus, en raison des variations anatomiques selon l’age du patient, toutes ces difficultés sont accentuées en pédiatrie et une compréhension anatomique claire est encore plus importante que pour les adultes. Pour ces raisons, il est important et utile d’être capable de fournir aux chirurgiens des modèles anatomiques 3D spécifiques aux patients, obtenus par traitement et analyse des images IRM.Dans cette thèse, nous proposons un ensemble de méthodes de segmentation d’images IRM de patients pédiatriques. Nous nous concentrons sur trois structures pelviennes importantes : les os du bassin, les vaisseaux sanguins et la vessie. Pour les os, nous proposons une méthode semi-automatique comportant une première étape de recalage de modèles osseux puis une étape de segmentation fine par modèles déformables. La principale contribution de la méthode proposée est l’introduction d’un ensemble de modèles osseux pour différentes tranches d’age, ce qui permet de prendre en compte la variabilité des os pendant la croissance. Pour les vaisseaux, nous proposons une méthode par patchs, apprentissage profond et transfert d’apprentissage, donc ne nécessitant que peu de donnes d’apprentissage. La principale contribution de ce travail est la conception d’une procédure semi-automatique pour l’extraction des patchs, qui permet a l’utilisateur de se focaliser uniquement sur les vaisseaux d’intérêt; et pour la planification chirurgicale. Pour la segmentation de la vessie, nous proposons d’utiliser une approche par modèles déformables, particulièrement robuste aux hétérogénéités de l’image et aux effets de volume partiel, souvent présents dans les images IRM pédiatriques. Toutes les méthodes proposées sont intégrées dans une plateforme logicielle libre pour le traitement d’images médicales, donnant aux chirurgiens des outils performants avec des interfacesutilisateur faciles a utiliser. De plus, nous mettons en place une stratégie de traitement et de portabilité pour la visualisation des modèles 3D du patient, permettant aux chirurgiens de générer, visualiser et partager ces modèles au sein de l’hôpital. En conclusion, les résultats obtenus avec les méthodes proposées sont quantitativement et qualitativement évalués de manière très positive par des chirurgiens pédiatriques, démontrant leurs potentialités pour l’utilisation en pratique clinique dans des procédures de planification chirurgicale
Surgical planning relies on the patient’s anatomy, and it is often based on medical images acquired before the surgery. This is in particular the case for pelvic surgery on children, for various indications such as malformations or tumors. In this particular anatomical region, due to its high vascularization and innervation, a good surgical planning is extremely important to avoid potential functional damages to the patient’s organs that could strongly affect their quality of life. In clinical practice the standard procedure is still to visually analyze, slice by slice, the images of the pelvic region. This task, even if quite easily performed by the expert radiologists, is difficult and tedious for the surgeons due to the complexity and variability of the anatomical structures and hence their images. Moreover, due to specific anatomy depending on the age of the patient, all the difficulties of the surgical planning are emphasized in the case of children, and a clear anatomical understanding is even more important than for the adults. For these reasons, it is very important and challenging to provide the surgeons with patient-specific 3D reconstructions, obtained from the segmentation of MRI images. In this work we propose a set of segmentation tools for pelvic MRI images of pediatric patients. In particular, we focus on three important pelvic structures: the pelvic bones, the pelvic vessels and the urinary bladder. For pelvic bones, we propose a semi-automatic approach based on template registration and deformable models. The main contribution of the proposed method is the introduction of a set of bones templates for different age ranges, which allows us to take into account the bones variability during growth. For vessels segmentation, we propose a patch-based deep learning approach using transfer learning, thus requiring few training data. The main contribution of this work is the design of a semi-automatic strategy for patches extraction, which allows the user to focus only on the vessels of interest for surgical planning. For bladder segmentation, we propose to use a deformable model approach that is particularly robust to image inhomogeneities and partial volume effects, which are often present in pediatric MRI images. All the developed segmentation methods are integrated in an open-source platform for medical imaging, delivering powerful tools and user-friendly GUIs to the surgeons. Furthermore, we set up a processing and portability workflow for visualization of the 3D patient specific models, allowing surgeons to generate, visualize and share within the hospital the patient specific 3D models. Finally, the results obtained with the proposed methods are quantitatively and qualitatively evaluated by pediatric surgeons, which demonstrates their potentials for clinical use in surgical planning procedures

Background. In the last years tissue engineering for cardiac pathologies has been broadly developed with the aim to restore or improve the diseased or damaged heart. Novel cardiac tissue engineering approaches combine the use of biocompatible scaffolds with stem cells to conjugate material science, surgery and cell therapy techniques. So far, different kinds of stem cells have been described and their potential for cardiac regeneration broadly investigated. We have previously described that it is possible to derive lines of broadly multipotent cells from the amniotic fluid (Amniotic Fluid Stem cells; AFS cells). The aim of this study was to characterize more in detail the AFS cells cardiomyogenic potential both in vitro and in vivo. Methods. Neonatal rat cardiomyocyte (rCM) cells were obtained by enzymatic digestion of 2-3-days old rat hearts. GFP-positive rat AFS (gfp+rAFS) cells were obtained from amniotic fluid samples from GFP-positive transgenic pregnant rats. Human AFS (hAFS) cells were obtained from healthy amniotic fluid back up samples from prenatal diagnosis, following informed consent. AFS cells were isolated by immunosorting for the stem marker c-kit. Before applying a tissue engineering approach, using biocompatible scaffolds, to the AFS and rCM cells coculture, the AFS cells “cardiomyocyte-like” phenotype, acquired in cocolture, had been functionally evaluated by patch-clamp analysis. In this work two different kinds of bidimensional micropatterned scaffolds were used: hydrogel films and PDMS (silicon) membranes. The scaffolds were obtained by microcontact printing technique and using a mold scratched with the desidered micropattern and their viability was tested using, at first, the rat neonatal primary culture. AFS and rCM cells were seeded together on the micropatterned PDMS membranes and analyzed for the expression of troponin T by immunostaining after 6 and 10 days of culture. For the in vivo study, immunodeficient nude male rats underwent a cryoinjury on the heart left ventricle with a 3D collagen scaffold implantation and 5x10e6 hAFS cells/animal local or systemic injection after 15 days. hAFS cells were previously labelled with the red intracellular fluorescent dye CMTMR. Animals were sacrificed at 24 hours, 15 and 30 days after cells injection and hearts stained for cardiac and inflammatory markers. For the acute myocardial infarct model, male Wistar rats underwent an ischemic injury by left anterior descendent coronary artery ligation for 30 minutes and then they were reperfused injecting via the external jugular vein 10e7 or 10e6 gfp+rAFS and 10e7 or 5x10e6 hAFS cells/animal for 2 hours; rats were sacrificed afterwards and hearts analyzed for infarct size measurement by Evans blue staining, by 2,3,5-triphenolltetrazolium chloride (TTC) staining and planimetry with the software Image J. Heart, lungs, spleen and liver were analyzed as well by immunostaining for evaluating hAFS cells content. hAFS cells were also analyzed for the presence of a subpopulation of cardiac progenitors, by RT-PCR analysis, for the expression of early cardiac commitment genes as Isl1 and Kdr. The cells were then studied by ELISA essay to speculate if they can secrete in the culture medium the protein thymosin beta 4, paracrine and cardioprotector factor. Results and Conclusions. Regarding the in vitro results, AFS cells were demonstrated to express a “pace maker cell-like” action potential, when cocultured with rat neonatal cardiomyocyte cells. Moreover, when cultured on the bidimensional scaffold, AFS cells showed to follow the longitudinal orientation of the microstruttured membrane, expressing beating activity and the cardiac protein troponin T. Our in vivo data revealed that hAFS cells, injected into the cryoinjured rat heart, survived in the host up to 30 days, moved from the injection site to the lesioned area in the heart and gave rise to new chimeric capillaries in the patch and cryoinjury area. In the acute myocardial infarct model the results obtained suggested that hAFS cells could exert a paracrine effect in vivo, decreasing the infarct size (measured as the ratio between the infarct area and the ischemic area at risk of necrosis) from a 53,9 ± 2,3% (obtained in control animals receiving PBS injection) to 40,0 ± 3,0% of the ischemic area. Furthermore, hAFS cells were also demonstrated to have a subpopulation of cardiac progenitors, positive for the expression of the early cardiac commitment genes Isl1 and Kdr and to to secrete in the culture medium thymosin beta 4, a paracrine factor previously shown to act as cardioprotector and angiogenic agent. In conclusions, our results are very encouraging and challenging, suggesting that AFS cells can show cardiomyogenic potential and cardioprotective therapeutic application in cell based therapy tissue engineering.

La dignità professionale infermieristica come concetto riferito all'opinione che si ha di se stessi come professionisti e all‘importanza che si attribuisce al ruolo e alle funzioni svolte, nei contesti sanitari, non ha una chiara definizione in letteratura. Si è cominciato ad indagare su tale costrutto da meno di 10 anni in ambito accademico. La dignità professionale è stata definita come una conquista che va oltre il ruolo professionale, in quanto, strettamente connessa alla dignità intrinseca di ogni essere umano. Gli ambienti di lavoro sono fondamentali per sentirsi riconosciuti, felici e rispettati nella propria dignità professionale, così come sono basilari i modelli di relazioni e di rispetto sia con se stessi che con gli altri. In generale, la dignità professionale è una particolare espressione del concetto di dignità umana connessa all'attività lavorativa. Partendo dal concetto di dignità sociale esplicitato da Nora Jacobson1 possiamo affermare che la dignità professionale infermieristica è l'espressione di questa dimensione nel lavoro. A differenza della dignità umana che come valore è intangibile e inalienabile e la si può solo violare, la dignità sociale è contingente e contestuale e può essere guadagnata, persa, violata o promossa. La dignità sociale ha due aspetti strettamente interconnessi, cioè, la dignità di sé e la dignità in relazione. La dignità di sé consiste nel rispetto di se stessi e del proprio valore, si identifica con alcune caratteristiche quali la fiducia verso la propria persona, l‘autostima e l‘integrità. La dignità in relazione, invece, si riferisce ai modi nei quali il rispetto e il valore sono comunicati, attraverso il comportamento individuale e collettivo. Le relazioni hanno una grande influenza sulla percezione del rispetto e del non rispetto della dignità professionale e lo sviluppo dell‘identità professionale risente di queste relazioni. Comprendere il significato, riconoscere e rispettare il valore della dignità professionale infermieristica ritengo possa contribuire alla trasformazione culturale degli ambienti di lavoro sanitari, favorendo un clima eticamente rispettoso, con una conseguente diminuzione degli errori e un miglioramento della qualità dell‘assistenza. Obiettivo generale del progetto dottorale: Con tale progetto si è inteso descrivere e analizzare le percezioni e le esperienze degli infermieri nei dipartimenti di chirurgia e medicina generale, riguardo la dignità professionale infermieristica per approfondire la comprensione del concetto, per meglio definirlo e articolarlo, specialmente nella sua dimensione sociale. Obiettivi specifici: 1. Mettere in risalto gli elementi del contesto lavorativo che incidono sulla definizione del concetto e sulla percezione della dignità professionale infermieristica; 2. Individuare le possibili strategie comportamentali e organizzative atte a migliorare il clima etico lavorativo, affinché i professionisti infermieri possano esprimere al meglio la propria professionalità, in termini di qualità del servizio fornito e migliorare la credibilità sociale del loro ruolo; 3. Porre in evidenza il punto di vista degli infermieri che lavorano nei setting di medicina e chirurgia in merito alla considerazione che loro stessi hanno del ruolo che rivestono e del lavoro che svolgono. Disegno di ricerca: La metodologia utilizzata è stata qualitativa, descrittiva e interpretativa; ha coinvolto infermieri in servizio nei setting di medicina e chirurgia, da più di un anno, in varie regioni italiane e in differenti nosocomi pubblici. Metodo: Per la raccolta dei dati si è utilizzata la tecnica dei focus group utile per ottenere informazioni su uno specifico argomento in un campo poco esplorato. Il campione propositivo, di convenienza, non probabilistico, si è ottenuto con il reclutamento di infermieri, coinvolti su base volontaria, in servizio presso i dipartimenti di medicina e chirurgia generale di alcuni ospedali pubblici in 12 regioni italiane, tra nord, centro e sud, includendo nell'area sud le isole della Sardegna e della Sicilia, al fine di ottenere un'eterogeneità dei dati. Nel complesso sono stati coinvolti 15 ospedali pubblici per un totale di 20 focus group. Ai focus group hanno preso parte 124 infermieri (96 donne e 28 uomini). I dati sono stati analizzati attraverso un approccio convenzionale interpretativo di tipo induttivo, che si caratterizza per la presenza di tre momenti principali: una fase di preparazione, una fase di organizzazione e una fase di reporting. Si sono analizzate 12.429 righe di testo, per un totale di 413 pagine in formato A4, con interlinea 1,5. In totale si sono estratti 1.411 codici o unità di analisi o di significato, creando un network concettuale induttivo sulla base delle similitudini e delle differenze, cosicché sono state estratte 49 sub-categorie e 17 categorie principali. Nella fase conclusiva sono state sviluppate sette aree tematiche. Risultati: Le sette aree tematiche che caratterizzano la dignità professionale infermieristica nei setting di medicina e chirurgia analizzati sono rappresentate da: la dignità inalienabile degli esseri umani; il contesto storico, sociale e culturale; l'evoluzione del contesto professionale infermieristico e i valori dell'identità professionale. Per quanto concerne gli elementi organizzativi del concetto sono emersi come significativi i temi legati: alle relazioni inter-professionali; alle relazioni intra-professionali e all'influenza dei fattori connessi all'ambiente lavorativo. Conclusioni: Gli ambienti organizzativi inclusi nel nostro studio, con il basso numero di professionisti nello staff infermieristico, con vincoli temporali stringenti e con faticoso sovraccarico lavorativo non sembrano promuovere il rispetto per la dignità professionale infermieristica. Negli ambienti sanitari esaminati, la collaborazione tra professionisti è ancora una questione aperta e tali ambienti, spesso, sono caratterizzati da un‘organizzazione lavorativa gerarchica ancora troppo ancorata ad antichi modelli gestionali e comportamentali. Anche se aspetti di innovazione sono visibili, una cultura professionale difensiva è ancora molto forte e dovrebbero essere intraprese misure di modernizzazione e riorganizzazione molto più veloci. Una di queste misure potrebbe consistere in una migliore attuazione dell‘educazione inter-professionale, inoltre, sarebbe necessario il coraggio morale per segnalare, perlomeno, i comportamenti più negativi e impropri messi in atto da alcuni professionisti sanitari. Limiti: Alcuni limiti individuati sono stati la mancanza di triangolazione dei metodi di raccolta dati, e l‘assenza di uno o due casi devianti (medici, fisioterapisti, ecc.) che avrebbero potuto contribuire con prospettive diverse alla definizione della dignità professionale infermieristica. Sviluppi futuri: In futuro, si potrebbero esplorare i vari elementi della dignità professionale infermieristica sia in altri setting sanitari, sia attraverso il coinvolgimento di personale medico o di altri professionisti sanitari. Inoltre, uno studio etnografico per osservare i comportamenti inter e intraprofessionali, potrebbe aiutare a comprendere l‘oggetto di indagine.

Dans ce travail, le concept d'approche mini-invasive est décrit dans sa globalité. Pour les chirurgiens pédiatres le concept a été analysé de manière systématique en répondant aux problématiques cliniques des patients dans tous les champs d'application. La somme de ce travail a le tour de force de répondre à toutes les grandes questions qui ont été posées lors des premiers temps de la coelioscopie pédiatrique, mais aussi de répondre, pour les plus récents, à des interrogations concernant les perspectives. Cette Thèse a donc pour objectif de développer l'évolution de la vidéochirurgie chez l'enfant et de mettre en valeur certaines applications que nous avons travaillées dans les différents domaines de la coelioscopie pédiatrique : tout d'abord dans la tolérance et la sécurité de la vidéochirurgie; puis ses applications en Chirurgie Digestive et Thoracique, en Rétropéritonéoscopie, en Oncologie et en Urologie ; mais aussi ses applications dans des techniques avancées de chirurgie néonatale ainsi que l'introduction de techniques encore moins invasives comme la chirurgie assistée par aimant ou des techniques non opératoires utilisées dans le traitement de certaines malformations de la paroi thoracique, en démontrant leurs bénéfices et leur efficacité
In this work, the concept of minimal invasive approach is described in its entirety. For pediatric surgeons, the concept was analyzed systematically meeting the clinical problems of patients in all fields of application. The result of this work is to answer all the big questions that were asked during the early days of the pediatric laparoscopy but also to respond to the latest questions about the perspectives. The goal of this thesis is to describe the evolution of laparoscopy in pediatric, and to report some applications. We have worked in several fields such as: Tolerance and safety of laparoscopy in advanced neonatal surgery, and its applications in Digestive Surgery, Thoracic, Retroperitoneoscopy, Oncology and Urology. This also introduces the use of less invasive techniques, such as magnet-assisted surgery of non-operative techniques in the correction on chest wall deformities, demonstrating their efficacity and efficiency

Les progrès continus de la recherche scientifique dans le domaine de la santé ont entraîné une augmentation de l'espérance et de la qualité de vie. Ainsi, le développement de nouveaux médicaments et des dispositifs médicaux a permis d'améliorer les conditions sanitaires et la prise en charge des patients au prix d'une inflation des dépenses de santé. Ces évolutions ont eu pour conséquences d'inciter les états à mettre en place des procédures d'évaluation de l'efficacité et de la gestion des risques liés à ces nouvelles approches thérapeutiques. Plus récemment, les restrictions budgétaires liées à la crise économique dans de nombreux pays de l'OCDE ont contraint les états à diminuer la part de leur budget consacré à la santé. Cette situation les a conduits à mettre en place des politiques de santé basées sur l'optimisation des ressources.En ce sens, l'évaluation médico-économique et la pharmaco-épidémiologie constituent pour les acteurs de santé et pour les décideurs politiques un outil d'analyse décisionnelle particulièrement légitime. Ils sont aujourd'hui de plus en plus intégrés dans les réflexions sur les stratégies de soins et dans la mise en place des programmes de santé. L'objectif de notre travail de recherche a été à travers deux projets, d'étudier l'intérêt de l'évaluation médico-économique et de la pharmaco-épidémiologie en chirurgie pédiatrique. Ainsi, dans une première partie plus théorique, une synthèse des différentes études de pharmaco-économie, de pharmaco-épidémiologie a été conduite et un état des lieux des études d'évaluation médico-économiques dans la chirurgie de l'enfant a été réalisé. Dans une seconde partie plus pratique, les deux projets concernant la chirurgie pédiatrique sont présentés :- Le projet 1 (pharmaco-économie) présente l'évaluation et l'analyse coût-efficacité dutraitement du reflux vésico-urétéral de grade modéré chez l'enfant.- Le projet 2 (pharmaco-épidémiologie) est une étude multicentrique prospective surl'épidémiologie de l'invagination intestinale aiguë de moins de 1 an (EPIstudy)
The continuing progress of scientific research in the field of health have led to increasingexpectancy and quality of life. Thus, the development of new medicines and medical deviceshave improved the health conditions and treatment of patients at the cost of inflation inhealth spending. These developments have effects for encouraging states to implementprocedures of effectiveness assessment and management of risks associated with these newtherapeutic approaches.More recently, budget cuts due to the economic crisis in many OECD countries havecompelled states to reduce the proportion of their budgets on health. This led them todevelop health policies based on resource optimization.In this sense, the health econoic evaluation and pharmacoepidemiology are for healthcarestakeholders and policy makers a tool for decisional analysis. They are now increasingly integrated into reflection on care strategies and the implementation of health programs. The objective of our research has been through two projects, to study the interest of the health economic evaluations and pharmacoepidemiology in pediatric surgery. Thus, in a first, theoretical part, it is a synthesis of various studies of pharmaco-economics, pharmacoepidemiology was conducted and an inventory of economic evaluation studies in pediatric surgery was performed. In the second part more convenient, both projects are presented in pediatric surgery :- Project 1 (pharmacoeconomic) presents evaluation and cost-effectiveness analysis oftreatment of moderate grade of vesicoureteral reflux in children.- Project 2 (Parmacoepidemiology) is a prospective multicenter study of theepidemiology of acute intussusception among infants (EPIstudy)

La coagulopathie induite par la circulation extracorporelle (CEC) chez les enfants porteurs d’une cardiopathie congénitale et bénéficiant d’une chirurgie cardiaque est complexe et multifactorielle. La prise en charge de ces enfants est délicate et doit être spécifique aux caractéristiques de cette population. De plus, cette prise en charge doit être multimodale, basée sur la prévention et le traitement précoce et ciblé.

Dans la première partie de ce mémoire, nous avons étudié la place de l’acide tranexamique, agent antifibrinolytique, dans la prévention de la fibrinolyse chez les enfants bénéficiant d’une chirurgie cardiaque avec CEC. Nous avons évalué les propriétés pharmacocinétiques et pharmacodynamiques de la molécule dans cette population particulière. Notre hypothèse étant que l’utilisation de schémas adaptés pourrait permettre d’optimaliser la balance bénéfice/risque de l’utilisation prophylactique de l’acide tranexamique.

Nous avons également développé un modèle expérimental susceptible d’améliorer la sensibilité des tests viscoélastiques pour la détection de la fibrinolyse et qui pourrait être utilisé pour estimer la concentration minimale d’acide tranexamique nécessaire pour inhiber la fibrinolyse.

Dans la seconde partie de ce mémoire, nous avons étudié l’importance de l’implémentation d’une prise en charge adaptée de la coagulopathie, en utilisant un algorithme défini en tenant compte des caractéristiques de la population cible. Si le ROTEM® s’avère être un outil important, son utilisation doit être limitée aux enfants qui présentent un saignement anormal afin de guider l’administration de produits hémostatiques. L’ensemble de nos travaux contribue à l’amélioration de nos connaissances dans la prise en charge de l’enfant à risque de saignement en période péri-opératoire de chirurgie cardiaque.
Doctorat en Sciences médicales
info:eu-repo/semantics/nonPublished

L’insuffisance rénale aiguë (IRA) représente une complication fréquente de lachirurgie cardiaque pédiatrique sous circulation extracorporelle (CEC). Son traitement resteessentiellement conservateur, visant à prévenir l’aggravation de l’atteinte rénale, ousubstitutif, par épuration extrarénale (EER). L’EER précoce améliore le pronostic des adultesen défaillance multiviscérale, mais ceci n’a pas été montré chez l’enfant après chirurgiecardiaque. Le diagnostic de l’IRA repose actuellement sur une diminution du débit defiltration glomérulaire (DFG), reflété par la hausse de la créatinine sérique (sCr), et laréduction de la diurèse. Ces critères traduisent une perte de la fonction glomérulaire ; orl’atteinte initiale dans l’IRA post-chirurgicale se situe au niveau tubulaire. Ces critères sontpeu spécifiques et tardifs, et risquent de retarder le diagnostic et la prise en charge de l’IRA.Des nouveaux biomarqueurs rénaux, traduisant la présence d’une lésion tubulaire, dont leNeutrophil Gelatinase-Associated Lipocaline urinaire (NGALu) est le plus populaire,permettraient un diagnostic plus précoce.Objectif. L’objectif de ce travail est triple : (i) explorer l’association entre le délai de la miseen route de l’EER et le pronostic à court et moyen terme chez le patient < 1an qui développeune IRA post-chirurgie cardiaque ; (ii) explorer les performances diagnostiques desvariations précoces de la sCr pour l’IRA sévère ; et (iii) explorer les performancesdiagnostiques de l’élévation de NGALu pour l’IRA sévère dans des populations similaires depatients < 1an.Méthode. Une cohorte monocentrique rétrospective de patients < 1an constituée sur 10 ansa servi pour étudier l’association entre le délai de la mise en route de l’EER et la survie àcourt et moyen terme. La technique de pondération inverse par le score de propension a étéutilisée afin de réduire le biais associé aux changements des pratiques inhérents à la longuepériode d’inclusion. Une deuxième cohorte monocentrique rétrospective de patients < 1anconstituée sur 3 ½ ans a servi pour étudier les performances diagnostiques des variationsprécoces de la sCr pour l’IRA sévère. Enfin, une troisième cohorte monocentriqueprospective de patients < 1an constituée sur 18 mois a servi pour étudier les performancesdiagnostiques de NGALu pour l’IRA sévère. Pour l’étude des deux biomarqueurs, sCr etNGALu, la méthodologie utilisée a été similaire : partition des trajectoires individuelles devariation, puis analyse de l’association avec un critère composite (recours à l’EER et/oudécès postopératoire) et définition du profil à faible risque d’IRA; enfin, utilisation de laméthodologie des courbes ROC et des tables de reclassification pour quantifier leursperformances diagnostiques respectives.Résultats. La mise en route de l’EER le jour de la chirurgie ou le lendemain a été associéeavec une augmentation d’environ 45% de la survie à 30 et 90 jours. La variation de la sCrdans les 2 jours suivant la chirurgie a été spécifique mais peu sensible et peu discriminantepour le diagnostic de l’IRA sévère ; le profil à faible risque, rencontré chez près de 50% despatients a été une diminution durable d’environ 25% de la sCr par rapport à la valeur basale.NGALu a été discriminant et prédictif pour le critère composite ; la concentration de NGALu aaugmenté dans les 2 heures suivant la chirurgie, et est restée élevée chez les patientsprésentant le critère composite.Discussion et conclusions. Si la prise en charge précoce par EER de l’IRA sévère est unepriorité en termes de pronostic chez le patient < 1an, alors il faut se munir de moyensdiagnostiques précoces et performants. La variation précoce de la sCr est peu sensible etpeu discriminante. En revanche, l’élévation précoce de l’NGALu présente d’excellentesperformances diagnostiques pour l’IRA sévère, faisant de NGALu un marqueur rénalprometteur dans la population < 1an bénéficiant d’une chirurgie cardiaque
Acute kidney injury (AKI) is common following congenital cardiac surgery withcardiopulmonary bypass (CPB). To date, no prophylactic intervention has proved to beuseful for the prevention of postoperative AKI. When AKI occurs, treatment is mainlysupportive and, when severe, requires renal replacement therapy (RRT). Several reportshave shown better outcome with early RRT in adults with multiorgan failure. No such data isavailable in children undergoing cardiac surgery, and criteria for RRT vary among centres.The definition of AKI is a reduction in the glomerular filtration rate (GFR), and the diagnosis isbased on an increase in serum creatinine (sCr) and a reduction in urine output; these arefunctional criteria, translating the consequences of glomerular injury. However, it iscommonly admitted that the first pathophysiologic finding in AKI following cardiac surgery istubular injury. Besides, the functional criteria are late, are not specific, and may delay thediagnosis of AKI. Novel AKI biomarkers, specific of tubular injury are available nowadays,with urine Neutrophil Gelatinase-Associated Lipocaline (uNGAL) being the most popular –they may allow for an early diagnosis of AKI.Objectifs. The aim of this work was: (i) explore associations between the delay to RRT, earlyand mid-term outcome in patients younger than 1 year of age who develop AKI followingcardiac surgery; (ii) assess the accuracy of early sCr variations and (iii) of uNGAL for severeAKI in two similar populations aged < 1 year.Methods. A single centre retrospective cohort of patients aged < 1 year undergoing surgeryover 10 years was used to asses the association between the delay to RRT et short and midtermsurvival. Inverse probability of treatment weighting was used to reduce bias due tochanges in practices that occurred during the long study period. A second retrospectivecohort of patients aged < 1 year undergoing surgery over 3 ½ years was used to asses theaccuracy of early sCr variations for the diagnosis of severe AKI. Finally, a third prospectivecohort of patients aged < 1 year undergoing surgery over 18 month was used to asses theaccuracy of uNGAL for the diagnosis of severe AKI. The study of both sCr and uNGAL useda similar methodology: first clustering of all individual trajectories of variation, enablingassessment of the association with a composite outcome (need for RRT and/or death) andidentification of the « normally expected » postoperative evolution of both sCr an uNGAL,associated with the best outcome; second, use of ROC curves and reclassification tables toassess the accuracy of each biomarker for the diagnosis of AKI.Results. Early RRT, initiated on the day of surgery or on day 1 following surgery, wasassociated with a 45% increase in 30-days and 90-days survival. Early sCr variation, within 2days of surgery, had a good specificity but was lacking sensitivity and discrimination for thediagnosis of severe AKI; the « expected » sCr evolution was a persistent 25% postoperativereduction relative to baseline. uNGAL had good discrimination and predictive ability for thecomposite outcome; uNGAL concentration increased within 2 hours of surgery, andremained high in patients with the composite outcome.Discussion and conclusions. If early RRT improves outcome in patients aged < 1 yearswith AKI following cardiac surgery, then it becomes important to perform an early diagnosisof severe AKI. To date, diagnosis of AKI is based on early sCr variations, but such variationslack sensitivity and discrimination for the diagnosis of severe AK. On the other hand, theincrease in uNGAL within hours of surgery has excellent accuracy for the diagnosis of severeAKI, making uNGAL a promising AKI biomarker in patients aged < 1 year undergoing cardiacsurgery with cardiopulmonary bypass

Des inégalités majeures sont reconnues dans le domaine de la santé bucco-dentaire chez les enfants avec troubles psychiques ou cognitifs. Les comportements d’opposition sont très fréquents. Les soins sont réalisés parfois dans des conditions difficiles. Ce travail étudie les enjeux éthiques retrouvés par le chirurgien-dentiste face au refus de soins chez ces enfants. Les objectifs sont : (1) d’exposer des éléments de contextualisation (2) de recenser les pratiques de soins à l’échelle nationale et internationale (3) de se concentrer sur les opinions et les perceptions des praticiens pour en dégager les lieux de tension éthique (4) de proposer une synthèse et une discussion. Deux enquêtes sur les pratiques de soins face au refus ont été menées auprès de chirurgiens-dentistes. Une démarche déductive a été conduite pour étudier des profils de praticiens selon leurs pratiques et les opinions qu’ils ont de ces pratiques (enquête quantitative en ligne) et analysée par AFM (Analyse Factorielle Multiple). Une démarche inductive à partir d’entretiens (focus groups) a été menée pour étudier la perception et l’opinion des praticiens. L’analyse de contenu thématique des discours a permis de comprendre les motivations et les difficultés rencontrées. La plupart des chirurgiens-dentistes s’inscrivent dans une démarche téléologique lorsqu’ils doivent choisir entre respect de l’autonomie et la bienfaisance. Néanmoins, si ces décisions contraintes sont imprégnées d’une conscience déontologique, cela garantit leur caractère éthique. Il serait nécessaire de développer la formation et l’éthique de la discussion pour concilier la double exigence technique et affective du soin
Children with intellectual disabilities experience major inequality in the field of oral health. Opposition behaviors are very common. The care is then carried out sometimes in difficult conditions. This work examines the ethical issues faced by the dentist in the refusal of care in children intellectual disabilities. The objectives are: (1) to expose elements of contextualisation (2) to identify the practices of dental care in a national and international contexte and to initiate the philosophical reflection (3) to focus on the opinions and perceptions of practitioners to explain these practices and to identify areas of ethical tension (4) to propose a synthesis and a discussion. Our research is based on two studies, each of which is directed at dentists who are specialists in special care dentistry in children. A deductive approach was conducted to study practitioner profiles according to their practices and the opinions they have of these practices (online quantitative survey) and analyzed by MFA (Multiple Factor Analysis). An inductive approach based on focus groups was conducted to study the perception and opinion of practitioners. The thematic content analysis made it possible to understand the motivations and difficulties encountered. The results showed that most dentists are part of a teleological approach when they have to choose between respect for autonomy and beneficence. Nevertheless, if these constrained decisions are impregnated with a deontological scruple, this guarantees their ethical character. It would be necessary to develop education and the ethics of the discussion to reconcile the dual technical and emotional requirements of care

Les fentes labio-palatines (FLP) sont la malformation cranio-faciale congénitale la plus fréquente. D'origine multifactorielle, elles sont la conséquence d'un défaut de fusion des bourgeons faciaux.Objectif et MéthodologieL'objectif de ce travail a été d'étudier la place des gènes de l'angiogenèse dans le cadre de la piste étiologique des FL/P. La méthodologie de ce travail comportait 3 étapes :- Une analyse systématique et exhaustive des gènes impliqués dans les FL/P comprenant les gènes identifiés mais aussi les gènes potentiellement impliqués.- Une analyse rétrospective des explorations génétiques des FL/P opérées au CHU de Reims entre 2003 et 2009.- La mise en place d'une analyse prospective (2009-2012, AOL) :- Génomique constitutionnelle par CGH Array- In situ au niveau des berges des fentes issues de déchets opératoires des chirurgies primaires des FL/P comprenant :Le développement d'un protocole de culture cellulaire de fibroblastesUne analyse anatomopathologiqueEt surtout le développement d'un modèle d'étude in vivo chez l'enfant d'analyse d'expression des gènes de l'angiogenèse.RésultatsL'analyse systématique des gènes impliqués dans les FL/P a mis en évidence 95 gènes dont plus d'une dizaine sont connus comme liés aux mécanismes d'angiogenèse (facteurs de croissance et protéases). Ces derniers sont en interaction entre eux mais aussi avec 18 autres gènes impliqués eux aussi dans les FL/P. Ainsi au total 1/3 des gènes d'intérêt sont soit des gènes de l'angiogenèse soit en lien avec eux.L'étude rétrospective nous a permis de mettre en exergue certaines formes cliniques originales qui ont été étudiées et publiées sous un angle « étiologique ».L'étude prospective nous a permis, après obtention des consentements, d'inclure 72 patients (30 FLP, 24FL, 18FP) opérés au CHU de Reims entre 2009 et 2012 d'une chirurgie primaire.Nous présentons :- nos résultats anatomopathologiques, et génétiques (CGH Array)- notre protocole de culture cellulaire- nos réflexions, notre cheminement aboutissant à la création du modèle d'étude d'analyse d'expression des gènes de l'angiogenèseDiscussionLa littérature a bien mis en avant une implication des phénomènes angiogéniques dans la constitution des FL/P par le biais des facteurs de croissance (TGFβ, PDGF C et Ra, FGF, TGFA, FGFR1, FGFR2 ; VEGF) et des protéases (MMP/TIMP2). L'ensemble de nos manipulations in situ nous permet aujourd'hui de disposer du matériel nécessaire pour l'étude de l'expression des facteurs impliqués dans l'angiogenèse sur les berges des fentes.Parallèlement, l'étude génomique constitutionnelle en CGH Array a permis de retrouver des variations non-connues comme polymorphiques chez 62% de nos patients. Des études familiales vont compléter notre travail. Elles permettront de savoir si ces CNV sont héritées ou De Novo et ainsi de préciser leur caractère bénin ou pathologique. L'identification chez un de nos patients d'une amplification, même de petite taille, du gène SKI (gène lié à la voie des TGFβ) nous encourage dans la poursuite de nos recherches d'anomalies constitutionnelles des gènes de l'angiogenèse dans les FL/PLa CGH array est une technique qui nous a paru particulièrement utile et fiable en terme de « scanning » et de dépistage.En conclusion, en pratique clinique, la découverte des anomalies préalablement certainement sous estimées par les cliniciens doit nous mener à une nouvelle réflexion sur le conseil génétique et sur l'utilité dans l'avenir d'un dépistage plus systématique
Cleft lip and palate (CLP) are the most common congenital craniofacial malformation. They have a multifactorial etiology and are the consequence of incomplete fusion of the facial buds.Objective and MethodologyThe objective of this work was to study the role of the genes of angiogenesis in the framework of studying the etiology of CL/P. Our methodological approach included 3 steps:- Systematic and thorough analysis of the genes involved in CL/P including identified genes but also genes that could be potentially involved.- A retrospective analysis of the operated clefts at the University Hospital of Reims between 2003 and 2009.- Implementation of a prospective analysis (2009-2012, AOL):- Constitutional genomic study by CGH Array- In situ with tissue specimens extracted from surgically excised cleft edges including:The development of a protocol for fibroblast cell culturesHistopathological analysisAnd above all the development of an in vivo study model in children for analyzing the expression of genes of angiogenesis.ResultsThe systemic analysis of genes involved in cleft lip palate unveiled 95 genes including about ten that are known to be related to angiogenesis mechanisms (growth factor and proteases). These genes interact between themselves but also with 18 other genes also involved in CL/P. In all, 1/3 of relevant genes are either angiogenesis-related genes or in direct relation with them.The retrospective study permitted to underline the some original clinical forms that were studied and published under an « etiological » angle.The prospective study included 72 patients (30 CLP, 24CL, 18CP), for whom we obtained informed signed consents, operated at the University Hospital of Reims between 2009 and 2012 for primary cleft surgery.We present:- Our histopathological and genetic results (CGH Array)- Our cell culture protocol (submitted for publication)- Our approaches and thought process behind the design of a study model for analyzing expression profiling of angiogenic genesDiscussionThe literature has highlighted the role of angiogenesis in the formation of cleft lip/palate via growth factors (TGFβ, PDGF C and Ra, FGF, TGFA, FGFR1, FGFR2, VEGF) and proteases (MMP/TIMP2). All our manipulations in situ have yielded the necessary material, i.e. edges of resected clefts, to study the expression of factors involved in cleft angiogenesis.In parallel, the constitutional genomic study in CGH Array enabled to uncover abnormalities in 62% of our patients. Family studies will complete our work. They will help to refine if these CNV are inherited or de novo and thus indicate their benign or pathological nature. In one of our patients, the identification of the SKI gene (related to the TGFβ pathway) encourages us to continue our research of genetic abnormalities of angiogenic genes involved in cleft lip/palate. CGH array appeared to be a very useful and reliable method in terms of scanning and screening.In conclusion, in clinical practice, the discovery of abnormalities which were probably underestimated by clinicians before, leads us to rethink the issue of genetic counseling and the relevance of a more systematic screening for these abnormalities in the future

AIM : Balanitis xerotica obliterans (BXO) is a chronic inflammatory skin disorder of unclear etiology, it is considered the male genital variant of lichen sclerosus. The etiology and the exact molecular mechanisms underlying the disease are still unknown. The histopathology of BXO is characterized by alterations in the epidermis and dermis as well as inflammatory cell infiltration. In this regard several factors may be involved in underling molecular changes associated with inflammatory response. Antiinflammatory drugs are commonly used in pre-operative setting to decrease the inflammatory/autoimmune response and for proper wound healing. Olive Oil Ozonides are used in several medical applications for its anti-inflammatory, anti-microbial and skin restoring properties. The human Transglutaminases (TGs) family consists of several proteins with catalytic activity essential for biological processes such as skin barrier formation and extracellular matrix assembly but can also contribute to the pathophysiology of various inflammatory , autoimmune and degenerative conditions. Given the key role played by TGs in the maintenance of epidermis integrity and extracellular matrix stability, the aim of this study was to investigate transcript levels of three TGs in foreskin of children underwent to surgery for phimosis without or with histologically confirmed BXO, to characterize the relationship between changes of TG levels and BXO and furthermore we evaluated the anti-inflammatory effects of treatment by assessing their effects on foreskin of patients with BXO. M&M. Thirty children with acquired phimosis were enrolled. The removed foreskins were sent both for the histological diagnosis and for the analysis of transcript levels of keratinocyte TG (TG1), tissue TG (TG2), epidermal TG (TG3) and IFN-γ, these were evaluated by quantitative Real-Time PCR .Furthermore, fifteen patients with BXO and previously treated by pediatrician with topical olive oil ozonides were compared with fifteen without any treatment. The foreskins were used to evaluate the transcript levels of pro-inflammatory cytokines, transglutaminase 2 (TG2), inducible nitric oxide synthase (NOS2), enzymes involved in the inflammatory process, as well as Vascular endothelial growth factor (VEGF) by Real-Time PCR. Results. We observed a significant increase in IFN-γ and TG2 mRNA levels by 2.8 and 2.9 folds (p<0.001), respectively, and a decrease in TG1 and TG3 transcripts by about 70% (p<0.001) in foreskin from patients with BXO (n=15) in comparison with patients without BXO (n=15). We observed a reduction by about 70% (p<0.001) in mRNA levels of cytokines, such IL-1β, TNF-α and INF–γ, as well as a decrease higher than 90% (p<0.001) in TG2 and NOS2 gene transcripts in tissues from Ozonides group. We also found an increase of 17 folds (p<0.001) in VEGF transcript in tissues treated with ozonides in comparison to untreated patients. Conclusion The reduced expression of TG1 and TG3 is associated with altered structure of foreskin in BXO and can be a consequence of damage to keratinocytes. Increased expression of TG2 and IFN-γ can be the result of chronic inflammation. TG2 overexpression can play a pivotal role in triggering and maintaining the inflammatory response in BXO patients. Our results suggest that pre-operatory treatment with Ozonides could provide a considerable benefit in terms of reduction of the inflammatory response in tissues with BXO. Additionally, the increased production of VEGF could stimulate a faster recovery and promote the healing process in patients undergoing surgery

The aim of this diploma thesis is to find out whether selected children aged 8-15 years are sufficiently educated about the course of the planned surgery in the Department of Pediatric Surgery at Kolín Hospital. In the theoretical part, I have described possible ways of communication with children aged 8 to 15, play therapy and the possibilities of its use, and perioperative care for children in childhood surgery at the Kolín hospital. I used the method of structured interviews with selected children between the ages of 8 and 15 who were hospitalized in the department of pediatric surgery for the planned surgery from June to September 2017. The practical part describes interviews with selected children. I used the interview results to prepare educational materials for children agend 4 to 10 years.

L’anémie est fréquente chez les patients pédiatriques en postopératoire de chirurgie cardiaque. Malgré le nombre important de patients transfusés, le taux d’hémoglobine (Hb) pour lequel les bénéfices surpassent les risques est inconnu chez ces patients. Récemment, Lacroix et al. ont démontré qu’une stratégie transfusionnelle restrictive n’était pas inférieure à une stratégie libérale en ce qui concerne le développement ou la progression du syndrome de défaillance multiviscérale (SDMV) et la mortalité chez les patients de soins intensifs pédiatriques (SIP).Devant le manque d’évidence, une analyse de sous-groupes des patients en postopératoire de chirurgie cardiaque de l’étude Transfusion Requirements in Pediatric Intensive Care (TRIPICU) a été réalisée. L’objectif de cette étude était de déterminer l’impact d’une stratégie transfusionnelle restrictive comparée à une stratégie libérale sur l’acquisition ou l’aggravation du syndrome de défaillance multiviscérale (SDMV) chez les enfants en postopératoire de chirurgie cardiaque. Cette étude n’a pas démontré de différences statistiquement, ni cliniquement significatives du nombre de patients ayant acquis ou aggravés un SDMV, ni des issues secondaires entre les stratégies transfusionnelles restrictive et libérale. L’analyse de sous-groupes permet de générer une hypothèse de recherche et les résultats devraient être confirmés par un essai randomisé contrôlé.
Anemia is frequent in pediatric patients following cardiac surgery. Despite frequent transfusions, the optimal hemoglobin threshold where benefits surpass risks is still unknown for these patients. Recently, Lacroix et al. showed that a restrictive transfusion strategy was not inferior to a liberal strategy concerning the development or progression of multiple organ dysfunction syndrome (MODS) and mortality in pediatric intensive care patients. In the absence of evidence, the aim of this study was to determine the impact of a restrictive versus a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome (MODS) in children following cardiac surgery. We conducted a subgroup analysis of the postoperative cardiac surgery patients of the Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) study. Our study showed no statistically and clinically significant differences in the number of patients who acquired or worsened MODS, nor secondary outcomes between a restrictive and a liberal transfusion strategy. This subgroup analysis generates a research hypothesis that should be confirmed by a randomized controlled trial.

L’anémie est fréquente chez les patients pédiatriques en postopératoire de chirurgie cardiaque. Malgré le nombre important de patients transfusés, le taux d’hémoglobine (Hb) pour lequel les bénéfices surpassent les risques est inconnu chez ces patients. Récemment, Lacroix et al. ont démontré qu’une stratégie transfusionnelle restrictive n’était pas inférieure à une stratégie libérale en ce qui concerne le développement ou la progression du syndrome de défaillance multiviscérale (SDMV) et la mortalité chez les patients de soins intensifs pédiatriques (SIP).Devant le manque d’évidence, une analyse de sous-groupes des patients en postopératoire de chirurgie cardiaque de l’étude Transfusion Requirements in Pediatric Intensive Care (TRIPICU) a été réalisée. L’objectif de cette étude était de déterminer l’impact d’une stratégie transfusionnelle restrictive comparée à une stratégie libérale sur l’acquisition ou l’aggravation du syndrome de défaillance multiviscérale (SDMV) chez les enfants en postopératoire de chirurgie cardiaque. Cette étude n’a pas démontré de différences statistiquement, ni cliniquement significatives du nombre de patients ayant acquis ou aggravés un SDMV, ni des issues secondaires entre les stratégies transfusionnelles restrictive et libérale. L’analyse de sous-groupes permet de générer une hypothèse de recherche et les résultats devraient être confirmés par un essai randomisé contrôlé.
Anemia is frequent in pediatric patients following cardiac surgery. Despite frequent transfusions, the optimal hemoglobin threshold where benefits surpass risks is still unknown for these patients. Recently, Lacroix et al. showed that a restrictive transfusion strategy was not inferior to a liberal strategy concerning the development or progression of multiple organ dysfunction syndrome (MODS) and mortality in pediatric intensive care patients. In the absence of evidence, the aim of this study was to determine the impact of a restrictive versus a liberal transfusion strategy on new or progressive multiple organ dysfunction syndrome (MODS) in children following cardiac surgery. We conducted a subgroup analysis of the postoperative cardiac surgery patients of the Transfusion Requirements in Pediatric Intensive Care Unit (TRIPICU) study. Our study showed no statistically and clinically significant differences in the number of patients who acquired or worsened MODS, nor secondary outcomes between a restrictive and a liberal transfusion strategy. This subgroup analysis generates a research hypothesis that should be confirmed by a randomized controlled trial.

La mastoïdite aiguë est l'une des complications les plus courantes de l'otite moyenne aiguë chez les enfants de moins de deux ans. Selon notre revue de la littérature, aucune directive nationale ou internationale ni étude prospective n’ont été émises concernant la sécurité des traitements de relai antibiotiques oraux ou intraveineux en période post-opératoire des mastoïdites aiguës sans complication intracrânienne. L’objectif de cette étude est de comparer les traitements antibiotiques post-opératoires oraux et intraveineux des mastoïdites aiguës sans complication intracrânienne chez l’enfant. Une étude de cohorte rétrospective par consultation de dossiers hospitaliers a été effectuée. Deux groupes d'enfants (n = 29) ayant subi une intervention chirurgicale appropriée, ont été comparés selon leurs données démographiques, selon le type d'antibiotiques utilisés en période postopératoire, selon la durée de leur hospitalisation ainsi que selon la prévalence des complications. Les deux groupes ont révélé des durées équivalentes d'hospitalisation et de traitement. Le groupe ayant reçu un traitement antibiotique intraveineux a présenté 14,3% de complications mineures (n = 2) et 7,1% de complications majeures (n = 1). Le groupe ayant reçu un traitement antibiotique oral a présenté 6,7% de complications mineures (n = 1) mais aucune complication majeure. Cette étude soutient l'idée que, dans la population pédiatrique, un drainage chirurgical adéquat des mastoïdites aiguës sans complication intracrânienne peut être suivi par un traitement antibiotique oral en toute sécurité avec des résultats similaires au traitement intraveineux post-opératoire.
Acute mastoiditis is one of the most common complication of acute otitis media in children under two years old. To our knowledge, neither guidelines have been published nor prospective study has compared the oral and intravenous post-operative antibiotic treatments of mastoïditis. Our objective was to compare the oral and intravenous post-operative treatments of pediatric acute mastoiditis without intracranial complication. A retrospective cohort study was done. Two groups of children (n = 29) diagnosed with acute mastoiditis without intracranial complication, who has been operated, were compared by the demographics, the type of antibiotics, the durations of hospitalization and postoperative treatment and the incidence of complications. Both groups had equivalent duration of hospitalization and postoperative treatment. The intravenous group had 14,3% of minor complications (n = 2) and 7,1% of major complications (n = 1). The oral group had 6,7% of minor complications (n = 1) without any major complication. This study supports the notion that, in the pediatric population, adequate surgical drainage of acute mastoiditis without intracranial complication can be followed by discharge with oral antibiotics to achieve the same satisfactory and safe outcomes of intravenous treatment.

L’hospitalisation d’un enfant pour une chirurgie cardiaque à cœur ouvert est un événement majeur dans la vie d’une famille. L’appréhension de l’acte chirurgical peut avoir de graves conséquences psychologiques et engendrer une anxiété élevée chez l’enfant, mais également chez ses parents. De nombreuses interventions ont été mises à l’essai afin de réduire cette anxiété préopératoire, mais il n’existe pas à ce jour de données probantes concernant le meilleur moyen de préparer ces familles à la chirurgie. Une étude qualitative d’inspiration phénoménologique dont le cadre de référence est le modèle d’intervention familiale de Wright et Leahey, (2013) a été effectuée, afin d’évaluer une préparation à la chirurgie par le jeu mettant en scène une poupée. À cette fin, des entretiens systémiques semi-structurés ont été menés auprès de dix familles ayant bénéficié de la préparation. L’étude a pris place au sein du service M3 de l’hôpital Marie Lannelongue. Les résultats de la recherche montrent que les familles dont l’enfant est hospitalisé pour une chirurgie cardiaque présentent un réel besoin en informations qui dépend de leurs expériences antérieures, de leur vécu et de leurs croyances. L’activité par le jeu doit donc s’adapter à ces paramètres afin de préparer efficacement les familles à la chirurgie. Cette étude permet de mieux comprendre l’expérience de ces enfants ainsi que de leurs parents. De plus, elle suggère des améliorations généralisables à d’autres interventions, afin que des services de soins puissent par la suite améliorer ou bâtir leurs propres programmes de préparation à la chirurgie.
Hospitalization of a child for open heart surgery is a major event in a family's life. Apprehension of the surgical procedure can have serious psychological consequences and cause high anxiety in the child, but also in his parents. Many interventions have been tried to reduce this preoperative anxiety, but there is no evidence to date on the best way to prepare these families for surgery. A phenomenological qualitative study with a reference framework of Wright and Leahey's family intervention model (2013) was conducted to evaluate a preparation for surgery using doll play. To this end, semi-structured systemic interviews were conducted with ten families who benefited from the preparation. The study took place within the M3 department of Marie Lannelongue Hospital. The results of the research show that families whose children are hospitalized for cardiac surgery have a real need for information that depends on their past experiences, experiences and beliefs. Activity through play must therefore adapt to these parameters in order to effectively prepare families for surgery. This study provides a better understanding of the experiences of these children and their parents. In addition, it suggests generalizable improvements to other interventions so that care services can subsequently improve or build their own surgical preparation programs.

Les pédiatres intensivistes ont plusieurs éléments disponibles pour guider leurs décisions par rapport à la ventilation mécanique. Par contre, aucune étude prospective ne décrit les éléments auxquels les intensivistes se réfèrent pour modifier les paramètres du respirateur. Objectifs : Décrire la pratique actuelle de la modification des paramètres du respirateur aux soins intensifs du CHU Sainte-Justine, un hôpital pédiatrique tertiaire. Hypothèse : 80% des modifications des paramètres du respirateur influant sur l’épuration du CO2 sont liées à l’analyse de la PCO2 ou du pH et 80% des modifications des paramètres d’oxygénation sont liés à l’analyse de l’oxymétrie de pouls. Méthodes : En se servant d’un logiciel de recueil de données, les soignants ont enregistré un critère de décision primaire et tous les critères de décision secondaires menant à chaque modification de paramètre du respirateur au moment même de la modification. Résultats : Parmi les 194 modifications des paramètres du respirateur influant sur l’épuration du CO2, faites chez vingts patients, 42.3% ±7.0% avaient pour critère primaire la PCO2 ou le pH sanguin. Parmi les 41 modifications de la pression expiratoire positive et les 813 modifications de la fraction d’oxygène inspirée, 34.1% ±14.5% et 84.5% ±2.5% avaient pour critère primaire l’oxymétrie de pouls, respectivement. Conclusion : Les médecins surestiment le rôle de la PCO2 et du pH sanguins et sousestiment le rôle d’autres critères de décision dans la gestion de la ventilation mécanique. L’amélioration de notre compréhension de la pratique courante devrait aider à l’éboration des systèmes d’aide à la décision clinique en assistance respiratoire.
Pediatric intensivists have a multiplicity of elements available to guide them in mechanical ventilator decision-making; however, no prospective studies describe which elements intensivists currently use to make ventilator setting changes. Objectives: We describe the current practice of ventilator setting modification in the intensive care unit at Sainte-Justine Hospital, a tertiary care pediatric hospital. Hypothesis: Eighty percent of ventilator settings affecting carbon dioxide clearance are based on the PCO2 or pH while eighty percent of settings affecting oxygenation are based on pulse oximetry. Methods: Caregivers recorded the primary element and any secondary elements leading to a ventilator setting change at the time of the change via a custom-designed data gathering software. Results: We included twenty patients. Of a combined 194 changes affecting CO2 clearance, 42.3% ±7.0% were in reference to blood PCO2 or pH. Of forty-one changes to positive end-expiratory pressure, 34.1% ±14.5% were in reference to pulse oximetry, as were 84.5% ±2.5% of the 813 changes to the fraction of inspired oxygen. Conclusion: Physicians over-estimate the role of blood pH and PCO2 in their ventilator management, while under-estimating the role of other elements. Improving our understanding of current practice patterns can help in the development of systems to aid in clinical decision-making in mechanical ventilation, improving clinical outcomes.

La transplantation hépatique est le seul traitement définitif des enfants ayant une hépatite fulminante sans résolution spontanée. L’évolution de cette maladie dans la population pédiatrique diffère de celle adulte, particulièrement en regard de l’encéphalopathie. Pour définir les indications de transplantation hépatique, plusieurs indicateurs précoces de pronostic furent étudiés chez les adultes. Ces indicateurs n’ont pu être transposés à la population pédiatrique. Objectif primaire : Déterminer les marqueurs de risque de mortalité des enfants recevant une transplantation hépatique pour une hépatite fulminante, se définissant par une insuffisance hépatique sévère sans antécédent au cours des huit semaines précédentes. Méthode : Il s’agit d’une étude rétrospective incluant tous les enfants ayant reçu une transplantation hépatique pour une hépatite fulminante à l’hôpital Sainte-Justine entre 1985 et 2005. Le score PELOD (Pediatric Logistic Organ Dysfunction) est une mesure de sévérité clinique d’un enfant aux soins intensifs. Il fut calculé à l’admission et avant la transplantation hépatique. Résultats : Quatorze enfants (cinq mois à seize ans) reçurent une transplantation hépatique pour une hépatite fulminante. Neuf enfants (64%) survécurent et cinq (36%) décédèrent. L’utilisation de la ventilation mécanique fut associée à un mauvais pronostic (p = 0,027). Entre l’admission et la transplantation hépatique, 88% des enfants ayant eu une variation du score PELOD inférieure à cinq survécurent. Tous ceux ayant eu une variation supérieure à cinq décédèrent. (p = 0,027) Conclusion : La variation du score PELOD pourrait aider à définir un indicateur précoce de l’évolution d’un enfant après une transplantation hépatique pour une hépatite fulminante.
Hepatic transplantation is the only definitive treatment for acute liver failure for those children who do not recover spontaneously. Early indicators of prognosis in acute liver failure have been studied in adults in order to define the indication for liver transplantation. The course of the disease in the pediatric population, particularly with respect to hepatic encephalopathy, differs from that in adults. Consequently, these criteria are not applicable to the pediatric population. Primary objective: To determine the risk markers for mortality in children receiving liver transplantation for acute liver failure. Liver failure is defined as being severe failure without prior liver disease within the last eight weeks. Method: A retrospective study was conducted with children who had received a liver transplantation for acute liver failure at Sainte-Justine’s Hospital between 1985 and 2005. Data including the PELOD (Pediatric Logistic Organ Dysfunction) Score, a clinical score (0-71) of illness severity in children in intensive care, were recorded from patients’ charts. Results: 14 children, aged from five months to sixteen years old, were transplanted for fulminant liver failure. Nine (64%) survived and five (36%) died. The need for mechanical ventilation was associated with a poorer survival (p= 0,027). Of all of the children who had a PELOD Score variation inferior to five, between admission and transplantation, 88% survived. None of those with a score variation superior to five survived (p=0,027). Conclusion: In our single centre study, the PELOD Score variation was a pre-transplant marker of mortality after liver transplantation for pediatric acute liver failure.

Introduction : La dysfonction diaphragmatique est très fréquente chez des patients adultes aux soins intensifs et elle est associée à des évolutions cliniques défavorables. Il n’y a pour l’instant aucune méthode reconnue pour évaluer la fonction du diaphragme chez l’enfant sous ventilation mécanique (VM), et aucune étude décrivant son évolution dans le temps chez cette population. Méthodes : Dans ce travail, nous avons évalué la fonction contractile du diaphragme chez des enfants sous ventilation invasive aux soins intensifs pédiatriques (SIP) et en salle d’opération (SOP). Pour ce faire, la pression au tube endotrachéal (Paw) et l’activité électrique du diaphragme (EAdi) étaient enregistrées simultanément lors de respirations spontanées pendant une brève manœuvre d’occlusion des voies respiratoires. Afin de prendre en compte la commande respiratoire, un ratio d’efficience neuro-mécanique (NME, Paw/EAdi) a d’abord été calculé puis validé par une analyse de variabilité. La fonction du diaphragme a ensuite été comparée entre les deux populations, et son évolution dans le temps au sein du groupe SIP décrite. Résultats : Le NME médian était la mesure de fonction diaphragmatique la plus fiable, avec un coefficient de variation de 23.7% et 21.1% dans les groups SIP et SOP, respectivement. Le NME dans le groupe SIP après 21 heures de VM (1.80 cmH2O/μV, IQR 1.25–2.39) était significativement inférieur à celui du groupe SOP (3.65 cmH2O/μV, IQR 3.45–4.24, p = 0.015). Dans le groupe SIP, le NME n’a pas diminué de façon significative pendant la VM (coefficient de corrélation -0.011, p = 0.133). Conclusion : La fonction diaphragmatique peut être mesurée au chevet des enfants sous VM par de brèves manœuvres d’occlusion. L’efficience du diaphragme était significativement plus élevée dans un groupe sain que dans une cohorte d’enfants critiquement malades, mais elle était stable dans ce groupe avec une commande respiratoire préservée. Dans le futur, les contributions relatives de la maladie critique et de la ventilation mécanique sur la fonction diaphragmatique devront être mieux caractérisées avant de procéder à l’évaluation de potentielles interventions visant à protéger le diaphragme.
Introduction : Diaphragmatic dysfunction is highly prevalent in adult critical care and is associated with worse outcomes. There is at present no recognized method to assess diaphragmatic function in children under mechanical ventilation (MV) and no study describing its evolution over time in this population. Methods : In this work, we have assessed the contractile function of the diaphragm in children under invasive MV in the pediatric intensive care unit (PICU) and in the operating room (OR). This was done by simultaneously recording airway pressure at the endotracheal tube (Paw) and electrical activity of the diaphragm (EAdi) over consecutive spontaneous breaths during brief airway occlusion maneuvers. In order to account for central respiratory drive, a neuro-mechanical efficiency ratio (NME, Paw/EAdi) was first computed and then validated using variability analysis. Diaphragmatic function was then compared between the two populations and its evolution over time in the PICU group described. Results : Median NME was the most reliable measure of diaphragmatic function with a coefficient of variation of 23.7% and 21.1% in the PICU and OR groups, respectively. NME in the PICU group after 21 hours of MV (1.80 cmH2O/μV, IQR 1.25–2.39) was significantly lower than in the OR group (3.65 cmH2O/μV, IQR 3.45–4.24, p = 0.015). In the PICU group, NME did not decrease significantly over time under MV (correlation coefficient -0.011, p = 0.133). Conclusion : Diaphragmatic function can be measured at the bedside of children under MV using brief airway occlusions. Diaphragm efficiency was significantly higher in healthy controls than in a cohort of critically ill children, but it was stable over time under MV in this group with preserved respiratory drive. In the future, the relative contributions of critical illness and mechanical ventilation on diaphragmatic function should be better characterized before evaluating potential interventions aimed at protecting the diaphragm.

Les accidents sont la cause la plus fréquente de décès chez l’enfant, la plupart du temps à cause d’un traumatisme cranio-cérébrale (TCC) sévère ou d’un choc hémorragique. Malgré cela, la prise en charge de ces patients est souvent basée sur la littérature adulte. Le mannitol et le salin hypertonique (3%) sont des traitements standards dans la gestion de l’hypertension intracrânienne, mais il existe très peu d’évidence sur leur utilité en pédiatrie. Nous avons entrepris une revue rétrospective des traumatismes crâniens sévères admis dans les sept dernières années, pour décrire l’utilisation de ces agents hyperosmolaires et leurs effets sur la pression intracrânienne. Nous avons établi que le salin hypertonique est plus fréquemment utilisé que le mannitol, qu’il ne semble pas y avoir de facteurs associés à l’utilisation de l’un ou l’autre, et que l’effet sur la pression intracrânienne est difficile à évaluer en raison de multiples co-interventions. Il faudra mettre en place un protocole de gestion du patient avec TCC sévère avant d’entreprendre des études prospectives. La transfusion sanguine est employée de façon courante dans la prise en charge du patient traumatisé. De nombreuses études soulignent les effets néfastes des transfusions sanguines suggérant des seuils transfusionnels plus restrictifs. Malgré cela, il n’y a pas de données sur les transfusions chez l’enfant atteint de traumatismes graves. Nous avons donc entrepris une analyse post-hoc d’une grosse étude prospective multicentrique sur les pratiques transfusionnelles des enfants traumatisés. Nous avons conclu que les enfants traumatisés sont transfusés de manière importante avant et après l’admission aux soins intensifs. Un jeune âge, un PELOD élevé et le recours à la ventilation mécanique sont des facteurs associés à recevoir une transfusion sanguine aux soins intensifs. Le facteur le plus prédicteur, demeure le fait de recevoir une transfusion avant l’admission aux soins, élément qui suggère probablement un saignement continu. Il demeure qu’une étude prospective spécifique des patients traumatisés doit être effectuée pour évaluer si une prise en charge basée sur un seuil transfusionnel restrictif serait sécuritaire dans cette population.
Trauma is the leading cause of death of children, with the burden of mortality related both to traumatic brain injury and hemorrhagic shock. Despite the frequency of trauma in the pediatric population, the management of these patients is often based on adult literature due the sparse amount of literature in pediatric trauma. The studies presented below were intended to establish current practice, and prepare for future prospective studies in pediatric trauma. The management of raised intracranial pressure (ICP) following traumatic brain injury (TBI) involves intracranial monitoring and the escalation of care to prevent secondary insults to the brain. Hyperosmolar therapy with mannitol (20%) and hypertonic saline (3%) are standard of care for the reduction of ICP, despite little evidence for their use. Our retrospective, single center study aimed to describe the clinical practice of hyperosmolar therapy in pediatric severe TBI, and its effect on ICP. We found that both mannitol and hypertonic saline are frequently used without a clear indication for one agent over another. There was insufficient power to confirm an effect on ICP, and multiple co-interventions given after boluses of hyperosmolar therapy may have contributed this lack of effect. In order to prospectively evaluate the effect of hyperosmolar therapy on ICP, a standardized approach to TBI care and hyperosmolar agents is necessary. Red blood cell transfusion is a key component of the management of the unstable trauma patient. Literature now suggests that transfusion is associated with increased mortality, and practices have shifted toward restrictive transfusion strategies in many clinical populations. We sought to describe the transfusion practices in pediatric trauma patients based on a secondary analysis of a large prospective study on blood loss in pediatric intensive care unit (PICU) patients. Compared to non-trauma patients, trauma patients were more likely to be transfused and transfused early in their course of stay. Younger age, higher PELOD and mechanical ventilation were associated with receiving a red blood cell transfusion in the PICU. Receiving a blood transfusion prior to PICU admission was most strongly associated with receiving a transfusion after PICU admission, suggesting ongoing bleeding in those transfused early. Future prospective studies geared specifically for trauma patients are necessary to determine whether osmotherapy for high ICP, and restrictive transfusion strategies can be applied to them, in order to improve the quality of the evidence based care provided to children.

Interleukin-2-Rezeptor-Antikorper (IL-2RA) sind monoklonale Anti-IgG-Antikörper, die den Interleukin-2-Rezeptor aktivierter T-Zellen blockieren und so zu einer signifikanten Reduktion von akuten Abstoßungsreaktionen (AR) nach Nierentransplantation führen. Ziel dieser Arbeit ist die Durchführung einer Meta-Analyse aller verfügbaren kontrollierten Studien, die Erwachsene und Kinder nach primarer Lebertransplantation mit einer Induktionstherapie mit IL-2RA behandelten und diese mit Placebo oder keiner Heilbehandlung verglichen. Die Meta-Analyse soll zeigen, dass durch IL-2RA-Gabe die AR, SRAR (steroidresistente AR), Tod des Patienten (D), Transplantatverlust (GL) sowie CNI- und Steroid-bedingte Nebenwirkungen durch Dosisreduktion signifikant reduziert werden. Sechs Studien mit pädiatrischen und 20 Studien mit adulten Transplantatempfängern erfüllten die Einschlusskriterien. Die Analyse der Endpunkte wurde mit dem Modell mit zufälligen Effekten durchgeführt. Die IL-2RA-Induktionstherapie kann als sicher und ohne signifikante Nebenwirkungen für mindestens zwölf Monate bei Patienten nach Lebertransplantation beurteilt werden. IL-2RA reduziert signifikant die AR bei pädiatrischen (RR 0,38 CI [0,22-0,66]; p=0,0126; NNT=4) und adulten Patienten (RR 0,83 CI [0,74-0,93]; p=0,0007; NNT=18) nach Lebertransplantation und SRAR bei adulten Patienten (RR 0,66 CI [0,48-0,91]; p=0,011; NNT=29). D und GL werden reduziert. In adulten Studien der Vergleichsgruppe delayed/reduced CNI wurden eine signifikante Reduktion der gepoolten renalen Dysfunktionen (RR 0,46; CI [0,27-0,78]; p=0,004; 5 Kohorten), des Serum-Kreatinin (MD -0,05; [0,11-0,01]; p=0,03; 3 Kohorten) sowie eine signifikante Steigerung der eGFR beobachtet. Bei adulten Patienten der Vergleichsgruppe no/low steroids zeigte sich eine signifikante Reduktion des PTDM (RR 0,42; CI [0,31-0,55]; p<0,0001; NNT=12) und des HTN (RR 0,49; CI [0,25-0,96]; p=0,04; NNT=11).

O presente Relatório de Atividade Clínica (RAC) reporta-se a todas as atividades clínicas desenvolvidas pela autora durante o curso de Medicina Dentária na Clínica Dentária Universitária da Universidade Católica Portuguesa (UCP), Instituto de Ciências da Saúde de Viseu. Este trabalho permitiu uma introspeção acerca dos conhecimentos adquiridos ao longo do curso, possibilitando a formação de uma base sólida de referências para o trabalho futuro. Foi efetuada uma análise estatística descritiva da amostra de pacientes cujo tratamento foi efetuado pelo binómio da autora, binómio 9. Esta análise foi realizada inicialmente de forma geral, sendo caracterizada em relação ao tipo de trabalho (distribuição por área disciplinar e segundo a ação da autora como operador/ajudante) e segundo as características individuais (género, antecedentes clínicos, hábitos de risco, estado periodontal, higiene oral e área geográfica). De seguida foi executada a análise específica para cada área disciplinar. Nomeadamente para as áreas de: Medicina Oral, Dentisteria Operatória, Periodontologia, Odontopediatria, Endodontia, Cirurgia Oral, Prótese Removível, Prótese Fixa, Oclusão e Ortodontia. Foram estudadas as especificações da amostra de cada uma, em relação ao diagnóstico, tipo de tratamento efetuado e nível de colaboração. Destacam-se três casos clínicos diferenciados que, por isso, terão uma abordagem específica dos restantes fazendo-se um desenvolvimento mais pormenorizado dos respetivos planos de tratamentos efetuados. No final do trabalho serão referidas as conclusões: aquisição e consolidação de conhecimentos e competências, relação médico-paciente e experiências vividas.
This Clinical Activity Report refers to all clinical activities developed by the author during the course of Dental Medicine at the University Dental Clinic of the Portuguese Catholic University (UCP) Institute of Health Sciences in Viseu. It allows introspection about the acquired knowledge, in order to create a solid base of references for future work. A descriptive statistical analysis was carried out on the sample of patients whose treatment was performed by the author's binomial, binomial 9. This analysis was initially performed in a general way, characterizing in relation to the type of work (distribution by disciplinary area and according to the author's action as operator / assistant) and according to individual characteristics (gender, clinical history, risk habits, periodontal status, oral hygiene and geographic area). Then, the specific analysis for each disciplinary area was performed. Particularly in the areas of: Oral Medicine, Dentistry, Periodontology, Pediatric Dentistry, Endodontics, Oral Surgery, Removable Prosthesis, Fixed Prosthodontics, Occlusion and Orthodontics. Were studied the sample specifications of each one, in relation to the determined diagnoses, type of treatment performed and level of collaboration. Differential clinical cases were highlighted, which, therefore will take a different approach from the others by making a more detailed development of the respective treatment plans carried out. At the end of the study, will be referred to the conclusions reached: acquisition and consolidation of knowledge and skills, doctor-patient relationship and experiences.

La prévalence du Staphylococcus aureus résistant à la méthicilline (SARM) a augmenté de façon dramatique dans les dernières années chez les patients atteints de fibrose kystique. Quoique le rôle du SARM dans la pathogénèse de l’atteinte respiratoire de la fibrose kystique ne soit pas clairement déterminé, certaines études récentes ont suggéré une association entre la persistance du SARM et le déclin accéléré de la fonction respiratoire. Cependant, l’importance clinique des diverses souches qui colonisent les patients atteints de fibrose kystique n’a pas encore été élucidée. Les objectifs de ce mémoire étaient de déterminer les effets d’une colonisation persistante par un SARM sur le statut clinique et respiratoire des enfants atteints de fibrose kystique. Également, nous tenions à étudier les caractéristiques des différentes souches de SARM dans cette population. Nous avons réalisé une étude rétrospective en analysant les données cliniques ainsi que les mesures de la fonction respiratoire chez les enfants atteints de fibrose kystique suivis à la Clinique de fibrose kystique du CHU Sainte-Justine entre 1996 et 2008 et ayant une colonisation persistante par un SARM. Afin de déterminer les souches qui colonisent cette population, nous avons effectué une caractérisation moléculaire des isolats du SARM. Nous avons identifié 22 patients avec une colonisation persistante par un SARM. Les résultats n’ont démontré aucun changement significatif en ce qui concernait le taux de déclin de la fonction respiratoire avant ou après l’acquisition du SARM. Cependant, la colonisation persistante par un SARM était associée à une augmentation du nombre d’hospitalisations pour une exacerbation pulmonaire. La plupart de nos patients étaient colonisés par le CMRSA-2, une souche épidémique au Canada. La présente étude suggère que la souche épidémique CMRSA-2 pouvait affecter l’évolution clinique des enfants atteints de fibrose kystique.
Over the last several years, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) has increased dramatically among cystic fibrosis (CF) patients. Although the exact role of MRSA in the pathogenesis of lung disease has not been clearly established, some studies suggest an association between persistent infection with MRSA and a more rapid rate of decline in lung function. It is uncertain whether all MRSA strains that infect CF patients are clinically important. The objectives of this thesis is to determine the effects of persistent MRSA on the clinical status and the lung function in children followed at the CF clinic at CHU Sainte-Justine and to characterize the MRSA strains in this population. We reviewed lung function measurements from subjects with persistent MRSA followed at our clinic between years 1996 and 2008. The first isolate from each patient was further characterized by molecular analysis. The results of the present study showed no significant difference for the rate of decline in lung function prior to and after MRSA colonization. However MRSA colonization was associated with an increased number of severe respiratory exacerbations requiring hospitalization. CMRSA-2, an epidemic clone in Canada, was found in the majority of our patients. This study suggests that persistent colonization with CMRSA-2 may affect the clinical outcome of children with cystic fibrosis.

L’acceptabilité d’un décès lors d’une simulation médicale reste débattue mais il existe peu de données sur la perspective des apprenants. Des médecins résidents ont effectué une pratique de code et ont rempli un questionnaire pré et post-simulation. Ils ont été exposés à deux scénarios où un bébé naissait sans signe de vie: 1. Nouveau-né ne répondant pas aux manœuvres de réanimation (DCD); 2. Nouveau-né s’améliorant avec une réanimation adéquate (REA). Les performances étaient évaluées à l’aide de la grille standardisée du Programme de Réanimation Néonatale. Le stress objectif (cortisol salivaire) et subjectif a été mesuré après le code. La rétroaction («feedback»), individuelle et en groupe, fut analysée à l’aide de méthodologies qualitatives. 59/62 apprenants ont répondu au questionnaire et 42 ont participé à la simulation. Tous les résidents trouvent les simulations bénéfiques et souhaitent y être exposés davantage. Le type et l’ordre des scénarios n’ont pas eu d’impact sur la performance. Un seul résident a interrompu les manœuvres de réanimation après 10 minutes d’asystolie, tel que recommandé, et 31% ont poursuivi après 20 minutes. Les participants trouvaient le scénario DCD plus stressant. Les niveaux de cortisol salivaire ont augmenté après les simulations (p<0.001) et ce, pour les deux scénarios. Cette augmentation était indépendante du scénario (p=0.06) et n’était pas associée à la performance. Les réponses à la question « Comment a été votre expérience? », ont permis d’identifier deux thèmes: 1. Le mannequin ne meurt pas en simulation médicale; 2. Le décès lors de la simulation signifie une réanimation inadéquate. Le décès lors d’une pratique de code est stressant, mais n’interfère pas avec la performance des soignants. Les apprenants trouvent cet exercice acceptable et bénéfique à leur pratique future.
The acceptability of simulated death has been debated by experts, but there is scarce information regarding trainees' perspective. Pediatric trainees were invited to perform medical simulation, including pre and post questionnaires. Participants were exposed to 2 mock codes of neonates born pulseless. In the RESUSC scenario, the manikin responded to adequate resuscitation; in the DEATH scenario, the manikin remained pulseless. Mock codes were evaluated using the Neonatal Resuscitation Program score sheet. Debriefing was analyzed using qualitative methodology. Salivary cortisol was collected from participants (objective stress). 59/62 trainees answered the questionnaire, and 42 performed mock codes. All trainees found mock codes beneficial and would appreciate being exposed to more. Scenario or order of scenario did not affect performance. Only one trainee stopped resuscitation after 10 minutes of asystole, as recommended by clinical guidelines of Neonatal Resuscitation Program (NRP), and 31% had not ceased resuscitation efforts by 20 minutes. Trainees found the DEATH scenario more stressful than RESUSC. Post-simulation salivary cortisol levels were significantly higher (p<0.001) than before simulation (for both scenario). This increase was not scenario dependent (p = 0.06) nor associated with performance scores. Trainees all answered the following question during debriefing: “How did this go for you?” Two themes were identified in their answers: 1. The manikin does not die; 2. Death equals inadequate resuscitation. The death of the manikin was stressful, but trainees thought this was acceptable and prepared them for their future. Having a mannequin die during simulation does not interfere with their performance.

Introduction: La ventilation non invasive (VNI) est un outil utilisé en soins intensifs pédiatriques (SIP) pour soutenir la détresse respiratoire aigüe. Un échec survient dans près de 25% des cas et une mauvaise synchronisation patient-ventilateur est un des facteurs impliqués. Le mode de ventilation NAVA (neurally adjusted ventilatory assist) est asservi à la demande ventilatoire du patient. L’objectif de cette étude est d’évaluer la faisabilité et la tolérance des enfants à la VNI NAVA et l’impact de son usage sur la synchronie et la demande respiratoire. Méthode: Étude prospective, physiologique, croisée incluant 13 patients nécessitant une VNI dans les SIP de l’hôpital Ste-Justine entre octobre 2011 et mai 2013. Les patients ont été ventilés successivement en VNI conventionnelle (30 minutes), en VNI NAVA (60 minutes) et en VNI conventionnelle (30 minutes). L’activité électrique du diaphragme (AEdi) et la pression des voies aériennes supérieures ont été enregistrées pour évaluer la synchronie. Résultats: La VNI NAVA est faisable et bien tolérée chez tous les enfants. Un adolescent a demandé l’arrêt précoce de l’étude en raison d’anxiété reliée au masque sans fuite. Les délais inspiratoires et expiratoires étaient significativement plus courts en VNI NAVA comparativement aux périodes de VNI conventionnelle (p< 0.05). Les efforts inefficaces étaient moindres en VNI NAVA (résultats présentés en médiane et interquartiles) : 0% (0 - 0) en VNI NAVA vs 12% (4 - 20) en VNI conventionnelle initiale et 6% (2 - 22) en VNI conventionnelle finale (p< 0.01). Globalement, le temps passé en asynchronie a été réduit à 8% (6 - 10) en VNI NAVA, versus 27% (19 - 56) et 32% (21 - 38) en périodes de VNI conventionnelle initiale et finale, respectivement (p= 0.05). Aucune différence en termes de demande respiratoire n’a été observée. Conclusion: La VNI NAVA est faisable et bien tolérée chez les enfants avec détresse respiratoire aigüe et permet une meilleure synchronisation patient-ventilateur. De plus larges études sont nécessaires pour évaluer l’impact clinique de ces résultats.
Introduction: The need for intubation after noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient’s neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort. Methods: This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine’s Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony. Results: NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study early because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both p< 0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values): 0 (0 - 0) in NIV-NAVA versus 12% (4 - 20) and 6% (2 - 22) in initial and final conventional NIV, respectively (p< 0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 - 10) in NIV-NAVA, versus 27% (19 - 56) and 32% (21 - 38) in initial and final conventional NIV, respectively (p= 0.05). No difference in term of respiratory effort was noted. Conclusion: NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings.

Introduction : La mortalité associée à l’insuffisance rénale aiguë (acute kidney injury ‘’AKI’’) aux soins intensifs pédiatriques (SIP) dépasse les 50%. Des études antérieures sur la thérapie de remplacement rénal (TRR) ont fait ressortir plusieurs facteurs de risque de mortalité dont le syndrome de défaillance multiviscérale (SDMV) et la surcharge liquidienne ≥ 10 à 20% avant l’initiation de la TRR. L’objectif de cette étude était d’identifier les principaux facteurs de risque de mortalité à 28 jours après l’initiation de la TRR chez les patients atteints d’AKI aux SIP. Méthode : Il s’agit d’une étude de cohorte rétrospective aux SIP d’un centre tertiaire. Tous les enfants ayant reçus de la TRR continue ou de l’hémodialyse intermittente pour AKI, entre janvier 1998 et décembre 2014, ont été inclus. Les facteurs de risque de mortalité ont été préalablement identifiés par quatre intensivistes et deux néphrologues pédiatres et analysés à l’aide d’une régression logistique multivariée. Résultats : Quatre-vingt-dix patients ont été inclus. L’âge médian était de 9 [2-14] ans. La principale indication d’initiation de la TRR était la surcharge liquidienne (64,2%). La durée médiane d’hospitalisation aux SIP était de 18,5 [8,0-31,0] jours. Quarante patients (44,4%) sont décédés dans les 28 jours suivant l’initiation de la TRR et quarante-cinq (50,0%) avant la sortie des SIP. Le score de PELOD ≥ 20 (OR 4,66 ; 95%CI 1,68-12,92) et la surcharge liquidienne ≥ 15% (OR 9,31; 95%CI 2,16-40,11) à l’initiation de la TRR étaient associés de façon indépendante à la mortalité. Conclusion : Cette étude a permis de faire ressortir deux facteurs de risque de mortalité à 28 jours à l’initiation de la TRR : la surcharge liquidienne et la sévérité du SDMV mesurée par le score de PELOD.
Introduction: Mortality rate associated with acute kidney injury (AKI) in pediatric intensive care units (PICU) exceeds 50%. Prior studies on renal replacement therapy (RRT) have highlighted different mortality risk factors including the presence of a multiple organ dysfunction syndrome (MODS) and fluid overload ≥ 10 to 20% before starting RRT. The aim of this study was to identify most important risk factors of 28-day mortality in patients with AKI at RRT initiation in PICU. Methods: We conducted a retrospective cohort study in a tertiary care pediatric center. All critically ill children who underwent acute continuous RRT or intermittent hemodialysis for AKI between January 1998 and December 2014 were included. A case report form was developed and specific risk factors were identified by a panel of four pediatric intensivists and two nephrologists. Risk factors analysis was made using logistic regression in SPSS and SAS software. Results: Ninety patients were included. The median age was 9 [2-14] years. The most common indication for RRT initiation was fluid overload (FO) (64.2%). The median PICU length of stay was 18.5 [8.0-31.0] days. Forty of the 90 patients (44.4%) died within 28 days after RRT initiation and forty-five (50.0%) died before PICU discharge. In a multivariate logistic regression analysis, a PELOD score ≥ 20 (OR 4.66; 95%CI 1.68-12.92) and percentage of FO ≥ 15% (OR 9.31; 95%CI 2.16-40.11) at RRT initiation were independently associated with mortality. Conclusion: This study suggests that fluid overload and severity of MODS measured by PELOD score are two risk factors of 28-day mortality in PICU patients on RRT.