A High-Grade Lachman's Exam Predicts a Ramp Tear of the Medial Meniscus in Patients with Anterior Cruciate Ligament Tear: A Prospective Clinical and Radiological Evaluation

Background: Medial meniscus ramp tears are present in 22.9-40.8% of anterior cruciate ligament tears. The diagnosis of ramp tears is difficult on MRI, with sensitivity reported around 48%, which has recently emphasized the importance of proper arthroscopic probing for ramp tears. Methods: A prospective evaluation was performed on patients undergoing a single bundle ACL reconstruction to assess patient demographics, posterior tibial slope, posterior cruciate ligament angle, Lachman's exam, and rotational instability to determine secondary findings associated with medial meniscal ramp tears. Results: A total of 96 patients underwent ACL reconstruction, of these, 63 patients had an isolated ACL tear, and 33 patients had an ACL tear with a concomitant medial meniscus ramp tear. A high-grade Lachman's exam and male sex were associated with medial meniscus ramp tears. There were no differences in posterior tibial slope, posterior cruciate ligament angle, or rotational instability between groups. Conclusions: This study found that a high-grade Lachman's exam and male sex were significantly associated with patients with an ACL tear with a concomitant medial meniscus ramp tear. These findings suggest that an ACL tear with concomitant medial meniscus ramp tear may be better diagnosed based upon the clinical evaluation rather than other secondary radiological findings.

Role of fibular autograft in ankle arthrodesis fixed using cannulated screws: a proportional meta-analysis and systematic review

Ankle arthrodesis is commonly performed to treat end-stage ankle osteoarthritis. The aim of this study was to determine whether the use of fibular autograft might increase the fusion rate and decrease the complication rate in ankle arthrodesis (AA) fixed using cannulated screws. To perform this PRISMA-compliant proportional meta-analysis, multiple databases were searched for studies in which patients undergone AA (using exclusively cannulated screws and augmented with fibular bone graft) were followed. The characteristics of the cohort, the study design, surgical details, the nonunion and complication rate at the longest follow-up were extracted and recorded. The modified Coleman Methodology Score (mCMS) was applied to appraise the quality of studies. Two groups were built: arthrodeses fixed with screws combined with cancellous autograft (G1) and arthrodeses fixed with screws combined with cancellous autograft and augmented with a lateral fibular onlay (G2). A third group (arthrodeses fixed with screws and no graft, G3) was extracted from previous literature for a further comparison. Overall, we included 306 ankles (296 patients) from ten series (ten studies). In G1 and G2 there were 118 ankles (111 patients) and 188 ankles (185 patients), respectively. In patients where cancellous autograft was used, a further augmentation with a fibular lateral strut autograft did not change significantly the nonunion (4% [95% CI 1-9] in G1 vs. 2% [95% CI 0-5) in G2, p = 0.99) nor the complication rate (18% [95% CI 0-36] in G1 vs. 13% [95% CI 6-21) in G2, p = 0.71). Upon comparison with 667 ankles (659 patients, G3) in which arthrodeses had been performed without grafting, the nonunion and complication rates did not differ significantly either (pooled estimates: 3% [95% CI 1-3) in G1 + G2 vs. 3% [95% CI 2-4] in G3, p = 0.73 for nonunion; 15% [8-23] in G1 + G2 vs. 13% [95% CI 9-17] in G3, p = 0.93 for complications). In ankle arthrodesis fixed with cannulated screws combined with cancellous autograft at the fusion site, a construct augmentation with a distal fibular onlay strut graft positioned laterally at the ankle joint does not reduce the risk of nonunion or complication. In general, the use of bone graft does not influence significantly the nonunion nor the complication rate as compared to non-grafted screw-fixed ankle arthrodeses.Kindly check and confirm the corresponding author mail id is correctly identified.It's all correct.

Periprosthetic joint infection in total ankle replacement: which are the current diagnostic criteria?

BACKGROUND AND AIM

Periprosthetic joint infection (PJI) is among the most common complications of Total Ankle Replacement (TAR) and its management may be challenging. We set out to define which are the criteria currently used to diagnose PJI after TAR.

METHODS

This PRISMA-compliant systematic review was registered in the Open Science Framework. Multiple databases were searched including clinical studies in which PJI after TAR was diagnosed and treated. Data were harvested regarding the cohort, the study design and the diagnostic criteria for PJI. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS).

RESULTS

Six papers (122 infected TARs) published between 2012 and 2022 were included in this review. Ankle pain with swelling and unexplained increased local temperature were the most common clinical findings leading to a suspicion of PJI. In 100% of cases the diagnosis was confirmed through synovial fluid analysis associated with positive blood tests. In all the revision surgeries intraoperative cultures (at least 3) were performed. In 109 ankles (90%) there was a microbiological isolation. Out of these, 38 (35%) were single organism infections by Staphylococcus coagulase negative and 37 (34%) were single organism infections by Staphylococcus Aureus. The mean mCMS was 37.6 out of 100.

CONCLUSIONS

There is a lack of diagnostic criteria specific for PJI after TAR. Clinical and laboratory tests inspired to the knowledge in total knee and total hip arthroplasty are generally adopted in the field of ankle arthroplasty. The quality of evidence for studies included in this review was poor.

Long-term longitudinal study on swine VML model

BACKGROUND

Volumetric Muscle Loss (VML), resulting from severe trauma or surgical ablation, is a pathological condition preventing myofibers regeneration, since skeletal muscle owns the remarkable ability to restore tissue damage, but only when limited in size. The current surgical therapies employed in the treatment of this pathology, which particularly affects military personnel, do not yet provide satisfactory results. For this reason, more innovative approaches must be sought, specifically skeletal muscle tissue engineering seems to highlight promising results obtained from preclinical studies in VML mouse model. Despite the great results obtained in rodents, translation into human needs a comparable animal model in terms of size, in order to validate the efficacy of the tissue engineering approach reconstructing larger muscle mass (human-like). In this work we aim to demonstrate the validity of a porcine model, that has underwent a surgical ablation of a large muscle area, as a VML damage model.

RESULTS

For this purpose, morphological, ultrasound, histological and fluorescence analyses were carried out on the scar tissue formed following the surgical ablation of the peroneus tertius muscle of Sus scrofa domesticus commonly called mini-pig. In particular, the replenishment of the damaged area, the macrophage infiltration and the vascularization at different time-points were evaluated up to the harvesting of the scar upon six months.

CONCLUSION

Here we demonstrated that following VML damage, there is an extremely poor regenerative process in the swine muscle tissue, while the formation of fibrotic, scar tissue occurs. The analyses performed up to 180 days after the injury revealed the development of a stable, structured and cellularized tissue, provided with vessels and extracellular matrix acquiring the status of granulation tissue like in human.

Tetra-block: ultrasound femoral, lateral femoral-cutaneous, obturator, and sciatic nerve blocks in lower limb anesthesia: a case series

BACKGROUND

The gold standard anesthesiologic procedure for urgent femur fracture surgery is Spinal Anesthesia. It is not always feasible because of patients' severe comorbidities and difficulties in optimizing drug therapy in the appropriate time frame such as discontinuation of anticoagulant drugs. The use of four peripheral nerve blocks (tetra-block) can be a winning weapon when all seems lost.

CASE PRESENTATION

We present, in this case series, three Caucasian adult femur fractures (an 83-year-old woman, a 73-year-old man, and a 68-year-old woman) with different and major comorbidities (cardiac or circulatory disorders on anticoagulants therapy that were not discontinued on time; breast cancer and others) underwent the same anesthesiologic approach in the urgent setting. Ultrasound peripheral nerve blocks, that is femoral, lateral femoral cutaneous, obturator, and sciatic with parasacral approach were successfully performed in all patients who underwent intramedullary nailing for intertrochanteric fracture. We evaluated the adequacy of the anesthesia plane, postoperative pain control with the VAS scale, and the incidence of postoperative side effects.

CONCLUSIONS

Four peripheral nerve blocks (Tetra-block) can be alternative anesthesiologic management in urgent settings, in patients where drug therapy cannot be optimized, as in antiplatelet and anticoagulant therapy.

Role of lateral soft tissue release in percutaneous hallux valgus surgery: a systematic review and meta-analysis of the literature

BACKGROUND

It is unclear whether lateral soft tissue release (LSTR) is required as part of percutaneous hallux valgus (PHV) surgery. The primary aim of this systematic review was to assess whether LSTR reduces the risk of recurrence of hallux valgus deformity. The secondary aims were to assess if LSTR increases the risk of complications, improves the clinical outcome and leads to a greater radiographic correction.

METHODS

We performed a PRISMA-compliant PROSPERO-registered systematic review, pooling clinical papers reporting results after PHV surgery into two categories (PHV with (Group 1, G1) and without LSTR (Group 2, G2)) and comparing them. Data regarding the study design, demographics, the surgical procedure and the clinical and radiological outcome were extracted and compared. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS).

RESULTS

Sixteen studies were selected (G1:594 feet; G2:553 feet). The pooled proportion of recurrence at a minimum 21-month follow-up (2%, 95%CI 0-3 vs 2%, 95%CI 0-5; p = 0.70) did not differ in the two groups. Similarly, the pooled proportion of complications (27%, 95%CI 17-38 vs 25%, 95%CI 12-37; p = 0.79) was similar. The pre- (p = 0.23) and post-operative AOFAS scores (p = 0.16), the pre-(HVA: p = 0.23) (IMA: p = 0.94) and post-operative radiological angles (HVA: p = 0.47) (IMA: p = 0.2) and the methodological quality of studies (p = 0.2) did not differ either between G1 and G2.

CONCLUSION

There is no evidence that LSTR performed during percutaneous HV surgery reduces the risk of recurrence of the deformity at a mean 4-year follow-up nor improves the clinical and radiological outcome.

LEVEL OF EVIDENCE

Level IV systematic review of Level I to IV studies.

Does the Number of Screws Influence the Union Rate in Ankle Arthrodesis? A Meta-analysis and Systematic Review

OBJECTIVE

The purpose of this study was to determine whether the number of cannulated screws used during ankle arthrodesis (AA) might influence the union and complication rate.

METHODS

In this Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant PROSPERO-registered systematic review, multiple databases were searched including studies in which patients undergone AA using cannulated screws as exclusive fixation method were followed. Data were harvested regarding the cohort, the study design, the surgical technique, the nonunion, and complication rate at the longest follow-up. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Two groups were built (arthrodeses fixed with 2 screws [group 1, G1] vs arthrodeses fixed with 3 screws [group 2 G2]) and compared.

RESULTS

Fifteen series of patients from 15 studies (667 ankles) were selected (G1 = 458 ankles and G2 = 209). The pooled proportion estimate revealed a similar nonunion rate in the 2-screw group as compared with the 3-screw group (4% vs 3%; P = .68). The pooled proportion of complications was higher in G1 (19%) than in G2 (8%), but it was not significantly different either (P = .45). After exclusion of "symptomatic hardware and screw removal," the difference was still not significant (P = .28) although it resulted lower in G1 than in G2 (4% vs 8%, respectively).

CONCLUSIONS

Using 3 cannulated screws during AA as compared with a 2-screw construct does not significantly reduce the risk of nonunion nor the risk of complications.

LEVEL OF EVIDENCE

Level IV, Systematic review of level IV.

Analysis of the 50 Most Cited Articles on Achilles Tendon Injury

Background

Achilles tendon injuries represent one of the most common reasons for referral to orthopaedic surgeons.

Purpose

To outline the characteristics, examine trends in publication, and evaluate the correlation between citations and study quality of the 50 most cited articles on Achilles tendon injury.

Study Design

Cross-sectional study.

Methods

After searching the Web of Science for articles published in orthopaedic journals, we identified the 50 most cited articles on Achilles tendon injury and abstracted their characteristics. Risk of bias was assessed using the modified Coleman Methodology Score (mCMS). Multiple bivariate analyses (Pearson or Spearman correlation coefficient) were used to evaluate the association among number of citations, citation rate (citations/year), 2020 journal impact factor (JIF), year of publication, level of evidence (LoE), study type (tendon rupture or chronic tendinopathy), sample size, and mCMS.

Results

The top 50 articles were cited 12,194 times. Each article had a mean ± SD 244 ± 88.8 citations (range, 157-657) and a citation rate of 12.6 ± 5.4 per year (range, 3-28). A total of 35 studies (70%) were published between 2000 and 2010. The citation rate of the 16 most recent studies was almost double that of the 16 oldest studies (17.5 vs 9.9; P < .001). Nineteen studies (49%) were classified as having poor quality (mCMS <50 points). The mean JIF of the 9 journals that published the studies was 5.1. The citation rate correlated with the number of citations (r = 0.56; P < .001), publication year (r = 0.60; P < .001), and LoE (r = -0.44; P = .005). The publication year correlated with the LoE (r = -0.40; P = .01). Study quality in terms of mCMS correlated with the JIF (r = 0.35; P = .03) and LoE (r = -0.48; P = .003) but not the citation rate (P = .15).

Conclusion

The mean LoE and the citation rate of the most cited articles on Achilles tendon injury both significantly increased over time. Although the JIF was positively correlated with study quality, almost half of the studies had poor-quality methodology.

Bösch osteotomy for hallux valgus correction: results at a mean 10-year follow-up

INTRODUCTION

Bösch osteotomy (BO), which is a first metatarsal subcapital osteotomy stabilised with a K-wire, is a surgical option to correct hallux valgus (HV). The aim of this study was to assess the long-term clinical and radiographic results in a cohort of patients treated at our institution with such osteotomy.

METHODS

In this retrospective monocentric single-surgeon cohort study, we included 58 HVs (46 patients) who underwent HV correction by BO and were followed at a minimum of 7 years. The range of motion (ROM), the American Orthopaedic Foot and Ankle Society's Forefoot scale (AOFAS-FS) and the Visual Analogic Scale (VAS) for pain were recorded. On weightbearing radiographs, the Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA), the Distal Metatarsal Articular Angle (DMAA), and the Lateral Sesamoid Position (LSP) were measured and compared with pre-operative values. The complication rate and first metatarsophalangeal joint stiffness were also assessed.

RESULTS

At a mean follow-up of 10 ± 2 (7-17) years, mean ± standard deviation AOFAS-FS and VAS were 89 ± 11 (67-93) and 2.1 ± 2.8 (0-7) points, respectively. In 42 (72%) cases there was no limitation in the choice of footwears. Radiographically, we found a significant improvement in the HVA (from 33.9° ± 6.7 to 18.8° ± 5.6, p < 0.001), in the IMA (14.2° ± 3.1 to 9.4° ± 2.7, p < 0.001), in the DMAA (from 30.3° ± 6.8 to 11.5° ± 5.1, p < 0.001) and in LSP (median value from 3 to 1, p < 0.001). In 36 (62%) cases the ROM was greater than 75° while in 22 (38%) it ranged between 30° and 75°. Minor complications occurred in six (10%) cases, which did not require any further surgery at the longest follow-up.

CONCLUSION

Bösch technique provided satisfactory clinical and radiographic outcomes in the treatment of hallux valgus which persisted at a mean 10-year follow-up. The complication rate did not differ from more recent techniques described in literature.

LEVEL OF EVIDENCE

Level IV, retrospective cohort study.

Statistical and agent-based modelling of the transmissibility of different SARS-CoV-2 variants in England and impact of different interventions

The English SARS-CoV-2 epidemic has been affected by the emergence of new viral variants such as B.1.177, Alpha and Delta, and changing restrictions. We used statistical models and the agent-based model Covasim, in June 2021, to estimate B.1.177 to be 20% more transmissible than the wild type, Alpha to be 50-80% more transmissible than B.1.177 and Delta to be 65-90% more transmissible than Alpha. Using these estimates in Covasim (calibrated 1 September 2020 to 20 June 2021), in June 2021, we found that due to the high transmissibility of Delta, resurgence in infections driven by the Delta variant would not be prevented, but would be strongly reduced by delaying the relaxation of restrictions by one month and with continued vaccination. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Statistical and agent-based modelling of the transmissibility of different SARS-CoV-2 variants in England and impact of different interventions

The English SARS-CoV-2 epidemic has been affected by the emergence of new viral variants such as B.1.177, Alpha and Delta, and changing restrictions. We used statistical models and the agent-based model Covasim, in June 2021, to estimate B.1.177 to be 20% more transmissible than the wild type, Alpha to be 50-80% more transmissible than B.1.177 and Delta to be 65-90% more transmissible than Alpha. Using these estimates in Covasim (calibrated 1 September 2020 to 20 June 2021), in June 2021, we found that due to the high transmissibility of Delta, resurgence in infections driven by the Delta variant would not be prevented, but would be strongly reduced by delaying the relaxation of restrictions by one month and with continued vaccination. This article is part of the theme issue 'Technical challenges of modelling real-life epidemics and examples of overcoming these'.

Role of Lateral Soft Tissue Release in Percutaneous Hallux Valgus Surgery: A Systematic Review of the Literature

Category:

Bunion; Midfoot/Forefoot

Introduction/Purpose:

The utility of Lateral soft tissue release (LSTR) in the setting of percutaneous Hallux Valgus (PHV) surgery is still debated. Our aim was to conduct a systematic review of the literature comparing the results of PHV surgery with and without LSTR in order to define the benefits and risks related to this procedure. Our hypotheses were that LSTR would 1) reduce the risk or recurrence of the deformity without increasing the risk of complication and 2) lead to an improved clinical outcome with greater radiological correction.

Methods:

This systematic review followed the PRISMA checklist and was prospectively registered in the Prospero database (CRD4202230). Pubmed, Embase, Cochrane Library and Scopus were used to identify clinical papers reporting results after PHV surgery. Studies were pooled in two categories: PHV with LSTR (Group 1 or G1) and PHV without LSTR (Group 2 or G2). Data regarding the study design, demographics, the surgical procedure and the clinical and radiological outcome were extracted and compared. The modified Coleman Methodology score (mCMS) was used to assess the quality of studies included.

Results:

Sixteen studies were selected (G1:594 feet;G2:553 feet). The sample size (p=0.11), sex distribution (p=0.57), length of follow-up (p=0.79), size of the incision (p=0.13) were comparable. Studies in G2 included a younger population (54+-6.3 vs 44.4+- 6.8 years;p=0.006), however age did not correlate with the clinical and radiological outcome (all p>0.05). The pooled proportion of complication in the two groups (27%, 95%CI 17-38 and 25%, 95%CI 12-37, respectively) and the pooled proportion of recurrence at a minimum 18-month follow-up (2%, 95%CI 0-3 and 2%, 95%CI 0-5, respectively) didn't differ (p=0.79 and p=0.70). The pre- (51.7+-10.6 and 45.8+-1.7 points;p=0.23) and post-operative AOFAS scores (89.4+-4.3 and 86.9+-3.2 points;p=0.16) and the pre-(HVA:29.7+-2.9 and 44.1+-26.8 degrees,p=0.23)(IMA:12.5+-4.2 and 14.1+-2.6 degrees;p=0.94) and post-operative radiological angles (HVA:12.1+-4.3 and 12.3+-2.3;p=0.47)(IMA:9.2+-2.2 and 7.9+-1.3;p=0.2) didn't differ in the two groups. The methodological quality of studies (mCMS: 68.7+-11 points in G1, 63.4+-14.3 points in G2;p=0.2) was similar in G1 and G2

Conclusion:

Lateral soft tissue release during percutaneous HV surgery does not seem to improve the clinical and radiological outcome nor reduces the risk of recurrence of the deformity at a mean 4-year follow-up.

Management of Osteoblastoma and Giant Osteoid Osteoma with Percutaneous Thermoablation Techniques

Osteoblastoma (OB) is a rare, benign bone tumor, accounting for 1% of all primary bone tumors, which occurs usually in childhood and adolescence. OB is histologically and clinically similar to osteoid osteoma (OO), but it differs in size. It is biologically more aggressive and can infiltrate extraskeletal tissues. Therapy is required because of severe bone pain worsening at night. Moreover, non-steroid anti-inflammatory drugs (NSAIDs) are not a reasonable long-term treatment option in young patients. Surgical excision, considered the gold standard in the past, is no longer attractive today due to its invasiveness and the difficulty in performing a complete resection. The treatment of choice is currently represented by percutaneous thermoablation techniques. Among these, Radiofrequency ablation (RFA) is considered the gold standard treatment, even when the lesions are located in the spine. RFA is a widely available technique that has shown high efficacy and low complication rates in many studies. Other percutaneous thermoablation techniques have been used for the treatment of OB, including Cryoablation (CA) and laser-ablation (LA) with high success rates and low complications. Nevertheless, their role is limited, and further studies are necessary.

Static versus dynamic fixation of distal tibiofibular syndesmosis: a systematic review of overlapping meta-analyses

PURPOSE

Multiple Level I meta-analyses were conducted comparing traditional static vs. more recently introduced dynamic strategies of fixation for injuries of the distal tibiofibular syndesmosis (TFS). The aim of this review was to assess their robustness and methodological quality, providing support in the choice of a treatment strategy in case of TFS injury using the highest level of evidence.

METHODS

In this systematic review, conducted in accordance with the PRISMA guidelines, meta-analyses/systematic reviews comparing static and dynamic fixation methods after acute TFS injury were identified. The robustness of studies was evaluated using the fragility index (FI) for meta-analysis and the fragility quotient (FQ). The risk of bias was evaluated using the Assessment of Multiple Systematic Reviews (AMSTAR) instrument. Finally, the Jadad was applied to select the study which provided the highest quality of evidence to develop recommendations for the fixation strategy of these lesions.

RESULTS

Out of 1.302 records, four Level I meta-analyses were included in this study. Analyzing the statistically significant dichotomous outcomes, the median FI was 3.5 (IQR, 2 to 5.5; range, 1 to 9), while the median FQ was 1.9% (IQR, 1 to 3.5; range 0.35 to 4.4). In total, 37% had an FI of 2 or less and 75% of outcomes had a FI of 4 or less. According to the AMSTAR score and Jadad algorithm, the largest meta-analysis was selected as the highest evidence provided so far.

CONCLUSION

The meta-analyses with statistically significant dichotomous outcomes comparing dynamic and static fixation for treating injuries of the distal tibiofibular syndesmosis are fragile, with a change in less than four patients or less than 2% of the study population sufficient to reverse a significant outcome to nonsignificant.

LEVEL OF EVIDENCE

Level I.

O2-O3 chemodiscolysis: How much, how long? Retrospective outcome evaluation of different treatment sessions in partially-responder patients

PURPOSE

To retrospectively evaluate the clinical and instrumental outcome of different treatment sessions of oxygen-ozone (O₂-O₃) chemodiscolysis in patients with lumbar disc herniation.

METHODS

We evaluated 73 patients partially responders to a single session of oxygen-ozone (O₂-O₃) chemodiscolysis and submitted to multiple injections sessions. All patients completed a pre- and post-treatment clinical (VAS and modified McNab score) and instrumental MRI follow-up. Imaging evaluation included assessment of intervertebral disc area (IDA). Pre- and post-treatment differences were compared to evaluate differences in variation between groups. Correlation analysis was used to evaluate the relationship between morphological and clinical parameters.

RESULTS

Based on the type and number of treatments performed, patients were divided into three groups: Group A) patients submitted to an additional periradicular anaesthetic/steroid injection; Group B) patients submitted to an additional session of intradiscal O₂-O₃ injection; Group C) patients submitted to two further sessions of intradiscal O₂-O₃ injection.The results showed an improvement of pain scores in all groups, and a smaller disc area change in group B. Comparing the differences between pre- and post-treatment features among the three different groups of patients, we did not find any statistically significant difference. Correlation analysis did not show any statistically significant correlation between the morphological changes of the intervertebral disc and the clinical output scores.

CONCLUSIONS

In our retrospective observation of partially responder patients, multiple intradiscal ozone injections were not associated with a higher disc shrinkage nor superior clinical outcome compared to a single intradiscal O₂-O₃ application with an additional periradicular injection session.

Musculoskeletal Interventional Radiology in the Pediatric Population: State of the Art

Interventional radiology procedures have been proven to be as effective as traditional surgery but usually are characterized by lower morbidity rates. In this article, the most diffuse IR treatments for pediatric lesions are reviewed with the aim of describing main advantages and drawbacks. Ablation procedures (in particular RFA and MRgFUS) are widely used for the management of osteoid osteoma and osteoblastoma whereas intracystic injection of methylprednisolone acetate is performed for simple bone cysts. Sclerosing agents and where possible, selective arterial embolization are used for treatment of aneurysmal bone cysts and other vascular malformations. In the management of malignant muscoloskeletal tumors, the role interventional radiology is mainly represented by percutaneous biopsies, and by adiuvant selective embolizations in presence of hypervascular lesions to be submitted to surgery.

Effects of dietary microbial feed supplement on production efficacy in lactating dairy cows

This study evaluated the effects of a microbial feed supplement (MFS; Galaxis, Ascus Biosciences Inc.) comprising 2 native rumen microbes on performance parameters in mid-lactation dairy cows. Forty-six lactating primiparous and multiparous Holstein cows [629 ± 62 kg of body weight, mean ± standard deviation (SD); parity 1.64 ± 0.49; 119 ± 38 days in milk; 45.11 ± 3.81 and 52.73 ± 4.77 kg/d of milk yield for primiparous and multiparous, respectively] were enrolled in a study containing 3 experimental periods (P). During all periods, enrolled cows were fed the same base total mixed ration (TMR) ad libitum once daily. During P1 (7 d), baseline data were obtained for covariate analysis. At the beginning of P2 (60 d), cows were assigned to 1 of 2 dietary treatment groups in a randomized complete block design to balance for milk yield (MY), parity, and days in milk: (1) a control diet (CON; base TMR; n = 23), or (2) a control diet supplemented with 5 g/d of MFS (MFS; n = 23). Sample size was determined based on previous, unpublished results involving this MFS; a 3-kg difference between groups with a SD of 3.5 kg could be detected with sufficient power (0.81) using a total sample size of 46 cows. Treatment was top-dressed and hand-mixed into the top one-third of the TMR. During P3 (7 d), no treatment was administered, and all cows were fed the base TMR. When analyzing all cows in the data set, MFS had little to no effect on performance. However, modeling revealed that the fixed effect of covariate milk production level had a significant effect on the response of MY and ECM, and further investigation of the data revealed that treatment effectiveness in P2 correlated with milk production during P1. Cows were retrospectively categorized into 2 milk production groups (MPG) balanced for parity: MPG1 (i.e., <53 kg/d of ECM during P1; n = 34) or MPG2 (i.e., ≥53 kg/d of ECM during P1; n = 12). Energy-corrected milk was increased by 4.4% in MFS-administered MPG1 cows compared with CON cows during P2. Although there were no significant effects of MFS on production variables for MPG2 cows, MY tended to be decreased by 3.9% in MFS-administered cows compared with CON cows. Further investigation is needed to understand production level response differences and the effect of supplemented native rumen microbes on animal health and productivity.

Could anaesthesia be a key factor for the good outcome of bone ablation procedures? A retrospective analysis of a musculoskeletal interventional centre

OBJECTIVE

To choose the best anaesthetic approach through the retrospective review of different bone ablation procedures.

METHODS AND MATERIALS

We retrospectively evaluated 118 ablation procedures carried out in our institute over the last 30 months. Three different anaesthetic approaches were used: general anaesthesia, i.v. sedation/analgesia and loco-regional anaesthesia (brachial plexus block, spinal anaesthesia). The outcomes were evaluated based on three parameters: technical success, patient comfort (Scale 1-5) and operator comfort (Scale 1-5).

RESULTS

The 118 interventional procedures were carried out on 62 benign and 56 malignant bone lesions. The overall procedural success rate was 100%. Three cases were treated under general anaesthesia: patient comfort was 5/5 in all cases; operator comfort was 5/5 in one case, and 4/5 in two cases. Twenty-one patients underwent sedation/analgesia: in three patients with benign bone lesions, patient comfort was 1/5 and operator comfort 3/5; in two patients with malignant bone lesions, patient comfort was 3/5 and operator comfort 4/5. Ninety-four patients underwent loco-regional anaesthesia: patient and operator comfort was 5/5 in all cases.

CONCLUSION

Based on our experience, loco-regional anaesthesia is probably the best anaesthetic approach during bone ablation procedures. Benign bone lesions ablation are the more painful procedures.

ADVANCES IN KNOWLEDGE

This is the first paper that systematically investigates about the best anaesthesiological support for IR procedures.

Biparametric (bp) and multiparametric (mp) magnetic resonance imaging (MRI) approach to prostate cancer disease: a narrative review of current debate on dynamic contrast enhancement

Prostate cancer is the most common malignancy in male population. Over the last few years, magnetic resonance imaging (MRI) has proved to be a robust clinical tool for identification and staging of clinically significant prostate cancer. Though suggestions by the European Society of Urogenital Radiology to use complete multiparametric (mp) T2-weighted/diffusion weighted imaging (DWI)/dynamic contrast enhancement (DCE) acquisition for all prostate MRI examinations, the real advantage of functional DCE remains a matter of debate. Recent studies demonstrate that biparametric (bp) and mp approaches have similar accuracy, but controversial evidences remain, and the specific potential benefits of contrast medium administration are still poorly discussed in literature. The bp approach is in fact sufficient in most cases to adequately identify a negative test, or to accurately define the degree of aggressiveness of a lesion, especially if larger or with major characteristics of malignancy. This feature would give the DCE a secondary role, probably limited to a second evaluation of the lesion location, for detecting small cancer or in case of controversy. However, DCE has proved to increase the sensitivity of prostate MRI, though a less specificity. Therefore, an appropriate decision algorithm is needed to standardize the MRI approach. Aim of this review study was to provide a schematic description of bpMRI and mpMRI approaches in the study of prostatic anatomy, focusing on comparative validity and current DCE application. Additional theoretical considerations on prostate MRI are provided.

THU0601 REFRACTORY ACUTE CORONARY SYNDROME AND CARDIOGENIC SHOCK AS ATYPICAL ONSET OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

Background:

Eosinophilic Granulomatosis with Polyangiitis (EGPA) is an ANCA-associated vasculitis, characterized by eosinophilic infiltration in tissues, intravascular and extravascular granuloma formation. It is a rare disease, affecting between 0 and 4 per million population per year. The cardiac involvement occurs in 15-60% of EGPA patients (generally ANCA-negative); it is often insidious, underestimated and it has a poor prognosis. The disease usually shows a prodromal phase characterized by asthma and allergic manifestations.

Objectives:

We report the case of a young patient with acute coronary syndrome (ACS) complicated by cardiogenic shock as the first manifestation of EGPA.

Methods:

A 36 year old Indian male patient, with a previous history of asthma, rhinitis, Raynaud syndrome and allergy to ketoprofen, presented to the emergency department with a complaint of chest pain and dyspnea. Cardiac troponin was elevated and he was admitted to intensive care unit with a diagnosis of ACS. The patient conditions rapidly deteriorated due to acute cardiogenic shock and an urgent coronary angiogram was performed. An occlusion of the left main coronary artery was treated with angioplasty and two drug-eluting stents. Echocardiography showed severe left ventricular dysfunction requiring inotropic and intra-aortic balloon pump support. A mild dermatitis after salicylic acid administration resolved with intravenous hydrocortisone 1 g. The thrombophilia screening was negative, as well as cardiovascular risk factors. Over the next days, the clinical conditions rapidly improved with recovery of normal ventricular function on discharge. However, two weeks later he was readmitted with recurrent mandibular and chest pain. Troponin levels were elevated and fluctuated, suggesting recurrent ischemic events. Repeated ECG during angina crisis showed ischemic alterations in different coronary territories. The coronary angiogram detected coronary vasospasm of the circumflex artery, reversible after nitroglycerin (Figure 1). Nitroglycerin and calcium channel blockers were initiated, but did not resolve the vasospastic angina crisis, occurring daily. Laboratory tests revealed eosinophilia (4390 cells/mcl), increased C reactive protein (9.4 mg/l) and positive antinuclear antibodies (1:320). The other serological and immunological tests were negative, including MPO-ANCA and PR3-ANCA. An abdomen and chest CT scan was negative.

Figure 1.

Coronary angiogram showing coronary vasospasm in the left circumflex artery (panel A, yellow arrow), reversible after nytroglicerin infusion (panel B, yellow arrow)

Results:

The eosinophilia and the history of asthma rose the suspect of EGPA vasculitis. The patient was treated with intravenous methylprednisolone 250 mg once daily for 3 days, followed by oral prednisone 1 mg/kg/day, with rapid and complete resolution of the recurrent angina episodes. Intravenous cyclophosphamide 10 mg/kg was administered every 2 weeks for 2 times, then 12 mg/kg every 4 weeks. Oral corticosteroid was tapered, with the persistence of a complete remission of the symptoms, after 2 months of immunosuppressive therapy.

Conclusion:

Coronary involvement in EGPA can mimic atherosclerotic artery disease and can be life threatening, if not promptly recognized. An accurate medical history and complete serological and immunological tests are crucial to detect an atypical onset of EGPA, prompting early immunosuppressive therapy which is pivotal for the patient survival.

References:

[1]MR Hazebroek et al. Prevalence and Prognostic Relevance of Cardiac Involvement in ANCA-associated Vasculitis: Eosinophilic Granulomatosis With Polyangiitis and Granulomatosis With Polyangiitis. Int J Cardiol 2015, 199: 170-9.

Disclosure of Interests:

None declared

DOI: 10.1136/annrheumdis-2020-eular.6482

A comparative study of combined intravenous and topical administration of tranexamic acid with topical tranexamic acid alone for blood loss reduction after primary uncemented total hip arthroplasty

The aim of the present study was to evaluate the efficacy of topical versus combined (intravenous + topical) tranexamic acid (TXA) to reduce perioperative blood loss after uncemented primary total hip arthroplasty (THA). Seventy-five patients were randomized in three comparable experimental groups: 1) topical TXA (3 g in 50 ml of saline solution); 2) intravenous + topical TXA (3 g topical + 2 g in 100 ml of saline solution intravenously); 3) controls. Pre- and post-operative hemoglobin (Hb) levels and hematocrit (Hct) values along with the rate of blood transfusion in the 3 groups were compared. The intravenous + topical TXA group demonstrated higher Hb levels and Hct values at postoperative day one (Hb = p <0.05, Hct = p <0.001), postoperative day three (Hb = p <0.05, Hct = p <0.001), and discharge (Hct = p <0.01) compared to the control group. The intravenous + topical group had a lower transfusion rate compared to the control group (0% vs 20%, p = 0.014). With the numbers available, no difference in postoperative Hb level and transfusion rate emerged between topical TXA and control group.

Characterizing the BCG induced T cell independent mechanisms for defense against Mycobacterium tuberculosis

Mycobacterium bovis Bacille Calmette Guérin (BCG) is a potent immune stimulator that activates innate and adaptive immunity. In the C57BL/6 mouse model of tuberculosis, BCG stimulated immunity causes a significant reduction of M. tuberculosis burden after pulmonary infection. The majority of work has focused on BCG induced T cell immunity as CD4+ T cells play a significant role in protection against tuberculosis. We hypothesized that BCG also induced a T cell independent mechanism that was sufficient to significantly restrict mycobacterial growth. BCG robustly activates innate immunity and our preliminary experiments showed that BCG induced a significant reduction in colony forming units (CFU) in the lungs of mice vaccinated 7 days before pulmonary infection. Our studies indicated that although BCG was administered through subcutaneous inoculation, increased numbers of Ly6C+ monocytes were observed in the lungs within 7 days. Selective depletion also determined that neutrophils played a role in priming innate immunity. Others have identified a role for innate immunity during BCG vaccination termed trained innate immunity. However, our results suggested that at day 7 post BCG vaccination trained innate immunity did not cause the CFU reduction, as the NOD2 receptor or NK cell activation were not absolute requirements, despite being linked to trained immunity. Furthermore, in vivo killing of mycobacterium was dependent on BCG being viable and was monocyte derived, highlighting a novel mechanism. Taken together our data suggest that an early innate mechanism induced by viable BCG is responsible for reducing the mycobacterial burden and precedes trained innate immunity.

Acute-phase endovascular management of an uncommon bleeding peripancreatic pseudoaneurysm

Pancreatic pseudoaneurysms represent relatively rare but potentially lethal complications of acute or chronic pancreatitis, involving several visceral arteries. Due to their intrinsic instability and subsequent high risk of massive bleeding, these lesions require prompt treatment, regardless of the size of the pseudoaneurysm. First option of treatment is today represented by transcatheter embolization; this treatment, in fact, shows higher rates of clinical and technical success and lower recurrence rates than conventional surgery. We present a clinical case of endovascular management of a large pseudoaneurysm, measuring 54 × 53 mm (AP × LL), involving right gastric artery in a 35-year-old woman with history of chronic alcoholic abuse presenting with severe anemia.

"I only watch for the commercials": Messages about weight, eating and race in Super Bowl advertisements

OBJECTIVE

Health experts and communication experts assert that the media influence individuals' health. Yet, incongruously, the public, policy-makers and the media themselves appear reticent to accept that the media could have extensive negative influence on health.

METHODS

The current study examined all ads that aired from Super Bowl XLVI through Super Bowl XLIX (N = 241) using a detailed, multistep coding process.

RESULTS

Ads had similar racial/ethnic diversity in the full sample and food/beverage ads. A minority (14.5%) of advertisements contained actors with overweight/obesity, who were more likely to be White and less likely to be Hispanic compared with race/ethnicity in all ads. Humour and tone were similarly present whether or not the ads included actors with overweight/obesity.

CONCLUSIONS

Findings are striking given the high prevalence of overweight/obesity in the USA, particularly among Black and Hispanic populations, and the comparatively low representation of actors with overweight/obesity in Super Bowl advertisements. Surprising weight findings may signal a change in how the media portray body-size norms (away from exclusively thin), although representations remain disproportionate from actual body-size distributions in the USA.

Giant endometrial cyst of the liver: a case report and review of the literature

Endometriosis is a benign condition described as the presence of endometrial- like tissue found outside the uterine cavity. Hepatic endometriosis is one of the rarest localization of extrapelvic endometriosis, only 22 cases have been reported in the literature. The preoperative diagnosis of hepatic endometriosis is rather difficult because in about the half of the patient affected they had no history of endometriosis. Moreover radiological images reveal no characteristic findings for hepatic endometriosis. It is often described as cystic mass with or without solid component, difficult to distinguish from hepatic abscess, hematoma, cystoadenoma or malignant neoplasia. We report a case of a 27-year-old female with a large cystic mass involving the left lobe of the liver. The patient underwent laparoscopic exploration and converted to laparotomy for resection of giant hepatic endometriosis.

Relationship between early administration of abciximab and TIMI flow in STEMI patients undergoing primary angioplasty: findings from a large regional STEMI network

AIMS

The aim of this study is to assess whether in S-T Elevation Myocardial Infarction (STEMI) a relationship between early administration of abciximab and Thrombolysis In Myocardial Infarction (TIMI) flow before and after primary percutaneous coronary intervention (PCI) in 960 consecutive patients exists.

METHODS

From 1 February 2001 onward, in the Province of Mantua it has been operating a 'Cardiology Network for the Acute Infarction Care' having its Hub in the Central Coronary ICU/Cath Lab of Mantua Hospital and being its Spokes centers represented by the emergency rooms and Central Coronary ICUs of the four territorial hospitals.

RESULTS

T1 (time from symptoms onset to first medical contact) and T2 (time from first medical contact to angioplasty) are shorter for patients rescued by first aid units rather than for those presented in emergency rooms as well as Ta (time from symptoms onset to abciximab administration). Furthermore, the patients that received abciximab before hospital arrival had less frequently a coronary occlusion [odds ratio = 0.74, 95% confidence interval (0.57-0.96), P = 0.013]. The patients with T1 less than 4 h are 753/960 (78.4%). For this type of patients, there was a significant Ta difference between the pre-PCI TIMI-flow classes (F = 4.467, df = 3, P = 0.04). Planned contrasts revealed that mean time of TIMI flow 0 (M = 104.2) is statistically different from mean time of TIMI flow 3 (M = 85.7), P = 0.013.

CONCLUSION

Our results suggest that the use of abciximab, free from pharmacokinetic limits of oral P2Y12 inhibitors, should be considered in STEMI patients with early presentation before primary PCI.

Design, development and characterization of a modular end effector for MIS procedures

The Minimally Invasive Surgery (MIS) paradigm is well established in modern surgical procedures. Although MIS is successful from the patient's viewpoint, the use of rigid instruments inserted through small skin incisions leads to dexterity constraints and loss of degree of motion. Robotics has been introduced as support for augmenting dexterity during interventions, restoring hand-eye coordination and providing tools with enhanced degrees of motion. However, surgical robots have high costs and large footprint, pushing the research towards the development of modular robots to be used in Naturally Orifice Trans-luminal Endoscopic Surgery (NOTES) procedures. The main need of having simple and cheap tools able to be interchanged during the surgical procedure became crucial. In this paper an innovative modular end-effector based on a compliant soft actuation system able to provide up to 5.78 N gripping forces is presented.

Renovascular anatomic variants at CT angiography

AIM

The aim of this paper was to assess the origin and course variations of vessels forming the renal vascular pedicle.

METHODS

The IRB approved study retrospectively evaluated 921 consecutive patients (503 females, 418 males; mean age, 54 years), who underwent multidetector computed tomographic (MDCT) of the abdomen for various purposes at our Department of Radiology, between January 2012 and December 2013. Multiplanar and volumetric reformations were performed in all cases. For each set of images, the locations of renal artery origins and renal venous drainage, such as all renal vessels variations, including division variations and presence of extrarenal vessels, were investigated.

RESULTS

The tract of the aorta between the upper margin of L1 and the lower margin of L2 originated 96% of main renal arteries and 72% of extra renal arteries. The most common location for renal artery origin was the L1- L2 intervertebral disc level. Sixty-nine percent of patients showed a single renal artery, with multiple arteries in 31%, bilateral multiple arteries in 11%, and early division in 6% of cases. Additional renal arteries were detected on the right side in 5% and on the left side in 12% of cases. With regard to the venous drainage, 89.8% of patients showed a single renal vein, with multiple vein in 10.2%, while 23.8% showed a retro-aortic course of the renal vein.

CONCLUSION

Renal arteries and veins variations of origin and course are not infrequent. Extrarenal vessels may compromise renal surgery. The awareness of any possible renovascular anomaly is crucial in case of a non-invasive diagnostic search for renal artery stenosis, and when renal surgery related to renal arteries is performed, such as in case of interventional radiological procedures, urological and vascular operations, and renal transplantation.

Recombinant adenovirus delivery of calreticulin-ESAT-6 produces an antigen-specific immune response but no protection against a Mycobacterium tuberculosis challenge

Bacillus Calmette-Guerin (BCG) has failed to efficaciously control the worldwide spread of the disease. New vaccine development targets virulence antigens of Mycobacterium tuberculosis that are deleted in Mycobacterium bovis BCG. Immunization with ESAT-6 and CFP10 provides protection against M. tuberculosis in a murine infection model. Further, previous studies have shown that calreticulin increases the cell-mediated immune responses to antigens. Therefore, to test whether calreticulin enhances the immune response against M. tuberculosis antigens, we fused ESAT-6 to calreticulin and constructed a recombinant replication-deficient adenovirus to express the resulting fusion protein (AdCRT-ESAT-6). The adjuvant effect of calreticulin was assayed by measuring cytokine responses specific to ESAT-6. Recombinant adenovirus expressing the fusion protein produced higher levels of interferon-γ and tumour necrosis factor-α in response to ESAT-6. This immune response was not improved by the addition of CFP-10 to the CRT-ESAT-6 fusion protein (AdCRT-ESAT-6-CFP10). Mice immunized with these recombinant adenoviruses did not decrease the mycobacterial burden after low-dose aerosol infection with M. tuberculosis. We conclude that calreticulin can be used as an adjuvant to enhance the immune response against mycobacterial antigens, but it is not enough to protect against tuberculosis.

40 Mb duplication in chromosome band 5p13.1p15.33 with 800 kb terminal deletion in a foetus with mild phenotypic features

Large duplication of the short arm of chromosome 5 is a rare condition normally associated to severe phenotype anomalies including heart and brain malformations. We report a prenatal case of a large 5p duplication with sub-telomeric deletion in a foetus with very mild phenotypic abnormalities. Foetal ultrasonographic examination at 22 weeks of gestation showed short femur, clubfeet, pielectasy, and facial dysmorphisms. Chromosome investigations revealed an inverted duplication of the short arm of chromosome 5 from 5p13.1 to 5p15.33 and a 800 kb deletion at 5pter. The absence of severe anomalies such as cardiac and cerebral defects, observed so far in all large 5p duplications, and the comparison to previous cases described both in literature and in DECIPHER database suggest that the critical region for the severe phenotype in 5p duplication syndrome might be smaller than that previously described, excluding half of the 5p13 band. This might help in prenatal genetic counselling.

Prevalence, predictors, and long-term prognosis of premature discontinuation of oral antiplatelet therapy after drug eluting stent implantation

To date, limited information is available on the long-term discontinuation rates of antiplatelet therapy after drug-eluting stent implantation. The aim of the present study was to determine the prevalence and predictors of premature discontinuation of oral antiplatelet therapy after drug-eluting stent implantation and to evaluate its effects on long-term prognosis. We studied 1,358 consecutive patients successfully treated with drug-eluting stents and discharged with dual oral antiplatelet therapy. Aspirin was to be maintained lifelong, and clopidogrel was prescribed for 12 months. The patients were followed for 36 months. The prevalence and predictors of aspirin and clopidogrel discontinuation were assessed. Major adverse cardiac events, defined as death, myocardial infarction, destabilizing symptoms leading to hospitalization, and nonfatal stroke, were recorded. Definite, probable, and possible stent thrombosis (ST) and major and minor bleeding were also determined. Of the 1,358 patients, 8.8% had discontinued one or both antiplatelet agents within the first 12 months ("early" discontinuation) and 4.8% had discontinued aspirin after 1 year ("late" discontinuation). Early discontinuation was predicted by in-hospital major bleeding, the use of oral anticoagulants at discharge, and the lack of a statin prescription. Previous stroke was the only independent predictor of late discontinuation. Patients with early discontinuation experienced a greater incidence of major adverse cardiac events (28.6% vs 13.7%, p <0.001) and ST (7.6% vs 3.4%, p = 0.038). All-cause mortality (13.4% vs 4.7%, p <0.001) and cardiovascular death (5% vs 1.2%, p = 0.007) were significantly more frequent among patients with early discontinuation. In patients with late discontinuation, a nonstatistically significant increase was seen in major adverse cardiac events (20% vs 13.3%, p = 0.128) and ST (6.2% vs 3.2%, p = 0.275). In conclusion, premature discontinuation of antiplatelet therapy is relatively common, especially within the first year, and strongly associated with increased cardiovascular events, including ST and death.

Rehabilitative treatment in peripheral artery disease: protocol application and follow-up

AIM

Peripheral arterial disease (PAD) is a chronic figure suitable to be treated at the II stage to prevent the extreme developments both of the critical limb ischemia and the amputation, as well. The aim of this study was to establish a rehabilitation program (pharmacological and physical) focused not only on the improvement of the flow but also on the metabolic rebalancing in the claudicant limb.

METHODS

The study enrolled 222 patients, (125 non-diabetics and 97 diabetics): 54 II A and 168 II B stage; 172 patients (131 II B and 41 II A; 104 non-diabetics and 68 diabetics) were submitted to iv. L-propionil carnytine (Lpc) and physical training on treadmill or exercise bike and 50 patients to iv. therapy alone. Instrumental (Rheoscreen, Oximetry, ABI, walking distance measurement) and clinical checks (questionnaire - Appendix 1) were performed at days: T0, T45,T 90,T180, T230 and during the follow up stated at T 90,T180,T360 from T 230 (end of DH).

RESULTS

A significant increasing of the walking distance has been reached in the group undergoing the rehabilitation program. Treadmill: non-diabetics +261.48% at 0% and +122.53% at slope 10% (T230) further increasing to +502.31% at 0% and +289.42% at slope 10% (T360); diabetics: + 158.49% at T0 and + 98.26% at slope 10% (T230) further increased to +287.74% at 0% and +197.39% at 10% (T360) in comparison with the group which had only iv. Lpc : non-diabetics +141.63% at 0% and +104.08% at slope 10% (T230) further increased to +202.064% at 0% and +155.10% at slope 10% (T360); diabetics: +109.124% at T0 and +100% at slop 10% (T230) further increased to +171.08% at 0% and +140% at 10% (T360) . Exercise bike: non-diabetics: +170.27% at T230 in comparison T0 increased to +305.4% at T360; diabetics: +166.66 at T230 reaching +288.88% at T 360.

CONCLUSION

Our rehabilitative program gives not only good results at the end of the treatment but mainly stable, with the chance to reach further improving of both walking distance and quality of life, particularly in those patients which observe constantly the physical training.

Systematic quality control for management of ST elevation acute myocardial infarction in setting of local network

AIM

Adherence to evidence based guidelines, assessed by measuring key indicators, allows to detect, evaluate and improve quality of care. Since 2004 in Carlo Poma Hospital, following the introduction of a network for ST-elevation myocardial infarction (STEMI) management, the authors carried out a clinical database in order to measure quality of care in STEMI patients.

MATERIALS AND METHODS

A real time upgradable database was developed, to assess clinical practice in myocardial infarction management. The authors evaluated prevalence and control of risk factors, pharmacological therapies and interventional procedures, pathways and delays to care.

RESULTS

From 1 February 2004 to 31 January 2008, 1,714 consecutive patients with myocardial infarction were admitted in the Intensive Care Unit (ICU). Primary percutaneous coronary intervention (PCI) was performed in 85% of STEMI patients. Door to balloon time was greater than 90 min in only 17% of patients, of whom 88% coming from emergency department and 12% transferred by 118.

CONCLUSION

In the authors' experience quality indicators proved useful in the management of myocardial infarction. Implementation of 118 and improvement of pre-hospital diagnosis in setting of local network can reduce time to treatment.

Changes in ectomycorrhizal community structure on two containerized oak hosts across an experimental hydrologic gradient

Shifts in ectomycorrhizal (ECM) community structure were examined across an experimental hydrologic gradient on containerized seedlings of two oak species, Quercus montana and Quercus palustris, inoculated from a homogenate of roots from mature oak trees. At the end of one growing season, seedlings were harvested, roots were sorted by morphotype, and proportional colonization of each type was determined. DNA was subsequently extracted from individual root tips for polymerase chain reaction, restriction fragment length polymorphism, and rDNA sequencing of the ITS1/5.8S/ITS2 region to determine identities of fungal morphotypes. Twelve distinct molecular types were identified. Analysis of similarity showed that ECM fungal assemblages shifted significantly in composition across the soil moisture gradient. Taxa within the genus Tuber and the family Thelephoraceae were largely responsible for the changes in fungal assemblages. There were also significant differences in ECM community assemblages between the two oak host species. These results demonstrate that the structure of ECM fungal communities depends on both the abiotic and biotic environments and can shift with changes in soil moisture as well as host plant, even within the same genus.

[Mortality triplicates in acute myocardial infarction patients affected by chronic renal failure]

In order to calculate the cardiovascular risk in patients with chronic renal failure (CRF), we retrospectively analyzed 1482 acute myocardial infarctions (AMIs) treated in the ICU at C. Poma General Hospital, Mantua, Italy, from 1 December 2004 to 31 July 2007. Of these patients, 133 suffered from CRF at hospital admission (eGFR <40 mL/min/1.73 m2 body surface and/or serum creatinine >2 mg/dL). During hospitalization for AMI, the CRF-affected patients showed a 2.7 times higher relative risk of mortality than patients without CRF (Yates chi square 14.46; p = 0.0001432). The evaluated comorbidities (hypertension, type 2 diabetes, supra-aortic vascular stenosis >70%, previous PTCA, COPD, previous AMI, previous coronary artery bypass and chronic obliterative peripheral arteriopathy) increased the relative risk of death 1.2- to 3.76-fold in those affected. In accord with recent evidence in the international literature, our results point to the importance of early assessment of CRF for the prognosis of patients with AMI.

Evaluation of the efficacy of propionyl-L-carnitine versus pulsed muscular compressions in diabetic and non-diabetic patients affected by obliterating arteriopathy Leriche stage II

AIM

The effectiveness of propionyl-L-carnitine (PLC) monotherapy regimen alone or in association with pulsed muscular compression was compared to the physical therapy by itself against obliterant arteriopathy Leriche Fontaine stage II. PLC is involved in cellular metabolism and is transformed into two active substances, free L-carnitine and propionyl-coenzyme A in the mitochondria, which take part in fatty acid transfer and in the citric acid cycle, respectively.

METHODS

Forty-two patients with arterial disease were selected (22 males and 20 females; mean age: 62+/-8 years; 21 type 2 diabetic [DB] and 21 non-DB [NDB]). At enrollment all patients completed a symptoms questionnaire enabling both clinical and social evaluation of the impact of the arteriopathy on the quality of life. Then, patients had: routine blood samples, echo duplex scan; evaluation of the ankle/arm (Winsor) index; impedance plethysmography (Rheoscreen) to measure the crest time (CT), index of the pathological changes due to the sclerosis on the vascular wall, and measurement of walking distance by means of treadmill test. Patients were randomized in three groups, each of them composed by 14 patients (7 DB and 7 NDB): the first group was submitted to infusional PLC therapy at a dosage of 4 fl (total: 1,200 mg PLC) in 250 cc of physiological solution for 5 days a week for 4 weeks; the second group was treated with PLC in association with pulsed muscular compression therapy by Vascupump (5 sessions a week for 4 weeks); the third group was submitted only to Vascupump.

RESULTS

The efficacy of both PLC and Vascupump in the treatment of the peripheral vasculopathies was confirmed. From a subjective point of view, patients referred benefits both in clinical terms, i.e. increased walking distance (average increaseaegroup I: DB 102%, NDB 118%; group II: DB 94%, NDB 193%; group III: DB 33%, NDB 67%) and of decreased intensity of the calf pain from the quality of life questionnaire (21.5 to 10.7). The instrumental parameters showed a trend towards normality, i.e decrease in CT and an increase of the Winsor index, indicators of increased peripheral blood circulation.

CONCLUSION

Combined pharmaco- and physical therapy was most efficient treatment regime and best results were seen in NDB compared to the DB patients.

[Evaluation of radon levels in bank buildings: results of a survey on a major Italian banking group]

Radon, the second cause of lung cancer after smoking, is a natural, radioactive gas, which originates from the soil and pollutes indoor air, especially in closed or underground spaces. Italian legislation recommends an action level of 500 Bq/m3 per year for occupational exposure in underground premises.

OBJECTIVES

Since banks usually use various underground premises (archives, safe-deposit room), a study was made of the radon levels on such premises with the aim of identifying useful monitoring strategies.

METHODS

134 branches of a major Italian banking group were examined using 1817 nuclear track dosimeters at ground level and underground level premises. The branches were located in 7 Italian regions in the north (Piedmont, Lombardy, Veneto), centre (Lazio) and south (Campania, Apulia, Sicily). Information on measurement points was recorded in a technical sheet and statistical analysis was carried out.

RESULTS

Annual underground measurements gave an average concentration of 157 Bq/m3, with 5.1% for 400 < C < 500 Bq/m3 and 2.9%for C > 500 Bq/m3. Seasonal variability was reflected in a significant decrease in concentrations between winter and spring (delta(mean)% = -47.3%) and good stability between autumn and winter (delta(mean)% = 3%); moreover quarterly concentrations account for 85% of the variability of the corresponding annual level. A multiple linear regression model (R2 = 0.33) indicated geographic location as the principal factor in radon accumulation, followed by underground level, humidity, use, lack of windows, heating and natural ventilation, and direct contact of at least one wall with ground rock; whereas the safe-deposit room structure seems to protect from radon accumulation. Moreover, the ground level measurement results were significantly associated with the corresponding underground average concentrations (p < 0.001).

CONCLUSIONS

The results could be a useful tool in planning a monitoring strategy for assessment of bank worker exposure, especially for banking groups with a large number of branches.

[A database in the coronary care unit to assess quality of care of acute myocardial infarction]

BACKGROUND

In the context of an operative network for acute coronary syndrome consisting in telemedicine equipment and 24-h catheter facility availability, a database was worked out to verify clinical pathways, timeline, prevalence of cardiovascular risk factors, diagnostic and therapeutic choices, and clinical results. The aim of this study was to evaluate the adherence to guidelines in the real world in order to assess quality of care.

METHODS

We implemented a database in the preexisting hospital intranet due to open source interactive pages. From international guidelines we obtained performance measures for each step of the care process, in order to have a continuous and updated evaluation of our healthcare performance. After an accurate analysis of the results of the first 2-year data collection, we modified the performance measurement set to optimize our database. All data were analyzed with statistical program SPSS.

RESULTS

A total of 1066 patient characteristics within a period of 5 semesters were analyzed: trends for each of the 11 performance measures were evaluated. In 852 patients clinical and angiographic characteristics were analyzed: cardiovascular risk factors and TIMI risk score for ST-elevation myocardial infarction patients, different pathways and first-aid timeline. Data about pharmacological therapy on admission, during intensive care unit stay and at discharge were also collected.

CONCLUSIONS

The present study assesses the utility of continuous monitoring and of verifying quality of care with a dedicated database in order to evaluate adherence to guidelines and to promote optimization of clinical practice.

Is heparin still necessary after primary angioplasty in the era of platelet glycoprotein IIb/IIIa receptor inhibitors? A review of the literature

While there is clear evidence for administering unfractionated heparin after systemic thrombolysis, there are not randomised trials supporting the usefulness of postprocedural heparin in the setting of primary angioplasty, especially in the era of glycoprotein IIb/IIIa inhibitors, and this issue is still a matter of debate. In this review we analysed the 30-day cardiac events of patients treated with primary angioplasty and abciximab, with or without postprocedural unfractionated heparin. We conducted a Medline search and eight studies were selected: in four of them heparin was continued for at least 12 h after the procedure (group 1), in the others heparin was used only during the procedure (group 2). The composite incidence of 30-day major adverse cardiac events was similar in the two groups (5.1 vs. 5.1%; 95% confidence interval 0.66-1.45; P = 0.91), whereas total bleeding occurred in 5.5% of group 1 compared with 3% of group 2 (relative risk 1.82; 95% confidence interval 1.19-2.80; P = 0.005). In conclusion, this review suggests that in the setting of primary angioplasty with concomitant glycoprotein IIb/IIIa inhibitors, postprocedural heparin does not appear to favourably affect cardiac and systemic ischaemic events and turns out to be associated with an increase in haemorrhagic complications.