Adipose Tissue-Derived Products May Present Inflammatory Properties That Affect Chondrocytes and Synoviocytes from Patients with Knee Osteoarthritis

Adipose tissue-derived cell-based injectable therapies have been demonstrated to have disease-modifying effects on joint tissues in preclinical studies on animal osteoarthritis (OA) models, but clinical results are heterogeneous and not always satisfactory. The aim of this study was to investigate the influence of adipose tissue properties on the therapeutic effects of the adipose-derived product in an in vitro OA setting. Micro-fragmented adipose tissue (MF-AT) samples were obtained from 21 OA patients (mean age 51.7 ± 11.8 years, mean BMI 25.7 ± 4.1 kg/m2). The analysis of the MF-AT supernatant was performed to analyze the release of inflammatory factors. The effects of MF-AT inflammatory factors were investigated on chondrocytes and synoviocytes gene expression levels. Patients' characteristics were analyzed to explore their influence on MF-AT inflammatory molecules and on the MF-AT effects on the gene expression of chondrocytes and synoviocytes. The study results demonstrated that adipose tissue-derived products may present inflammatory properties that influence the therapeutic potential for OA treatment, with products with a higher pro-inflammatory profile stimulating a higher expression of genes related to a more inflamed and catabolic phenotype. A higher pro-inflammatory cytokine pattern and a higher pro-inflammatory effect were found in adipose tissue-derived products obtained from OA patients with higher BMI.

Tendinopathy: sex bias starts from the preclinical development of tendon treatments. A systematic review

Tendinopathies are common overuse disorders that arise both in athletes and the general population. Available tendon treatments are used both for women and men without distinction. However, the existence of a sex-based difference in tendon biology is widely demonstrated. Since basic research represents the foundation for treatment development, an equal female–male representation should be pursued in preclinical studies. This systematic review quantified the current evidence by analyzing 150 studies on 8231 animals. Preclinical studies largely neglected the importance of sex, none analyzed sex-based differences, and only 4% of the studies reported disaggregated data suitable for the analysis of treatment results in males and females. There is an alarming female under-representation, in particular in the field of injective therapies. Despite the growing awareness on the importance of investigating treatments in both males and females, the investigated field proved resistant from properly designing studies including both sexes, and the lack of sex-representation remains critical.

Tendinopathy has sex-specific features, with sex hormones affecting tendon metabolism, structure, biomechanical properties, and injury risk.

The preclinical research on tendinopathy treatments still neglects sex-based differences, leading to translation of male data to females which may affect clinical effectiveness in women.

None of the reviewed studies looked at differences between sexes, and only 4% of the studies reported disaggregated data. Besides, female animals are under-represented.

The lack of sex-representation in tendinopathy research remains critical.

The Long-Lasting Effects of "Placebo Injections" in Knee Osteoarthritis: A Meta-Analysis

OBJECTIVES

To quantify the placebo effect of intraarticular injections for knee osteoarthritis in terms of pain, function, and objective outcomes. Factors influencing placebo effect were investigated.

DESIGN

Meta-analysis of randomized controlled trials; Level of evidence, 2. PubMed, Web of Science, Cochrane Library, and grey literature databases were searched on January 8, 2020, using the string: (knee) AND (osteoarthritis OR OA) AND (injections OR intra-articular) AND (saline OR placebo). The following inclusion criteria were used: double-blind, randomized controlled trials on knee osteoarthritis, including a placebo arm on saline injections. The primary outcome was pain variation. Risk of bias was assessed using the RoB 2.0 tool, and quality of evidence was graded following the GRADE (Grading of Recommendations Assessment, Development and Evaluation) guidelines.

RESULTS

Out of 2,363 records, 50 articles on 4,076 patients were included. The meta-analysis showed significant improvements up to the 6-month follow-up: Visual Analogue Scale (VAS)-pain -13.4 mean difference (MD) (95% confidence interval [CI]: -21.7/-5.1; P < 0.001), Western Ontario and McMaster Osteoarthritis Index (WOMAC)-pain -3.3 MD (95% CI: -3.9/-2.7; P < 0.001). Other significant improvements were WOMAC-stiffness -1.1 MD (95% CI: -1.6/-0.6; P < 0.001), WOMAC-function -10.1 MD (95% CI: -12.2/-8.0; P < 0.001), and Evaluator Global Assessment -21.4 MD (95% CI: -29.2/-13.6; P < 0.001). The responder rate was 52% (95% CI: 40% to 63%). Improvements were greater than the "minimal clinically important difference" for all outcomes (except 6-month VAS-pain). The level of evidence was moderate for almost all outcomes.

CONCLUSIONS

The placebo effect of knee injections is significant, with functional improvements lasting even longer than those reported for pain perception. The high, long-lasting, and heterogeneous effects on the scales commonly used in clinical trials further highlight that the impact of placebo should not be overlooked in the research on and management of knee osteoarthritis.

Synovial Fluid Biomarkers in Knee Osteoarthritis: A Systematic Review and Quantitative Evaluation Using BIPEDs Criteria

OBJECTIVE

The aim of this systematic review was to analyze the evidence about the efficacy of the several synovial fluid (SF) biomarkers proposed for knee osteoarthritis (OA), categorizing them by both molecular characteristics and clinical use according to the BIPEDs criteria, to provide a comprehensive and structured overview of the current literature.

DESIGN

A systematic review was performed in May 2020 on PubMed, Cochrane Library, and Embase databases about SF biomarkers in patients with knee OA. The search was limited to articles in the last 20 years on human studies, involving patients with knee OA, reporting SF biomarkers. The evidence for each selected SF biomarker was quantified according to the 6 categories of BIPEDs classification.

RESULTS

A total of 159 articles were included in the qualitative data synthesis and 201 different SF biomarkers were identified. Among these, several were investigated multiple times in different articles, for a total of 373 analyses. The studies included 13,557 patients with knee OA. The most promising SF biomarkers were C4S, IL-6, IL-8, Leptin, MMP-1/3, TIMP-1, TNF-α, and VEGF. The "burden of disease" and "diagnostic" categories were the most represented with 132 and 106 different biomarkers, respectively.

CONCLUSIONS

The systematic review identified numerous SF biomarkers. However, despite the high number of studies on the plethora of identified molecules, the evidence about the efficacy of each biomarker is supported by limited and often conflicting findings. Further research efforts are needed to improve the understanding of SF biomarkers for a better management of patients with knee OA.

Acetic acid bioproduction: The technological innovation change

Acetic acid is an organic acid of great importance globally and the demand of this product is currently increasing. The production of this acid has consequently aroused more and more interest over the years, especially for more sustainable processes. From a biological point of view, acetic acid can be produced by acetogenesis using inorganic substrates like CO₂ or CO (with acetogenic bacteria) and aerobic fermentation (with acetic acid bacteria or fungi). With the aim of investigating the progress of technological innovation, the methodology applied by this review was an analysis of the international patents with the Espacenet platform, which ensured a worldwide invention overview. Another criterion was the selection of a precise period of time, from 1990 to 2020. A patent review is able to create an overview of the inventions designed for the real scale implementation, providing a whole picture of the state of the art of the technological innovation change. In addition, the most representative works of literature, that consider the influence of operating conditions (T, pH, oxygenation), have been analysed for each process. The present review, with an innovative approach focused on the technological innovation change, highlighted the ongoing interest for acetic acid bioproduction by acetogenic and acetic acid bacteria. The number of patents related to acetic acid bacteria was consistent also in the past years, but recently the interest is moving forward the utilization of genetic engineering (36% of the patents) and new substrates, like agriculture waste (26% of the patens), responding to circular economy principles. On the other hand, the acetic acid production by acetogenic bacteria is most recent, with over the 90% of the patents developed in the last 10 years. In this case the interest is mainly focused on the use of synthesis gas as substrate, that could increase the process sustainability.

The Italian coronavirus disease 2019 outbreak: recommendations from clinical practice

Novel coronavirus 2019 is a single-stranded, ribonucleic acid virus that has led to an international pandemic of coronavirus disease 2019. Clinical data from the Chinese outbreak have been reported, but experiences and recommendations from clinical practice during the Italian outbreak have not. We report the impact of the coronavirus disease 2019 outbreak on regional and national healthcare infrastructure. We also report on recommendations based on clinical experiences of managing patients throughout Italy. In particular, we describe key elements of clinical management, including: safe oxygen therapy; airway management; personal protective equipment; and non-technical aspects of caring for patients diagnosed with coronavirus disease 2019. Only through planning, training and team working will clinicians and healthcare systems be best placed to deal with the many complex implications of this new pandemic.

Platelet-rich plasma in tendon-related disorders: results and indications

PURPOSE

Platelet-rich plasma (PRP) is currently the most exploited strategy in the clinical practice to provide a regenerative stimulus for tendon healing. The aim of the present study was to systematically review the available evidence on the treatment of the main tendon disorders where PRP is currently applied.

METHODS

A systematic review of the literature was performed on the use of PRP as a treatment for tendinopathies focusing on the following sites: Achilles tendon, patellar tendon, rotator cuff tendons, and lateral elbow tendons. The following inclusion criteria for relevant articles were used: clinical trials written in English language up to 21 June 2016 on the use of PRP in the conservative or surgical treatment of the aforementioned tendinopathies.

RESULTS

The research identified the following clinical trials dealing with the application of PRP in the selected tendons: 19 papers on patellar tendon (6 being RCTs: 4 dealing with PRP conservative application and 2 surgical), 24 papers on Achilles tendon (4 RCTs: 3 conservative and 1 surgical), 29 on lateral elbow tendons (17 RCTs, all conservative), and 32 on rotator cuff (22 RCTs: 18 surgical and 3 conservative).

CONCLUSION

Patellar tendons seem to benefit from PRP injections, whereas in the Achilles tendon, PRP application is not indicated neither as a conservative approach nor as a surgical augmentation. Lateral elbow tendinopathy showed an improvement in most of the high-level studies, but the lack of proven superiority with respect to the more simple whole-blood injections still questions its use in the clinical practice. With regard to rotator cuff pathology, the vast majority of surgical RCTs documented a lack of beneficial effects, whereas there is still inconclusive evidence concerning its conservative application in rotator cuff disorders.

LEVEL OF EVIDENCE

Systematic review of level I-IV trials, Level IV.

Cultures of a human synovial cell line to evaluate platelet-rich plasma and hyaluronic acid effects

Synovial inflammation plays an important role in osteoarthritis (OA) pathogenesis. Different biological compounds have been tested mainly on chondrocytes, to treat early stages of OA. However, because OA has been recently defined as "an organ" pathology, investigation on synoviocytes is also needed. Therefore, the aim of the present study was to validate a human fibroblast-like synoviocytes cell line (K4IM) to test the effects of platelet-rich plasma (PRP) and hyaluronan (HA) on anabolic and catabolic gene expression and on HA secretion from cell cultures. In order to determine the effect of PRP and HA, K4IM cells were maintained in culture with or without TNF-α stimulation. In the presence of PRP, unstimulated K4IM cells presented the same expression of IL1B, IL6, CXCL8, VEGF, TIMP1, and hyaluronic synthase isoform HAS3 as primary human synoviocytes, while HA addition did not change their expression pattern, which was similar to control cells. Stimulated cells expressed significantly higher values of IL1B, CXCL8, and VEGF compared with unstimulated ones. PRP did not show any modification, except for VEGF, while HA addition modulated IL1B expression. PRP did not modulate HA release of both stimulated and unstimulated cells. Our study showed the possibility to use K4IM synoviocytes as an in vitro model to test biological compounds useful for the treatment of early OA. Primary cells reflect the phenotype of cells in vivo, but limited recovery from biopsies and restricted lifespan makes experimental manipulation challenging. Therefore, despite cell lines present some limitations, they could be used as an alternative for preliminary experiments.

Patients control preferences and results in knee arthroplasty

PURPOSE

Patient engagement in a patient-physician decision-making process has been correlated with satisfaction and clinical outcomes. Aim of this study is to evaluate if patient control preference may also influence TKA results.

METHODS

One hundred and seventy-six patients (120w-56m, age 66 ± 9 years, BMI 28 ± 4) underwent TKA and were prospectively evaluated, before surgery and at 6 and 12 months. The preoperative assessment included the Control Preference Scale (CPS) and other scales measuring psychological aspects (STAI, BDI, TSK), as well as SF12 (physical and mental subscales) and the assessment of pain and function. Pain, function, and SF12 subscales were then used to evaluate the improvement at 6- and 12-month follow-up.

RESULTS

Pain, function, and SF12 scores improved at 6 and 12 months. CPS correlated with the outcome: pain and functional improvement at 6 months (p = 0.014; p = 0.003, respectively), patient function at 6 months (p = 0.022), improvement of SF12 physical subscale at 6 and 12 months (p = 0.027; p = 0.037, respectively), and satisfaction at 6 months (p = 0.033). Moreover, the multivariate analysis confirmed the importance of CPS regardless of other demographic, physical or psychological characteristics.

CONCLUSION

In contrast with previous literature findings, this study shows that patients with more propensity for control presented lower improvements of pain and function than those more prone to rely on the physician making the decision. Physicians should be aware that the patient control preference may influence the treatment outcome and undertake measurements to optimize patient participation in the shared process to optimize the chances of TKA success.

LEVEL OF EVIDENCE

IV.

Maxillofacial trauma in the emergency department: pearls and pitfalls in airway management

Maxillofacial trauma poses a challenge for the anesthesiologist because injuries can often compromise the patient's airways. Airway maintenance is the first step in the American College of Surgeons Advance Trauma Life Support (ATLS®) protocol. However, clinical dilemmas may arise about the best way to manage a potentially life-threatening injury. There are no recommendations about the best time to intubate, the warning signs for deciding to intubate, or which device should be used when difficulty is expected. In this context the ATLS® approach is important but not sufficient. It is also necessary to recognize and be able to manage specific problems in this scenario where clinical priorities may be conflicting, may suddenly change or may be hidden. This clinical review discusses the complexity of this scenario, providing an overview of the conditions at greatest risk for airway obstruction and the options for airway management, on the basis of the recent literature. Clinicians must recognize the milestones and pitfalls of this topic in order to adopt a systematic approach for airway management, to identify specific characteristics associated with it, and to establish the utility of different instruments for airway management.

D-dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial

BACKGROUND

D-dimer concentrations have not been evaluated extensively as a predictor of increased venous thromboembolism (VTE) risk in acutely ill, hospitalized medical patients.

OBJECTIVES

To analyze the relationships between D-dimer concentration, VTE and bleeding in the MAGELLAN trial (NCT00571649).

PATIENTS/METHODS

This was a multicenter, randomized, controlled trial. Patients aged ≥ 40 years, hospitalized for acute medical illnesses with risk factors for VTE received subcutaneous enoxaparin 40 mg once daily for 10 ± 4 days then placebo up to day 35, or oral rivaroxaban 10 mg once daily for 35 ± 4 days. Patients (n = 7581) were grouped by baseline D-dimer ≤ 2 × or > 2 × the upper limit of normal. VTE and major plus non-major clinically relevant bleeding were recorded at day 10, day 35, and between days 11 and 35.

RESULTS

The frequency of VTE was 3.5-fold greater in patients with high D-dimer concentrations. Multivariate analysis showed that D-dimer was an independent predictor of the risk of VTE (odds ratio 2.29 [95% confidence interval 1.75-2.98]), and had a similar association to established risk factors for VTE, for example cancer and advanced age. In the high D-dimer group, rivaroxaban was non-inferior to enoxaparin at day 10 and, unlike the low D-dimer group, superior to placebo at day 35 (P < 0.001) and days 11-35 (P < 0.001). In both groups, bleeding outcomes favored enoxaparin/placebo.

CONCLUSIONS

Elevated baseline D-dimer concentrations may identify acutely ill, hospitalized medical patients at high risk of VTE for whom extended anticoagulant prophylaxis may provide greater benefit than for those with low D-dimer concentrations.

Using targeted variants of aequorin to measure Ca2+ levels in intracellular organelles

Aequorin is a Ca(2+)-sensitive photoprotein isolated from the jellyfish Aequorea victoria. It is an ideal probe for measuring Ca(2+) concentration ([Ca(2+)]) in intracellular organelles because it can be modified to include specific targeting sequences. On the binding of Ca(2+) to three high-affinity sites in aequorin, an irreversible reaction occurs in which the prosthetic group coelenterazine is released and a photon is emitted. This protocol presents procedures for expressing, targeting, and reconstituting aequorin in intact and permeabilized mammalian cells and describes how to use this photoprotein to measure intracellular [Ca(2+)] in various subcellular compartments.

The use of aequorin and its variants for Ca2+ measurements

Ca(2+)-sensitive photoproteins are ideal agents for measuring the Ca(2+) concentration ([Ca(2+)]) in intracellular organelles because they can be modified to include specific targeting sequences. Aequorin was the first Ca(2+)-sensitive photoprotein probe used to measure the [Ca(2+)] inside specific intracellular organelles in intact cells. Aequorin is a 22-kDa protein produced by the jellyfish Aequorea victoria. On the binding of Ca(2+) to three high-affinity sites in aequorin, an irreversible reaction occurs in which the prosthetic group is released and a photon is emitted. Aequorin has become widely used for intracellular Ca(2+) measurements because it offers many advantages: For example, it can be targeted with precision, functions over a wide range of [Ca(2+)], and shows low buffering capacity. In this article we describe the main characteristics of the aequorin probe and review the reasons why it is widely used to measure intracellular [Ca(2+)].

The mitochondrial calcium uniporter is a multimer that can include a dominant-negative pore-forming subunit

Mitochondrial calcium uniporter (MCU) channel is responsible for Ruthenium Red-sensitive mitochondrial calcium uptake. Here, we demonstrate MCU oligomerization by immunoprecipitation and Förster resonance energy transfer (FRET) and characterize a novel protein (MCUb) with two predicted transmembrane domains, 50% sequence similarity and a different expression profile from MCU. Based on computational modelling, MCUb includes critical amino-acid substitutions in the pore region and indeed MCUb does not form a calcium-permeable channel in planar lipid bilayers. In HeLa cells, MCUb is inserted into the oligomer and exerts a dominant-negative effect, reducing the [Ca(2+)]mt increases evoked by agonist stimulation. Accordingly, in vitro co-expression of MCUb with MCU drastically reduces the probability of observing channel activity in planar lipid bilayer experiments. These data unveil the structural complexity of MCU and demonstrate a novel regulatory mechanism, based on the inclusion of dominant-negative subunits in a multimeric channel, that underlies the fine control of the physiologically and pathologically relevant process of mitochondrial calcium homeostasis.

The mitochondrial calcium uniporter (MCU): molecular identity and physiological roles

The direct measurement of mitochondrial [Ca(2+)] with highly specific probes demonstrated that major swings in organellar [Ca(2+)] parallel the changes occurring in the cytosol and regulate processes as diverse as aerobic metabolism and cell death by necrosis and apoptosis. Despite great biological relevance, insight was limited by the complete lack of molecular understanding. The situation has changed, and new perspectives have emerged following the very recent identification of the mitochondrial Ca(2+) uniporter, the channel allowing rapid Ca(2+) accumulation across the inner mitochondrial membrane.

Hospital-based costs associated with venous thromboembolism treatment regimens

INTRODUCTION

Venous thromboembolism (VTE) poses a significant health and economic burden in US hospitals. Clinical guidelines for acute VTE treatment recommend antithrombotic therapy (at least 5 days) with low molecular weight heparin (LMWH) or unfractionated heparin (UFH). With upcoming US national performance measures requiring successful implementation of evidence-based therapy, cost considerations for anticoagulant choice are of increasing importance to hospitals.

METHODS

This retrospective cohort analysis utilizes discharge records from a large real-world US population (January 2002 to December 2006) to provide total, direct, inpatient medical costs associated with LMWH and UFH for acute VTE treatment. Furthermore, for both LMWH and UFH discharges, we compare VTE-related readmission rates at 30 and 90 days after discharge.

RESULTS

In total, 57 131 discharges were identified (57.7% LMWH; 42.3% UFH). After adjustment for covariates, including age, severity of illness, and length of stay, total direct medical costs per hospital discharge for UFH were $3476.22 vs. $3056.42 for LMWH (P < 0.0001; difference $420). Costs were significantly higher in the UFH group for most cost categories. Notably, drug acquisition cost was higher for LMWH. LMWH treatment was 12% [odds ratio (OR) 0.876; P < 0.001] and 10% (OR 0.895; P = 0.0006) less likely to result in VTE readmission within 30 and 90 days, respectively.

CONCLUSIONS

This study provides the first large, real-world analysis of the total direct medical costs of treating VTE in-hospital. It confirms that, despite higher drug acquisition costs, LMWH is cost-saving compared with UFH in the inpatient setting, and is associated with a lower VTE readmission rate at 30 and 90 days than is UFH.

Results of a pilot study involving the use of an antisense oligodeoxynucleotide directed against the insulin-like growth factor type I receptor in malignant astrocytomas

PURPOSE

Preclinical animal experiments support the use of an antisense oligodeoxynucleotide directed against the insulin-like growth factor type I receptor (IGF-IR/AS ODN) as an effective potential antitumor agent. We performed a human pilot safety and feasibility study using an IGF-IR/AS ODN strategy in patients with malignant astrocytoma.

PATIENTS AND METHODS

Autologous glioma cells collected at surgery were treated ex vivo with an IGF-IR/AS ODN, encapsulated in diffusion chambers, reimplanted in the rectus sheath within 24 hours of craniotomy, and retrieved after a 24-hour in situ incubation. Serial posttreatment assessments included clinical examination, laboratory studies, and magnetic resonance imaging scans.

RESULTS

Other than deep venous thrombosis noted in some patients, no other treatment-related side effects were observed. IGF-IR/AS ODN-treated cells, when retrieved and assessed, were < or = 2% intact by trypan blue exclusion, and none of the intact cells were viable in culture thereafter. Parallel Western blots disclosed IGF-IR downregulation to < or = 10% after ex vivo antisense treatment. At follow-up, clinical and radiographic improvements were observed in eight of 12 patients, including three cases of distal recurrence with unexpected spontaneous or postsurgical regression at either the primary or the distant intracranial site.

CONCLUSION

Ex vivo IGF-IR/AS ODN treatment of autologous glioma cells induces apoptosis and a host response in vivo without unusual side effects. Subsequent transient and sustained radiographic and clinical improvements warrant further clinical investigations.

Subcutaneous enoxaparin once or twice daily compared with intravenous unfractionated heparin for treatment of venous thromboembolic disease

BACKGROUND

Low-molecular-weight heparins administered subcutaneously once or twice daily have been reported to be as safe and efficacious as intravenous unfractionated heparin in the treatment of acute venous thromboembolic disease.

OBJECTIVE

To determine whether subcutaneous enoxaparin administered once or twice daily is as effective as continuously infused unfractionated heparin in acute symptomatic venous thromboembolic disease.

DESIGN

Randomized, controlled, partially blinded equivalence trial.

SETTING

74 hospitals in 16 countries.

PATIENTS

900 patients with symptomatic lower-extremity deep venous thrombosis, including 287 (32%) with confirmed pulmonary embolism.

INTERVENTIONS

Initial therapy with dose-adjusted intravenous unfractionated heparin compared with subcutaneous enoxaparin at fixed dosages of 1.0 mg/kg of body weight twice daily or 1.5 mg/kg once daily. Long-term oral anticoagulation was started in all patients within 72 hours of randomization.

MEASUREMENTS

Clinical end points assessed during a 3-month follow-up period.

RESULTS

Equivalent efficacy was seen in the heparin group and both enoxaparin groups. Symptomatic venous thromboembolism recurred in 12 of 290 patients receiving unfractionated heparin (4.1%), 13 of 298 patients receiving once-daily enoxaparin (4.4%), and 9 of 312 patients receiving twice-daily enoxaparin (2.9%). Compared with unfractionated heparin, the treatment difference was 0.2% (95% CI, -3.04% to 3.49%) for once-daily enoxaparin and -1.2% (CI, -4.2% to 1.7%) for twice-daily enoxaparin. Incidence of major hemorrhage did not differ among the three treatment groups. Major hemorrhage occurred in 6 of 290 patients (2.1%) in the unfractionated heparin group, 5 of 298 patients (1.7%) in the once-daily enoxaparin group, and 4 of 312 patients (1.3%) in the twice-daily enoxaparin group.

CONCLUSIONS

Subcutaneous enoxaparin once or twice daily is as effective and safe as dose-adjusted, continuously infused unfractionated heparin in the prevention of recurrent symptomatic venous thromboembolic disease.

[The timing of tracheotomy. Advantages of early timing]

Tracheotomy is widely performed in Intensive Care Units, but no general agreement exists about its correct timing in ventilated patients. Many articles examine the complications of long-term endotracheal intubation and tracheotomy; few data, however, relate these damages and ventilated patients outcome to tracheotomy timing. No universally accepted guidelines exist, but last years clinical practice prefer early tracheotomy, particularly if performed by percutaneous approach. Many authors suggest prospective and randomized clinical trials in order to evaluate tracheotomy performance correct time. At this time decision making must consider risks and benefits related to patient clinical conditions: at this regard some reports seem to advantage early tracheotomy.

The influence of length of stay in the ICU on power of discrimination of a multipurpose severity score (SAPS). ARCHIDIA

OBJECTIVE

To assess how the power of discrimination of a multipurpose severity score (Simplified Acute Physiology Score; SAPS) changes in relation to the length of stay (LOS) in the intensive care unit (ICU).

DESIGN

In order to compute the SAPS probability, a model derived from logistic regression was developed in a cohort of 8059 patients. Measures of calibration (goodness-of-fit statistics) and discrimination [receiver operating characteristic (ROC) curve and relative area under the curve (AUC)] were adopted in a developmental set (5389 patients) and a validation set (2670 patients), both randomly selected. Once the logit was developed and the model validated, the whole database (8059 patients) was again assembled. To evaluate the accuracy of first-day SAPS probability over time, area under the ROC curve was computed for each of the initial 10 days of ICU care and for day 15.

SETTING

24 Italian ICUs.

PATIENTS

A total of 8059 patients out of 10065 consecutive admissions over a period of 3 years (1990-1992) were included in this study. Patients whose SAPS was not correctly compiled (n = 687), patients younger than 18 years (n = 442), and patients whose LOS was less than 24 h (n = 877) were excluded from this analysis.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The logistic model gave good results in terms of calibration and discrimination, both in the developmental set (goodness-of-fit: chi 2 = 9.24, p = 0.32; AUC = 0.79 +/- 0.01) and in the validation set (goodness-of-fit: chi 2 = 8.95, p = 0.537; AUC = 0.78 +/- 0.01). The AUC for the whole database showed a loss in discrimination closely related to LOS: 0.79 +/- 0.01 at a day 1 and 0.59 +/- 0.02 at day 15.

CONCLUSION

The logistic model that we developed meets high standards for discrimination and calibration. However, SAPS loses its discriminative power over time; accuracy of prediction is maintained at an acceptable level only in patients who stay in the ICU no longer than 5 days. The stay in the ICU represents a complex variable, which is not predictable, that influences the performance of SAPS on the first day.

Lymphoscintigraphy. A reliable test for the diagnosis of lymphedema

The efficacy of lymphoscintigraphy in the diagnosis of lymphedema was evaluated in 17 patients (total of 20 extremities). Final diagnoses were: three extremities with primary lymphedema, eight with secondary lymphedema, and nine with edema due to other causes. Qualitative interpretation of image patterns was reliable in differentiating lymphedema from edema of other origins (sensitivity 73%, specificity 100%). There were eight true-positive, nine true-negative, no false-positive, and three false-negative extremities. The three false-negative results occurred in extremities that were not imaged within the first hour. Lymphoscintigraphy is a reliable, objective, and noninvasive means of supporting the diagnosis of lymphedema, and lends itself more readily to repeated studies for follow-up than other available tests.

[Cystic dilatation of the choledochus]

The authors show a case of cystic dilatation of choledochus in a woman patient aged 10. After reporting its nosologic classification, drawn from the world literature, they dissert about the treatment, which should be essentially surgical. The Authors performed a new surgical technique, as an alternative to the suggestion of other Authors. The method adopted consists of the partial resection of the cyst and subsequent reconstruction of choledochus on Kohr's tube.

[Method for radiographic determination of body contours (author's transl)]

After a brief description of some methods used for the determination of body contour in radiotherapy, the authors present a method which using the double radiographic exposition, allows such a determination with precision and without having need of expensive equipments. They present the graphic results of the tests done on phantom and in vivo, comparing these ones with the measures obtained by CT, performed in purpose of diagnosis. For a rapid execution of the method, they list the passages to follow for its application.

[Vascular compression of the duodenum. Apropos of a case of acute obstruction]

A case of acute obstruction of the duodenum in an aged patient due to aorto-mesenteric squeezing is described. An account of the anatomopathological features, symptomatology, radiological diagnosis, and treatment of this condition is presented. Duodedenojejunostomy is the operation of choice, but it must be adjusted to the local and general anatomopathological situation.