Comparisons of the morbidities of a double gastrocnemius flap and a medial gastrocnemius flap in the orthoplastic reconstruction around the knee

BACKGROUND

The pedicled gastrocnemius flap is commonly used to treat lower limb defects. Either the medial, lateral, or both heads can be used. When extended soft tissue defects are present, a double gastrocnemius (DG) flap may be used. However, no data of the additional donor site morbidity compared to a medial gastrocnemius (MG) flap are available. The aim of this study was to compare the donor site morbidity of a DG with that of a MG.

METHODS

Patients with a soft tissue defect around the knee, treated with a gastrocnemius flap between 2018 and 2021 at the University Hospital of Lausanne and Bari, with a minimum follow-up of 12 months, were included. According to the size and the position of the defect, it was decided whether one (10 patients) or two (9 patients) heads of the gastrocnemius were necessary for the coverage. The mean age was 61 years (range 42-82) in DG, and 63 years (range 45-78) in MG. The average defect size was 89.8 cm2 in the DG group and 53.4 cm2 in the MG group. The etiologies were trauma (n = 10), infection (n = 7) and sarcoma (n = 2). A medial approach or a posterior midline approach was used for the harvesting of the gastrocnemius muscle. Once the flap was harvested, it was rotated and transposed anteriorly over the defect, either through a subcutaneous tunnel or by dividing the intervening skin bridge, depending on the soft tissue defect. A split-thickness skin graft was used to close the skin over the remaining exposed muscle flap. The active range of motion of the ankle and knee joints was measured. Muscle strength was assessed with a hand-held dynamometer and by the ability to stand on tiptoe. Physical function was evaluated through the Lower Extremity Functional Scale (LEFS).

RESULTS

The two groups were homogeneous, with no significant difference in age, sex, and BMI. All flaps survived in both groups. Both groups showed lower values in strength and range of motion of the operated leg, when compared to contralateral side. In plantar flexion, this accounted for a reduction in MG by 3.8 ± 1.0 kg of strength and 8 ± 3° of ROM, and in DG by 4.7 ± 1.7 kg and 16 ± 4°, respectively. For knee flexion, the reduction in MG was 4.4 ± 0.6 kg and 16 ± 7°, while in DG 5.6 ± 1.0 kg and 28 ± 6°. In the MG group, 60% were able to stand on the tiptoe of the operated leg, as opposed to 0% in DG. The average LEFS score in DG was lower by 10.9 points (p < .05). Questions concerning running and jumping had a lower score in DG (p < .01).

CONCLUSIONS

The harvesting of both gastrocnemii led to significant additional donor site morbidity compared to the harvesting of the medial gastrocnemius alone. However, the additional morbidity did not have an impact on activities of daily living and walking, even though it limited the ability to perform more demanding tasks such as running and jumping. Therefore, based on our study, the choice of a DG flap should be critically assessed in younger, more demanding patients.

Evaluating the Trend of VRE carriages in Health Facilities: A Retrospective Study from 2019-2022

Background

Healthcare-associated infections (HAIs) and multidrug resistance (MDR) are a growing public health threat and pose a risk to patient safety in healthcare facilities. Vancomycin-resistant Enterococci (VRE) are responsible for nosocomial infections and have intrinsic and acquired resistance to many antibiotics, including glycopeptides. VRE carriage can remain undetected, increasing the risk of contact transmission. Identifying colonized patients is crucial for the implementation of preventive measures.

Aims

The aims of this study were to evaluate the trend of VRE carriage based on rectal swab results between 2019 and February 2022 in a large Italian trust and the percentage of patients with VRE colonization at the time of hospitalization.

Methods

This was a retrospective observational study based on results of rectal swabs performed for screening on admission between January 2019 and February 2022 in four hospitals part of a single trust in Turin, North-Western Italy. The study collected data on the date of specimen collection, type of specimen, isolated pathogen and the date of hospital admission. Descriptive analysis of data was performed, and duplicate samples were not considered.

Results

From January 2019 to February 2022 we collected 5025 rectal swabs performed in hospitals of the trust, of which 3037 were performed in 2019 (60%), 741 in 2020 (15%), 611 in 2021 (12%) and 636 in the first two months of 2022 (13%). VRE positivity was found in 162 (3%) rectal swabs, of which 2 cases in both 2019 (0.1%) and 2020 (0.3%), 95 in 2021 (15.5%) and 63 in the first two months of 2022 (9.9%). Furthermore, 52% (84/162) of positive rectal swabs were performed at admission, whereas the remaining 48% (78/162) of positive rectal swabs were performed after 48h.

Conclusions

This study found an increasing trend of VRE carriage in the study population during the SARS-CoV-2 pandemic, highlighting the importance of screening patients for VRE carriage to prevent worsening clinical conditions, environmental contamination, and prolonged hospitalization.

Covid-19 Hospitalization Costs Assessment in an Italian Covid Hospital

Introduction

Many consequences resulted from the breakout of the COVID-19 pandemic in Europe, which have disrupted our economic, social and medical world. This allowed us to measure and assess the hospitalisation costs regarding the COVID-19 disease at Martini Hospital in Turin, one of the hospitals entirely committed to the COVID-19 care, between January and June 2021.

Methods

In this single center retrospective study, we collected and analysed cost data on patients admitted at Martini Hospital in the time frame of January-June 2021 and compared the analysis with the same period in 2020, at a time when the hospital was not dedicated to Covid-19 patients. Cost data included full-time and temporary employees salaries, drugs, medical and non-medical supplies and equipment and facility utilities. We then estimated the cost per treated COVID-19 episode, in comparison with the cost per any desease including Covid-19.

Results

The first 6 months of 2021 registered 2,136 hospital discharges, while same period in 2020 counted 4376. The mean duration of the hospital stay was 7,67 days in 2020 and 12,83 in 2021. The average charge per treated episode doubled (+52,5%) from Euros 8997 in 2020 to Euros 19026 in 2021. The mean revenue increased of 35% from Euros 3280 in 2020 to Euros 5041 in 2021. This is due to the major complexity of care required for Covid patients. As it is, in 2021 the average complexity index of 2.13 while in 2020 it was 1.39.

Conclusions

Clinical management and treatment of COVID-19 economically strain the European health-care systems. The study of COVID-19 treatment costs, and their differences between 2020 and 2021 suggests an economic challenge for the entire Italian health system and emphasises the necessity to avoid the recurrence of such an economic impact by implementing effective infection prevention and control policies.

Key messages

• The Covid-19 pandemic has been straining both the European health and economic systems.

• Studying the Covid-19 expenditures allows to frame unexpected new challenges regarding health-care systems.

Primary care management strategies and COVID-19 related hospitalization: a population-based study

Background

Due to SARS-CoV-2 rapid mutations, the ending of the pandemic is still proceeding at a slow pace and there is the need to strengthen and invest in health systems that avoid hospital overload and its consequences on patients’ health. Most symptomatic infections have mild to moderate respiratory symptoms and patients are managed in the context of primary care. In Italy, literature on COVID-19 outpatients management by general practitioners (GPs) is scarce. This study explores the effect of GP active care and monitoring on COVID-19-related hospitalization in patients in the province of Modena (Italy) and investigates the possible determinants of GP's management.

Methods

This is a retrospective cohort study of SARS-CoV-2 infected adult outpatients managed by their GPs from March 2020 to April 2021 in the province of Modena (Italy). Data on GPs’ characteristics, management strategies (visits and remote monitoring), patients’ socio-demographic characteristics, and hospitalization were extracted from the GP's electronic medical records and were analyzed using descriptive statistics and multiple logistic regression.

Results

46 GPs agreed to participate, and 5340 patients were included in the analyses. 3014 (56%) patients received active daily remote monitoring and 840 (16%) were visited at home. Remote monitoring and home visits were both associated with a reduction of the probability of hospitalization rate of approximately 50% (respectively OR:0.52, 95%CI:0.33, 0.80 and OR:0.50, 95%CI;0.33, 0.78). Preliminary analysis of determinants showed that GPs’ patient load, setting, age, and sex were significantly associated with management strategies.

Conclusions

Active monitoring performed by GPs was effective in reducing the probability of hospitalization. Primary and hospital care integration can be effective for COVID-19 management. Studies on GPs’ characteristics and patient load and their effect on their ability to care for patients are needed.

Key messages

• Active remote monitoring and visits performed by Italian general practitioners effectively reduced hospitalization for COVID-19.

• Primary and hospital care integration can be effective for COVID-19 management.

Use of polarimetric lidar for the study of oriented ice plates in clouds

A polarization lidar operating at 532 nm was converted into an automatic, polarimetric lidar capable of measuring the entire Stokes vector of backscattered light and its derived quantities. Among these quantities, circular and linear depolarizations were studied as tools for investigating the presence of anisotropic scattering media. Isotropic scatterers show a simple relationship between linear and circular depolarization, a relation that we confirm theoretically and experimentally. Deviations from this relation, which are possible in the presence of anisotropic scatterers such as horizontally oriented ice plates when they are observed with a slant lidar, were studied both numerically and experimentally.

Functional group characterization of indoor, outdoor, and personal PM: results from RIOPA

Fourier transform infrared (FTIR) spectra of outdoor, indoor, and personal fine particulate matter (PM(2.5)) samples were collected during the Relationship of Indoor, Outdoor, and Personal Air (RIOPA) study. FTIR spectroscopy provides functional group information about the entire PM(2.5) sample without any chemical preparation. It is particularly important to characterizing the poorly understood organic fraction of PM(2.5). To our knowledge this is the first time that FTIR spectroscopy has been applied to a PM(2.5) exposure study. The results were used to chemically characterize indoor air and personal exposure. Sulfate was strongest in outdoor samples, which is consistent with the generally accepted understanding that sulfate is of outdoor origin. Absorbances attributed to soil dust were also seen in many outdoor and some indoor and personal samples. Inorganic nitrate absorbances were a common feature of many California and some New Jersey samples. Carbonyl absorbances showed substantial variation in strength, number of peaks, and wave number shift between samples, indicating variability in composition and sources. Absorbances attributed to aliphatic hydrocarbon and amide functional groups were enhanced in many personal and indoor samples, which suggested the influence of indoor sources in these homes. We speculate that meat cooking is one possible source of particulate amides.

PRACTICAL IMPLICATIONS

To our knowledge this is the first time that FTIR spectroscopy has been used to characterize the composition of indoor and personal PM(2.5). The presence of sulfate, nitrate, ammonium, soil dust and a number of organic functional groups are all detected in one analysis on filter samples without extraction or other sample preparation. Differences between indoor and outdoor spectra are used to identify spectral features due to indoor-generated PM(2.5). Particularly interesting are the much larger aliphatic absorbances, shifts in carbonyl absorbances, and occasional small amide absorbances found in indoor and personal spectra but rarely in outdoor spectra. These observations are important because organics make up a large portion of PM(2.5) mass and their composition and properties are poorly characterized. The properties and behavior of organic compounds in airborne particles are often predicted based on their functional group composition. This analysis begins the development of a better understanding of the functional group composition of indoor and personal PM(2.5) and how it differs from that of outdoor PM(2.5). Eventually this will lead to an improved understanding of the properties, behavior and effects of PM(2.5) of indoor and outdoor origin.

Assessment of butadiene exposure in synthetic rubber manufacturing workers in Texas using frequencies of hprt mutant lymphocytes as a biomarker

1,3-Butadiene (BD), which is used to manufacture synthetic rubber, is a mutagen and carcinogen. Because past occupational exposures have been associated with an increased risk of leukemia, there has been a dramatic reduction in workplace exposure standards. The health benefits of these reduced levels of occupational exposure to BD will be difficult to evaluate using relatively insensitive traditional epidemiological studies; however, biomarkers can be used to determine whether there are genotoxic effects associated with recent exposures to BD. In past studies of BD-exposed workers in Southeast Texas, we observed an increase in the frequency of lymphocytes with mutations in a reporter gene, hprt. Frequencies of hprt mutant cells correlated with air levels of BD and with the concentration of a BD metabolite in urine. Average exposures to 1-3 parts per million (p.p.m.) of BD were associated with a threefold increase in hprt variant (mutant) frequencies (Vfs). We now report results from a follow-up study of workers in a synthetic rubber plant in Southeast Texas. Thirty-seven workers were evaluated on three occasions over a 2-week period for exposure to BD by the use of personal organic vapor monitors and by determining the concentration of a BD metabolite in urine. The frequency of hprt mutants was determined, by autoradiography, with lymphocyte samples collected 2 weeks after the final exposure measurement. Based on their work locations, the study participants were assigned to high-exposure (N=22) or low-exposure (N=15) groups. The BD exposure, +/-standard error, of the workers in the high-exposure group (1.65+/-0.52 p.p.m.) was significantly greater than the low-exposure group (0.07+/-0.03 p.p.m.; P<0.01). The frequency of hprt mutant lymphocytes was also significantly different in the two groups (high, 10.67+/-1.5 x 10(-6); low, 3.54+/-0.6 x 10(-6); P<0.001). The concentration of the urine metabolite was greater in the high-exposure group, but the difference was not significant. The correlation coefficient between hprt Vf and BD exposure levels was r=0.44 (CI(95), 0.11-0.69; P=0.011). This study reproduced the findings from a previous study at this plant. Although studies of butadiene-exposed workers in other countries have not detected an effect of exposure on frequencies of hprt mutant lymphocytes, we have repeatedly observed this result in our studies in Texas.

Treatment of ipsilateral femoral neck and shaft fractures with the Russell-Taylor reconstructive nail

Twenty-seven ipsilateral femoral neck and shaft fractures were treated with the Russell-Taylor reconstructive nail. Follow-up ranged from 6-48 months (average: 23.6 months). Femoral neck fractures healed within an average of 3.7 months and femoral shaft fractures healed within an average of 4.8 months. Complications included one case of avascular necrosis of the femoral head, a varus healing of one femoral neck fracture, and a rotational malalignment of the femoral shaft in another case. There were no cases of hardware failure. The Russell-Taylor reconstructive nail allows concomitant hip and shaft fractures to be fixed with a single implant.

MF59 adjuvant enhances the antibody response to recombinant hepatitis B surface antigen vaccine in primates

The effect of the proprietary adjuvant MF59 on the immunogenicity of a recombinant hepatitis B virus (HBV) vaccine, PreS2+SAg, was investigated in baboons. The magnitude and duration of the antibody response to hepatitis B surface antigen (anti-HBs) induced by the HBV/MF59 vaccine was compared with the same antigen combined with alum and with two licensed alum vaccines. After one immunization, the HBV/MF59 vaccine generated anti-HBs titers >10 mIU/mL in a greater proportion of animals, and mean titers were 26- to 84-fold higher than titers from alum vaccines. After a third immunization, the HBV/MF59 vaccine generated titers 38- to 127-fold higher than alum vaccines. Seven months after the third immunization, HBV/MF59 elicited titers 75- to 472-fold higher than alum vaccines. The dramatic immune response elicited by HBV/MF59 in baboons suggests that MF59 may be a desirable adjuvant for use in improved HBV vaccines for humans.

[Allergic rhinitis due to cockroach antigenic components. An emerging pathology?]

The aim of our study was the evaluation of the role of these insects as causative agents of perennial rhinitis. We studied 317 subjects of both sexes (175 F and 142 M) living in Naples area and examined consecutively in our Centre for perennial nasal symptoms of suspected IgE mediated aetiology. All patients underwent the following diagnostic procedures: anamnestic procedures by using an internal questionnaire, clinical examination, skin prick test by using commercially available allergenic extracts and an allergenic extract containing the whole bodies of Blattella germanica and orientalis, Periplaneta americana. Blood samples for specific IgE determinations and a rhinologic visit were also carried out in patients with cockroach skin Prick test positivity. 14 of 317 subjects, prevalently young males, presented a skin positivity to cockroach allergens. All patients showed a moderate low degree of cutaneous and a low degree of serologic sensitization to allergens of these insects. Our preliminary data seem to demonstrate a mild role of cockroaches as causative agents of perennial rhinitis in Naples area. Further studies are necessary for a more appropriate knowledge of this allergy.

Parameterization of cloud lidar backscattering profiles by means of asymmetrical Gaussians

A fitting procedure for cloud lidar data processing is shown that is based on the computation of the first three moments of the vertical-backscattering (or -extinction) profile. Single-peak clouds or single cloud layers are approximated to asymmetrical Gaussians. The algorithm is particularly stable with respect to noise and processing errors, and it is much faster than the equivalent least-squares approach. Multilayer clouds can easily be treated as a sum of single asymmetrical Gaussian peaks. The method is suitable for cloud-shape parametrization in noisy lidar signatures (like those expected from satellite lidars). It also permits an improvement of cloud radiative-property computations that are based on huge lidar data sets for which storage and careful examination of single lidar profiles can't be carried out.

Derivation of Mount Pinatubo stratospheric aerosol mean size distribution by means of a multiwavelength lidar

A multiwavelength lidar operated in Sodankyla, Finland, during the European Arctic Stratospheric Ozone Experiment (December 1991-March 1992). It produced vertical profiles of stratospheric aerosols at four wavelengths. The determination of aerosol mean size distribution has been performed by use of extinction/backscattering ratios as obtained from lidar data processing at 355, 352, and 750 nm. Lognormal distributions of sulfuric particles with mode radius of r(m) = 0.12-0.25 µm and corresponding widths of s = 2-1.6 have been retrieved as best fits of experimental data, in good agreement with in situ measurements. A successful attempt to derive bimodal log-normal distributions is also described, together with the experimental and theoretical problems involved.

Infected tibial pseudarthrosis. A 2-year follow up on patients treated by the Ilizarov technique

The Ilizarov technique with a circular external fixator was used in the treatment of infected tibial nonunions. This is a report on 13 patients with a 2-year follow up after removal of the external fixation. There was no debridement of the site of nonunion performed. Union was obtained in all cases. There was no recurrence of infection at follow up. The Ilizarov technique provides the orthopedic surgeon with another alternative in the treatment of complicated tibial nonunions and their associated problems.

The structure and development of osteogenetic repair tissue according to Ilizarov Technique in man. Characterization of extracellular matrix

Distraction osteogenesis by the method of Ilizarov has permitted the study of bone formation. This is an analysis of 64 human biopsies in patients who were undergoing tibial lengthening by the method of Ilizarov. After analysis by conventional and polarized light microscopy, four stages of bone formation were identified. Bone formation is of the direct type with no cartilaginous phase.

Posture and VDU operator satisfaction

Few studies have looked at how workers adapt their posture to fit their work environment and virtually none have compared this adaptation to reports of user satisfaction. This study focused on the relationship between users' size and posture, and the physical attributes of VDU workplaces. A survey on VDU operator satisfaction was conducted and compared to results from a controlled study on posture transitions occurring at VDU workplaces. Results demonstrate that workers adapt their posture to fit their work environment, rather than adjust their workstation to permit an optimal posture that may increase productivity. These results support the recommendations for comprehensive worker training on the ergonomic benefits of workstation adjustment and suggest the need for dynamically adjustable workstation components that periodically conform to the workers posture.

Posterolateral lumbosacral arthrodesis (P.L.A.). A study of 85 cases

Posterolateral lumbar and lumbosacral arthrodesis has been used during the last 50 years as a method of posterior arthrodesis in patients who have undergone previous laminectomies or after previous unsuccessful attempts at posterior fusion. The higher percentages of successful fusion has extended the use of this technique to other conditions such as spondylolisthesis and lumbar pain due to segmental instability. The present study is a clinical and radiographic evaluation of the results obtained in a series of 84 patients affected by lumbar or lumbosciatic pain arising from different causes - spondylolisthesis, degenerative lumbar disc disease or failed operations for lumbar disc prolapse. The follow-up was 2-6 years.

Surgical treatment of giant-cell tumor of the spine. The experience at the Istituto Ortopedico Rizzoli

We reviewed the cases of nine patients with a giant-cell tumor of the vertebrae. All segments of the spine can be affected by the tumor, but there was a predilection for the lumbar segments in our series. Pain was present in all patients. The maximum duration before the diagnosis was made was three years and the minimum, forty-five days (average, 12.2 months). In six patients a neural deficit was also present. One patient was treated many years ago by radiation therapy alone; three patients were treated by decompressive laminectomy; two, by excision of the lesion and postoperative radiation therapy; and three patients underwent lesional but extensive excision as well as arthrodesis without any preoperative or postoperative radiation therapy. We have obtained good results with the latter treatment; after follow-ups of sixty, twenty-six, and twenty-four months in three patients the pain and the neural symptoms subsided, while roentgenographic examination showed no evidence of local recurrence. In all patients the autogenous bone grafts appeared to be incorporated, without any secondary deformity. We concluded that, due to the development of better surgical techniques, the surgical approach is probably the best modern treatment for a giant-cell tumor located in the spine.

Congenital hyperphosphatasaemia. Case report of a patient observed between the ages of three and eleven years

The authors investigated a case of congenital hyperphosphatasaemia. This disease is due to a change in the bone metabolism and produces severe skeletal deformities. Treatment with calcitonin relieved the pain but had no effect on either the evolution of the deformities or the laboratory findings.

[Methemoglobinemia; a description of a case of NADH methemoglobulin reductase deficiency]

A case of NADH-methaemoglobin-reductase deficiency in a 64 year old man with marked cyanosis and without evidence of cardiac or pulmonary diseases is reported. The level of methaemoglobin was 36% and reached 25% after treatment with ascorbic acid. Erythrocyte NADH-methaemoglobin-reductase activity was only 5% of normal value. Some erythrocyte biochemical and enzymatic characteristics have been evaluated. A family study has also been carried out. Our patient has been considered homozygous for NADH-methaemoglobin-reductase deficiency.