Tibiotarsal Arthrodesis with Retrograde Intramedullary Nail and RIA Graft: A Salvage Technique

Ankle arthrodesis is a commonly used salvage procedure in the management of post-traumatic ankle fractures, which often result in severe disability and may require the amputation of the distal third of the leg. Successful ankle arthrodesis relies on a thorough assessment of local and systemic risk factors to ensure optimal results. Failure to accurately assess these factors may lead to unsatisfactory results. High-energy trauma causing bone defects and soft tissue necrosis often results in osteomyelitis, a condition that poses a significant threat to the success of the arthrodesis procedure. It is important to apply a standardised surgical protocol to minimise the possibility of superficial and deep infection and limit damage to the neighbouring soft tissues. Therefore, it is critical to undertake surgical lavage and debridement and administer systemic and local antibiotic therapy, along with the use of a spacer, to eradicate infection prior to performing arthrodesis. In this study, we present our experience in the recovery of limbs with post-traumatic complications via tibio-astragalic or tibio-calcaneal arthrodesis using a retrograde intramedullary nail technique. The approach involves a multi-step procedure using a previous antibiotic spacer implant and an autologous bone graft (RIA). This study spanned a period from January 2014 to December 2021 and included 35 patients (12 women and 23 men) with a mean age of 47.8 ± 20.08 years (range: 22-85 years). Among the patients, 18 had osteomyelitis following AO 43 C3 fractures, and 9 of them had previous exposure and bone loss at the time of injury. The remaining cases included 10 patients with AO 44 C fracture outcomes and 7 patients with AO 44 B fracture outcomes. Our results emphasise the importance of the meticulous management of local and systemic risk factors in ankle arthrodesis procedures. The successful eradication of infection and subsequent arthrodesis can be achieved via the implementation of surgical lavage, debridement, and systemic and local antibiotic therapy using spacers. This surgical protocol implemented by us has yielded excellent results, saving affected limbs from post-traumatic complications and avoiding the need for amputation. Our study contributes to the existing knowledge supporting the use of retrograde arthrodesis with intramedullary nails in severe cases where limb salvage is the primary goal. However, further research and long-term follow-up studies are needed to validate these results and evaluate the effectiveness of this technique in a larger patient population.

Burden of rare coding variants in an Italian cohort of familial multiple sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a chronic inflammatory and neurodegenerative demyelinating disease of the central nervous system. It is a complex and heterogeneous disease caused by a combination of genetic and environmental factors, and it can cluster in families.

OBJECTIVE

to evaluate at gene-level the aggregate contribution of predicted damaging low-frequency and rare variants to MS risk in multiplex families.

METHODS

We performed whole exome sequencing (WES) in 28 multiplex MS families with at least 3 MS cases (81 affected and 42 unaffected relatives) and 38 unrelated healthy controls. A gene-based burden test was then performed, focusing on two sets of candidate genes: i) literature-driven selection and ii) data-driven selection.

RESULTS

We identified 11 genes enriched with predicted damaging low-frequency and rare variants in MS compared to healthy individuals. Among them, UBR2 and DST were the two genes with the strongest enrichment (p = 5 × 10^-4 and 3 × 10^-4, respectively); interestingly enough the association signal in UBR2 is driven by rs62414610, which was present in 25% of analysed families.

CONCLUSION

Despite limitations, this is one of the first studies evaluating the aggregate contribution of predicted damaging low-frequency and rare variants in MS families using WES data. A replication effort in independent cohorts is warranted to validate our findings and to evaluate the role of identified genes in MS pathogenesis.

Identification of differential DNA methylation associated with multiple sclerosis: A family-based study

Multiple Sclerosis (MS) is caused by a still unknown interplay between genetic and environmental factors. Epigenetics, including DNA methylation, represents a model for environmental factors to influence MS risk. Twenty-six affected and 26 unaffected relatives from 8 MS multiplex families were analysed in a multicentric Italian study using MeDIP-Seq, followed by technical validation and biological replication in two additional families of differentially methylated regions (DMRs) using SeqCap Epi Choice Enrichment kit (Roche®). Associations from MeDIP-Seq across families were combined with aggregation statistics, yielding 162 DMRs at FDR ≤ 0.1. Technical validation and biological replication led to 2 hypo-methylated regions, which point to NTM and BAI3 genes, and to 2 hyper-methylated regions in PIK3R1 and CAPN13. These 4 novel regions contain genes of potential interest that need to be tested in larger cohorts of patients.

Lower core body temperature and greater body fat are components of a human thrifty phenotype

BACKGROUND/OBJECTIVES

In small studies, a thrifty human phenotype, defined by a greater 24-hour energy expenditure (EE) decrease with fasting, is associated with less weight loss during caloric restriction. In rodents, models of diet-induced obesity often have a phenotype including a reduced EE and decreased core body temperature. We assessed whether a thrifty human phenotype associates with differences in core body temperature or body composition.

SUBJECTS/METHODS

Data for this cross-sectional analysis were obtained from 77 individuals participating in one of two normal physiology studies while housed on our clinical research unit. Twenty-four-hour EE using a whole-room indirect calorimeter and 24-h core body temperature were measured during 24 h each of fasting and 200% overfeeding with a diet consisting of 50% carbohydrates, 20% protein and 30% fat. Body composition was measured by dual X-ray absorptiometry. To account for the effects of body size on EE, changes in EE were expressed as a percentage change from 24-hour EE (%EE) during energy balance.

RESULTS

A greater %EE decrease with fasting correlated with a smaller %EE increase with overfeeding (r=0.27, P=0.02). The %EE decrease with fasting was associated with both fat mass and abdominal fat mass, even after accounting for covariates (β=-0.16 (95% CI: -0.26, -0.06) %EE per kg fat mass, P=0.003; β=-0.0004 (-0.0007, -0.00004) %EE kg(-1) abdominal fat mass, P=0.03). In men, a greater %EE decrease in response to fasting was associated with a lower 24- h core body temperature, even after adjusting for covariates (β=1.43 (0.72, 2.15) %EE per 0.1 °C, P=0.0003).

CONCLUSIONS

Thrifty individuals, as defined by a larger EE decrease with fasting, were more likely to have greater overall and abdominal adiposity as well as lower core body temperature consistent with a more efficient metabolism.

A novel USP9Y polymorphism allowing a rapid and unambiguous classification of Bos taurus Y chromosomes into haplogroups

A new sequence-tagged site (STS) was identified within intron 26 of the bovine USP9Y gene, showing an 81-base pair insertion (g.76439_76440ins81 in sequence with GenBank accession FJ195366) able to distinguish Y2 and Y3 Bos Y haplogroups from Y1. Moreover, four Y3-specific sequence variants allow a distinction from haplogroup Y2. The typing of a Bison bison Y chromosome indicates that the ancestral allele for the USP9Y 81-bp insertion is the short Y1 version. The results from typing the new STS in 1230 cattle Y chromosomes are fully consistent with their classification through standard methods. Thanks to the newly identified STS, it is now possible to assign cattle Y chromosomes to the currently known haplogroups using a single marker.

Comparative mapping and genomic annotation of the bovine oncosuppressor gene WWOX

WWOX (WW domain-containing oxidoreductase) is the gene mapping at FRA16D HSA16q23.1, the second most active common fragile site in the human genome. In this study we characterized at a detailed molecular level WWOX in the bovine genome. First, we sequenced cDNA from various tissues and obtained evidence in support of a 9-exon structure for the gene, similar to the human gene. Then, we recovered BACs using exon tags and annotated the gene to a >1-Mb genomic region of BTA18 using the Btau 4.0 genome assembly as a reference, thus resolving an issue related to exon 9, which is not included in the genomic annotation of the gene in the Entrez database. Finally, BACs spanning WWOX were used as FISH probes to obtain comparative mapping of the gene in Bos taurus, Bubalus bubalis, Ovis aries and Capra hircus to BTA18q12.1, BBU18q13, OAR14q12.1 and CHI18q12.1, respectively. Our data show that the chromosomal location of WWOX is conserved between man and 4 major domesticated species. Moreover, the annotation of the bovine gene also suggests a highly conserved genomic arrangement, including number and size of introns.

[Infectious diseases in general practice and antibiotic prescription. Observational study in Sicily]

Drug utilisation studies have shown wide differences, among different countries, in the prescribing behaviour in general practice. In Italy, for instance, the choice of antibiotic prescription seems to show a wider use of parental antibiotic. Aim of this study was to describe antibiotic prescribing pattern and therapeutic doses used by Sicilian general practitioners (GPs) and evaluate their prescribing attitudes regarding the use of parental ones. Each practitioner had to fill a questionnaire for each therapeutic intervention ended with an antibiotic prescription during a period of 6 months. Diagnosis and drugs were classified according to the International Classification of Diseases (ICD-10) and to Anatomical Therapeutic Chemical Classification (ATC), respectively. On 9395 prescriptions performed by 76 doctors of 25 Sicilian towns, the analysis indicated that acute respiratory symptoms represent the commonest indication (31.7%) for a medical consultation, and that Macrolides [such as azithromycin (8.8%) and clarithromycin (8.3%)], Penicillin [such as amoxycillin (7.1%%) and co-amoxiclav (8.4%)], III generation of Cephalosporins [such as cefixime (5.5%) and ceftriaxone (5.1%)] represent the most common used therapeutic groups. The choice of the route of administration was influenced by age of the patients and, more significantly, by symptoms and signs of the disease, rather than by bacteria suspected to cause the disease. In conclusion, our data clearly indicate lack of knowledge of antibacterial therapy guidelines among GPs in Sicily, as well as the need of an independent educational training in order to improve knowledge of antibiotics and to decrease the cost of the health care.

Epilepsy: a study of adolescence and groups

We report a 2-year study of 'psychological support' of a group of seven adolescents (five female and two male) with both non-symptomatic generalized and partial epilepsy with onset before puberty. Two child neuropsychiatrists, supervised by a Freudian psychoanalyst specializing in group therapy, conducted the sessions. Sessions were aimed at improving comprehension and acceptance of the condition and its consequences through comparison of thoughts, fantasies, and preoccupations regarding epilepsy, including significance of epileptic seizures and their possible effects on sexuality, pregnancy, mental state, patient resistance to drug therapy, speaking openly about illness, and social and job-related problems. Group dynamics were also examined to improve subject interaction and self-identification. This method varies from the 'self-help' type of intervention which uses an interpretative and reflective approach to interaction of group members.

[Acute cholecystitis]

Acute cholecystitis is a non-rare disease, the incidence of which was increasing in the last years parallel to biliary lithiasis, which in 90% of cases is the first cause of such pathology. From the anatomopathological standpoint, we distinguish three types of acute cholecystitis: catarrhal, suppurative and gangrenous. The most frequently remarked symptom is ache at right hypochondrium. Only in 30% of cases cholecyst can be palpated, in form of ovoid mass; typical is the positiveness of Murphy's manoeuvre; constant is fever, but not subicterus. The introduction of new methods of ascertainment, exempt from any risks, simple to be performed and remarkably careful, made the diagnostics of acute cholecystites easier: parietal cholecystotomography, hepato-biliary scintigraphy, echotomography (first approach investigation), computerized axial tomography and laparoscopy almost always succeed in dispelling doubts. By using more than one of these investigations, a diagnostic accuracy, touching on 100%, can be reached. The differential diagnosis should be placed with: peptic ulcer, acute pancreatitis, acute appendicitis, gonococcus perihepatitis, virus hepatitis, acute pyelonephritis, right basal pneumonia. The complications an acute cholecystitis can occur are: perforation (localized, in free peritoneum or in a hollow organ), choleperitonaeum, necrosis of hepatic parenchyma, acute pancreatitis. Due to the possible arising of such complications, the mortality unfortunately is not indifferent (5%), especially in patients already weakened by other chronic diseases. Still discussed is the question as to when performing operation. In fact, there are three trends: intervention in immediate emergency, in postponed emergency, or in remote time (preceded by a medical treatment). The Authors prefer the intervention in postponed emergency, as, in their experience, they remarked the poor effectiveness of the delay medical treatment, also involving a greater difficulty in the technical execution of the intervention and a longer stay in hospital. From 1973 up to 1983, 241 cases of acute cholecystitis (158 women and 83 men) were hospitalized at the First Aid Surgical Centre of the Catania University. Eight patients refused the surgical intervention. The remaining 233 underwent, depending upon the seriousness of the affection, the associated diseases and the different reactiveness to the medical treatment, operation: in immediate emergency (26.1%); in postponed emergency (67.8%; in remote time (6.1%). The mortality was 2.2%, with the lowest percentage in the second group.