Patient Perception of Preoperative Nutrition and Recovery After Orthopaedic Surgery

BACKGROUND

Mounting evidence supports the use of nutritional supplementation to improve patient outcomes. The intent of this study was to utilize an anonymous questionnaire to determine patients' baseline knowledge, attitude, and belief regarding nutrition before total hip (THA) or total knee arthroplasty (TKA).

METHODS

After receiving Institutional Review Board approval, an anonymous questionnaire was administered to 300 patients, comprising 184 women (61.3%) and 116 men (38.6%), averaging 67 years (range, 39 to 89). There were 238 TKAs (79.3%), 12 revision TKAs (4%), 44 THAs (14.6%), and 6 revision THAs (2%).

RESULTS

Almost all (99.6%) subjects recognized the importance of preoperative nutrition. Most (83.0%) claimed that they knew what to eat preoperatively to optimize their surgical outcomes and expressed high levels of self-reported confidence (98.6%). Women were more likely to report having knowledge of preoperative nutrition (P = .05), and advanced education levels were linked to higher confidence (P = .002). Only 169 (56.3%) subjects reported knowing what supplements to take. When asked, 84% of subjects stated that they would purchase a nutrition program if recommended by their surgeon. Most studies show that an improved diet and appropriate supplementation can optimize nutritional status and potentially improve surgical outcomes.

CONCLUSIONS

The results of this study confirm that most patients do not know how to achieve optimal nutrition. Therefore, we believe there is a need for patient education on preoperative nutrition and its benefits.

Achieving Correct Balance in Total Knee Arthroplasty with Fixed Varus Deformity

Varus knee deformity is one of the most common deformities presenting for total knee arthroplasty (TKA). When present, a varus knee deformity contributes to overload of the medial joint compartment during gait, leading to increased medial compartment forces as well as lateral soft tissue lengthening. Additionally, a fixed varus deformity is associated with medial soft tissue contractures of the deep and superficial medial collateral ligament (MCL) and posteromedial capsule. With a fixed varus deformity, soft tissue releases may be necessary to create equivalent and rectangular flexion and extension gaps. There may also be anteromedial tibial bone defects, medial femoral condyle defects, and occasionally flexion contractures, especially in more severe cases. In cases of severe varus deformity with medial tibial bone loss, bone defects must be addressed to ensure adequate implant support. In many cases, a primary knee implant can be utilized in cases of varus knee deformity, but occasionally prostheses with higher levels of constraint may be required to balance and stabilize the knee. TKA has had a successful track record, with high levels of long-term implant survivorship even in cases of severe varus. Iatrogenic MCL instability and tibial aseptic loosening are complications associated with TKA in cases of severe varus, and multiple methods to avoid complications are presented here.

Surgical Trends for Managing Knee Osteonecrosis: A 2010 to 2020 United States Nationwide Study

BACKGROUND

Knee osteonecrosis (ON) is rare, with an estimated incidence of 0.01-0.17 per 1,000 person years. Our study aimed to do the following: 1) quantify total operative procedures with rates normalized to the United States population; 2) compare arthroplasty versus joint-preserving procedural trends; and 3) determine rates of specific operative techniques/demographics in patients aged <50 versus >50 years.

METHODS

Using a nationwide database, 8,269 patients diagnosed with knee ON underwent surgical treatment from 2010 to 2020. Documented surgical procedures included total knee arthroplasty (TKA), unicompartmental knee arthroplasty (UKA), and core decompression. Primary outcomes included procedural utilization with subanalyses comparing arthroplasty versus joint-preserving procedures, and age-stratified by under/over 50 years. Linear regressions were evaluated for trends in procedural volumes over time.

RESULTS

From 2010 to 2014, 0.54% of all knee procedures were to treat ON compared to 0.71% from 2015 to 2020 (P < .001). Overall rates of TKA (85.4%) and UKA (10.3%) far exceeded rates of joint preserving procedures (4.3%). Comparing 2010-2014 with 2015-2019, joint-preserving procedures proportionally increased (0.7 to 5.0%, P < .001). Patients <50 years had significantly more joint-preserving procedures (19.5 versus 2.7%). Overall, TKA was the most common procedure (7,062; 85.40%), following by UKA 853; 10.32%) and core decompression (354; 4.28%).

CONCLUSION

To our knowledge, this is the first study to characterize surgical trends in management of knee ON. Overall surgical volume for knee ON has continued to increase, outpacing population growth. Patients who have knee ON are most commonly managed with arthroplasty procedures, specifically TKA. Younger aged patients (<50 years) are more likely to undergo joint-preserving procedures, namely core decompression.

Unusual case of enlarged choroidal vessels in neurofibromatosis type 1 observed with near-infrared reflectance and spectral domain optical coherence tomography

The cardinal diagnostic signs of neurofibromatosis type 1 (NF1) are Lisch nodules of the iris and optic pathway gliomas. Retinal mi-crovascular alterations have been described but with uncertain signi-ficance. Choroidal nodules, detectable with near-infrared reflectance (NIR) imaging, are present in most cases and have been proposed as a new diagnostic criterion. Recently, a study reported the presence of unusual dilated choroidal vessels, visible through NIR examination. We report a case of a 65-year-old patient with NF1. Best-corrected visual acuity was 20/20 with a refractive error of +2.75 diopters in both eyes. Anterior segment examination revealed Lisch nodules in both eyes. At NIR imaging the patient presented typical choroidal alterations in both eyes. No retinal vessel anomalies were detected. The patient presented enlarged choroidal vessels in the left eye, first detected by NIR and then analyzed through enhanced depth imaging spectral domain optical coherence tomography (EDI-SDOCT). These vessels extended from the choroidal-scleral junction to the outer border of the retinal pigment epithelium/Bruch's layer. The choriocapillaris layer was absent above the dilated vessels. The presence of enlarged choroidal vessels may be considered as a novel distinctive ophthalmologic aspect of NF1, but further studies are necessary.

Early identification of keratoconus using pachymetric indexes obtained with spectral domain optical coherence tomography

Purpose

To evaluate the diagnostic ability of pachymetric indexes obtained with Spectral Domain Optical Coherence Tomography (SD-OCT) for early detection of keratoconus (Kc).

Methods

64 patients with Kc in at least one eye (95 eyes, 46 men and 18 women, average age 27.84 ±13.50), 59 healthy control subjects (100 eyes, 28 men and 31 women, average age 27.15 ±16.14). All patients underwent detailed clinical examination, topography and anterior segment OCT. 37 subjects (37 eyes, 27 men and 10 women, average age 24.23 ± 14.24) having one eye with manifest Kc and the fellow eye without clinical signs of Kc were identified. We studied two groups of pachymetric indexes: C1-C2, M1-M2, pCLMI, Pmin-P2 (Group 1 indexes) and PPD, PSD, PSSD and PASD (Group 2 indexes). A ROC (Receiver Operating Characteristic) curve was developed to compare the diagnostic accuracy, relative sensitivity and specificity for each index.

Results

In manifest keratoconus, C1-C2, M1-M2, and pCLMI are significantly higher compared to the control group (P<0.0001); for suspect keratoconus, all Group 1 indexes are significantly higher compared to healthy subjects (P<0.0001) excluding M1-M2 obtained using a constant area circle (P = 0.02). Furthermore, for manifest and suspect keratoconus, PPD, PSD, PSSD and PASD are significantly higher compared to the control group (P <0.0001).

Conclusion

The studied pachymetric indexes in patients with Kc have high diagnostic accuracy and are statistically significant when compared with healthy subjects (p<0.0001) and can provide a useful tool for keratoconus screening.

Periarticular Knee Injection With Liposomal Bupivacaine and Continuous Femoral Nerve Block for Postoperative Pain Management After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Local periarticular infiltration (PAI) analgesia has emerged as an important component of multimodal approaches to treat total knee arthroplasty postoperative pain. Liposomal bupivacaine may provide prolonged analgesic duration when injected into the surrounding tissues. The purpose of this study was to compare the analgesic efficacy and serum bupivacaine levels of a continuous femoral nerve block (CFNB) with bupivacaine to PAI with liposomal bupivacaine.

METHODS

Sixty-five patients undergoing primary unilateral total knee arthroplasty were randomized into 2 groups: (1) CFNB and PAI with bupivacaine (CFNB group) or (2) PAI with bupivacaine:liposomal bupivacaine mixture at the end of surgery (LB group). The primary outcome was pain intensity at maximum knee flexion 24 hours following surgery. Secondary outcomes included pain intensities at rest and movement at timed intervals and serum bupivacaine levels.

RESULTS

Patients in the CFNB group experienced lower pain scores at maximum knee flexion at 24 hours (7.91; 95% confidence interval, 7.19-8.61) compared to the LB group (8.95; 95% confidence interval, 8.42-9.48; P = .02). The mean peak serum bupivacaine level in the LB group up to 72 hours was 0.55 μg/mL versus 1.4 μg/mL for CFNB group (P = .0008) with one patient in the CFNB group exceeding the reported minimum serum bupivacaine threshold for toxicity.

CONCLUSION

While similar pain control was observed on the day of surgery for both groups, patients with a CFNB experienced lower pain intensities during maximum knee flexion at 24 hours. Total serum concentrations in LB group remained below the toxicity threshold over the study period.

A nationwide comparative analysis of medical complications in fibromyalgia patients following total knee arthroplasty

Background

Fibromyalgia is a disease primarily characterized by chronic widespread pain and associated symptoms of fatigue, mild cognitive impairment, and sleep disturbance. The condition affects 1% to 6% of the general population in the United States and is more commonly diagnosed in women (2:1 ratio). There is evidence to suggest that fibromyalgia patients may be more at risk of postoperative complications. The rate of total knee arthroplasties (TKAs) performed worldwide is escalating and thus it is expected that the proportion of fibromyalgia patients under orthopaedic care will increase accordingly. However, the literature on TKA outcomes in this subpopulation is limited. We assessed whether fibromyalgia patients have a higher likelihood of developing medical complications compared to a matched cohort of non-fibromyalgia patients following TKA. Specifically, we assessed the likelihood of developing (I) any medical complication and (II) specific medical complications.

Methods

Using the Medicare Standard Analytical Files of the PearlDiver supercomputer, patients who underwent a TKA between 2005 and 2014 were queried. Propensity score matching was used to match patients with and without fibromyalgia in a 1:1 ratio based on age, sex, and the Charlson Comorbidity Index (CCI). A total cohort of 305,510 patients (female =242,198; male =59,810; and unknown =3,502) with (n=152,755) and without fibromyalgia (n=152,755) was identified. Statistical analyses involved the calculation of odds ratios, 95% confidence intervals (95% CI), and P values (<0.05) were utilized to evaluate the occurrence of any and specific medical complications.

Results

Compared to a matched cohort of non-fibromyalgia patients, fibromyalgia patients had increased odds of developing any medical complication following TKA [odds ratio (OR): 1.95, 95% CI: 1.86-2.04, P<0.001]. Furthermore, compared to a matched cohort, these patients had significantly greater odds of developing urinary tract infections (OR: 2.08, 95% CI: 1.89-2.29, P<0.001), acute post-hemorrhagic anemia (OR: 1.56, 95% CI: 1.41-1.73, P<0.001), thoracic or lumbosacral neuritis or radiculitis (OR: 5.85, 95% CI: 4.82-7.10, P<0.001), shortness of breath (OR: 3.02, 95% CI: 2.60-3.51, P<0.001), other diseases of lung not elsewhere classified (OR: 2.32, 95% CI: 1.77-3.03, P<0.001), other respiratory abnormalities (OR: 3.49, 95% CI: 2.87-4.24, P<0.001), transfusion of packed cells (OR: 1.69, 95% CI: 1.36-2.10, P<0.001), pneumonia (OR: 2.17, 95% CI: 1.71-2.76, P<0.001), acute kidney failure (OR: 1.27, 95% CI: 1.02-1.57, P<0.05), and neuralgia neuritis and radiculitis (OR: 5.29, 95% CI: 3.53-7.92, P<0.001).

Conclusions

As the number of fibromyalgia patients under orthopaedic care is expected to rise, it is imperative that the TKA outcomes of these patients are tracked in order to provide optimal patient care. This study identified fibromyalgia as a risk factor for a number of medical complications following TKA. Orthopaedic surgeons must be aware of the potential for poor TKA outcomes among these patients and should provide them with appropriate medical care and pre-operative guidance.

A 5-Year Analysis of Organ Donors and Recipients in Italy

This article describes the improvement of organ donation and transplantation in Italy during 1995–1999. In 1999, the mean number of donors per million population reached 13.7 in Italy. In addition, an analysis regarding major characteristics of donors and recipients is presented, focusing particularly on donor characteristics that have changed in the past 5 years. Despite the encouraging results, further efforts are required to reach the European mean, which still remains higher than the Italian national mean. In particular, an increase of organ donation and procurement in regions with a poor activity in this field is crucial. A 1999 law on donation and transplantation should help in solving problems that continue to affect part of the nation, especially preparing the healthcare staff dedicated to organ retrieval to promote organ procurement.

Intracameral epinephrine without the addition of intracameral lidocaine in the management of tamsulosin associated intraoperative floppy iris syndrome

OBJECTIVE

Intracameral mydriatics using epinephrine associated with lidocaine have been reported as efficacious in reducing intraoperative floppy iris syndrome (IFIS) complications during cataract surgery. The aim of this study was to verify the efficacy of intracameral epinephrine without intracameral lidocaine as prophylaxis against IFIS in patients on tamsulosin.

MATERIALS AND METHODS

This was a retrospective study on the results of cataract surgery in 18 patients on therapy with tamsulosin. Patients had undergone routine phacoemulsification in one eye. Successively, they underwent phacoemulsifcation in the fellow eye using non preserved intracameral epinephrine 1:4000 diluted with BSS. Intraoperative complications during cataract surgery had been documented and IFIS was graded based on iris billowing, miosis or iris prolapse. Follow-up was 3 months.

RESULTS

Thirty-six eyes of 18 patients were included in the evaluation. The incidence of IFIS was significantly higher in the eyes where routine phacoemulsificaton had been performed (100%) with respect to eyes where phacoemulsification was carried out using intracameral epinephrine (33%) (Chi Square test =15.12, p<0.001). In routine phacoemulsification 16 eyes showed iris billowing, 14 eyes had some extent of miosis and 14 eyes had tendency to iris prolapse. In phacoemulsification with the use of intracameral epinephrine 5 eyes showed iris billowing, 4 eyes presented some extent of miosis and 2 eyes had tendency to iris prolapse. There were no serious intraoperative complications.

CONCLUSIONS

Intracameral epinephrine without the addition of lidocaine was efficacious in the management of IFIS in patients on tamsulosin.

A new method for calculating femoral anterior cortex point location and its effect on component sizing and placement

BACKGROUND

Variation in anterior femoral cortex morphology can cause improper component placement and alignment. When surgical inaccuracies occur, the mechanical properties of the distal femur may be altered, which could result in lower surgical success rates and an increased chance of postoperative complications.

QUESTIONS/PURPOSES

The purpose of the study is to come up with a reproducible computational algorithm to simulate what the surgeon does in the operating room. This method could help in surgical preplanning, patient-specific instruments, and implant design. From there, we evaluated (1) the angular difference between reference alignment axes; and (2) whether the location of the anterior cortex point and alignment axes had an effect on implant placement and amount of bone resected in seven implant systems.

METHODS

We analyzed 470 femurs from white and black individuals. Two points were defined using automatic three-dimensional landmarking: sizing point and femoral resection anterior cortex (FRAC) point. Alignment axes including the transepicondylar, posterior condylar, distal anatomical (DAA), and mechanical axes (MAs) were automatically calculated and used along with the resection point to define the anterior reference plane. Two mechanical axes were defined for the purpose of this study: MA-1 is a virtual construct used in navigated surgeries defined as the axis joining the center of the femoral head and the knee center and MA-2 was calculated as the axis joining the center of the femoral head and distal exit point of the DAA. Amounts of anterior, posterior, and distal resected bone were calculated along with the difference in orientation between the alignment axes.

RESULTS

The mean angular difference between transepicondylar axis and posterior condylar axis (PCA) was 5.44°±2.99°. All seven implant families showed more total bone resection on both the lateral and medial sides when the implants were aligned using MA-2 and PCA+3 of external rotation (PCA+3) when compared with using MA-1 and PCA+3 (p<0.01). Using MA-2 and PCA+3 as an alignment method reduced the amount of bone resection on both medial and lateral anterior surfaces from 1 to 2 mm.

CONCLUSION

The FRAC point is a key landmark in the placement and sizing of the femoral component. Improper sizing, notching, undercutting, or overstuffing can occur based on selecting the highest or lowest cortex point.

CLINICAL RELEVANCE

Balanced placement, prevention of notching, and anterior and posterior cut balancing were accomplished when using the suggested cortex point.

Three-dimensional morphology of the knee reveals ethnic differences

BACKGROUND

Studies have demonstrated sex differences in femoral shape and quadriceps angle raising a question of whether implant design should be sex-specific. Much of this research has addressed shape differences within the Caucasian population and little is known about differences among ethnic groups.

QUESTIONS/PURPOSES

We therefore asked: Do shape differences in the distal femur and proximal tibia exist among different ethnic groups and between the sexes in each ethnic population? And if ethnic differences exist, do they have a clinical impact on current TKA design?

SUBJECTS AND METHODS

We analyzed 1000 normal adult knees (80 African American, 80 East Asian, and 860 Caucasian). Three-dimensional surface models were created for each bone and added to three-dimensional statistical bone atlases. Statistical shape analysis was conducted with a process combining principal components and multiple discriminate analyses. Eleven femoral and nine tibial measurements were calculated.

RESULTS

We found differences in mean measurements between the sexes and ethnicities. Males had larger knees, with a mean 5-mm-larger anteroposterior dimension than females in all ethnicities. African American females had a 7.4-mm-deeper patellar groove, 2.3-mm-smaller tibial mediolateral dimension, and 2.5-mm-larger tibial anteroposterior dimension than Caucasian females. African American males had a 4.3-mm-larger femoral anteroposterior dimension, 10.1-mm-larger tibial mediolateral dimension, and 6-mm-larger tibial anteroposterior dimension than Asian males.

CONCLUSIONS

We identified differences in three-dimensional knee morphology among Caucasian, African American, and East Asian populations. Clinical studies will be required to determine whether these differences are important for implant design.

Affective temperaments are associated with higher hopelessness and perceived disability in patients with open-angle glaucoma

AIM

The aims of the study were to study: (i) affective temperaments in open-angle glaucoma (OAG) patients with some degree of functional visual impairment; (ii) psychological well-being and perceived disability, and their associations with affective temperaments; and (iii) associations between visual impairment, affective temperaments and psychological well-being.

METHOD

Participants were 91 outpatients (39 women, and 52 men) with open-angle glaucoma (OAG) who were assessed for Visual Field Index, Mean Defect and Pattern Standard Deviation. Patients were also administered the Beck Hopelessness Scale, the TEMPS-A (Rome), the Gotland Male Depression Scale, the Emotional Well-being Scale, the Perceived Disability Questionnaire and the Suicidal History Self-Rating Screening Scale.

RESULTS

Open-angle glaucoma patients (compared with a non-clinical sample of university students) had higher scores on the TEMP-A dysthimic and hyperthimic traits and lower scores on cyclothimic, irritability and anxiety traits. Such temperament variability was not linked to differences in severity of glaucoma. We did not find strong evidence supporting the fact that measures of visual impairment were linked to emotional well-being and depression. However, logistic regression analysis revealed that patients may have different patterns related to their illness according to specific temperaments.

CONCLUSION

Patients with OAG may have different temperament profiles than non-clinical individuals. Such categorisation may be useful for predicting how they face the illness, for providing better care as well as for early recognition of mood disorders symptoms.

First Report of Sclerotinia Stem and Twig Blight Caused by Sclerotinia sclerotiorum on Citrus volkameriana Rootstock in Italy

Volkamer lemon (Citrus volkameriana Ten. & Pasq., Rutaceae family) is the most commonly used rootstock for some ornamental citrus (oval kumquat and calamondin), improving the aesthetic quality of the plants and their marketable value. During the winter of 2011, symptoms of stem blight were observed on approximately 10% of 12,000 1-year-old potted C. volkameriana seedlings grown in different blocks in a commercial nursery near Catania (eastern Sicily, Italy). In the same nursery, only 1% of 15,000 older seedlings (2-year-old) showed disease symptoms. Initial symptoms included gray lesions on stems and occasionally on twigs. Later, buff lesions and gum exude appeared. Symptomatic stems and twigs were usually girdled and killed. In the lesions, irregular, dark gray sclerotia (1.0 to 5 × 1.0 to 7.0 mm, average 2.5 × 3.9 mm) were produced. In high relative humidity, cottony, white mycelia on the bark surface of infected tissues were also observed. Isolations were performed by transferring approximately 300 fragments of symptomatic tissues from 15 C volkameriana seedlings, surface-sterilized with 1% NaClO for 1 min, on potato dextrose agar (PDA) amended with 100 mg/liter of streptomycin sulfate. Sclerotinia sclerotiorum (Lib.) de Bary was recovered from all infected plants. Colony type, morphology, and dimensions of sclerotia were examined on PDA at 22 ± 1°C after 10 days in the dark. Sclerotia produced on PDA measured 2.0 to 7.0 × 1.5 to 4.0 mm (average 5.6 × 2.6 mm). DNA isolation was performed with the DNA Purification Kit (Puragene-Gentra, Minneapolis, MN) following the manufacturer's instructions. Amplification and sequencing of the internal transcribed spacer (ITS) region of rDNA was performed with primers ITS1/ITS4 (2). BLAST analysis of the 550-bp segment showed a 98% homology with S. sclerotiorum strain ms85 (GenBank Accession No HQ833450.1), thus confirming identification based on morphology. Koch's postulates were fulfilled by pathogenicity tests carried out on 20 1-year-old potted C. volkameriana seedlings. Each seedling was inoculated with five mycelial agar plugs (6 mm in diameter) and five sclerotia from the edge of 10-day-old colonies on PDA and placed in wounds made with a sterile blade in the bark of stem and twigs. Inoculated wounds (10 for each plant) were wrapped with Parafilm. The same number of control plants were wounded and inoculated with sterile PDA plugs. All inoculated plants were incubated in a growth chamber at 22°C with 80 to 90% relative humidity for 14 days. Blight symptoms and lesions on the stem and twigs identical to those observed in the nursery developed on all plants with both types of inoculum. Noninoculated control plants remained symptomless. S. sclerotiorum was reisolated from all symptomatic tissues and identified by morphology as previously described, completing Koch's postulates. To our knowledge, this is the first report of S. sclerotiorum stem and twig blight on C. volkameriana. Worldwide, Sclerotinia stem and twig blight is considered a minor disease on citrus (1), but this evidence suggests that in eastern Sicily, S. sclerotiorum may be an important pathogen of young C. volkameriana seedlings in nurseries. References: (1) J. A. Menge. Page 35 in: Compendium of Citrus Diseases. 2nd ed. The American Phytopathological Society, St. Paul, MN, 2000. (2) T. J.White et al. Page 315in: PCR Protocols: A Guide to Methods and Applications. M. A. Innis et al., eds. Academic Press, San Diego, 1990.

Disseminated Kaposi's sarcoma and HCV infection: only a casual relationship? A case report

The authors present a case of disseminated Kaposi's sarcoma in a male patient, HIV negative and Hepatitis C virus (HCV) positive. Although it is well-known that in HCV positive patients the onset of cutaneous diseases such as porphyria cutanea tarda, mixed essential cryoglobulinemia, lichen planus, polyarteritis nodosa, itch/prurigo, is possible, papers on its association with disseminated Kaposi's sarcoma in HIV negative patients are rare in the literature. Such an association is probably not a matter of chance: in fact, the changes to the immune system induced by the HCV virus, in synergy with those induced by the Human Herpetic virus-8, could likewise play a role in the development of Kaposi's sarcoma as happens in patients with immunodeficiency .

An unique case of Y-type urethral duplication associated with posterior urethral valve

This case report is about a 4-year-old patient with a IIA2 ''Y-type'' duplication, with the accessory urethra arising from the anterior orthotopic urethra and exiting in perineal-scrotal position, in association with posterior urethral valves (PUV). Cystourethroscopy through the ventral urethra revealed a type III urethral valve (diaphragm) and this was fulgurated. Duplicated dorsal urethra was excised surgically. Postoperative period was uneventful. This case is unique, because it shows PUV in a child with a very rare type of ''Y-type'' duplication. The presence of PUV in patients with urethral duplication is probably not an incidental finding but, to date, embryology of this rare association is not known.

Visual field damage and progression in glaucomatous myopic eyes

PURPOSE

To make a visual field retrospective analysis on a group of patients with primary open angle glaucoma (POAG) and to evaluate whether different refractive errors could have different progression of the 30 degrees central sensitivity.

METHODS

A total of 110 patients with POAG (52 men and 58 women) were included in the study. All the patients were divided into four subgroups based on the refractive error. The visual field of all the included patients was assessed by an Octopus 30 degrees central visual field every 6 months, for a total of 837 visual fields examined. The resulting data were analyzed by PERIDATA for Windows 1.7 TREND function. Mean defect (MD) and loss variance (LV) were considered for the analysis.

RESULTS

At the first examination, 82% of eyes showed a global decrease of differential light sensitivity (MD >2 dB) and in 67% the distribution of the defect was nonhomogeneous (LV >6 dB). The analysis of variance for subgroups showed a more significant decrease of MD in highly myopic patients. A linear regression analysis highlighted a statistically significant change in time of MD in 36% and of LV in 34% of the eyes studied. Highly myopic patients had the highest (p<0.01) percentage of change of MD and LV (46% and 42%, respectively). Among the four subgroups, there was no difference in progression of MD decrease in time.

CONCLUSIONS

These results showed that after 5 years of glaucoma, the visual field was altered in most of the eyes examined (82%) and that in 67% of cases, its defect was nonhomogeneous and worsened with the increase of myopia. The regression linear analysis of visual field changes in time showed a progressive increase of MD and LV in approximately one third of all the eyes examined.

Serum levels of interleukin 1beta, interleukin 8 and tumour necrosis factor alpha as markers of gastric cancer

Despite the efforts made, a serum marker reliable for the screening and follow-up of patients with gastric cancer has not yet been identified. The aim of this preliminary study was to test the role of pro-inflammatory cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha in patients with gastric cancer and in control groups. The statistical analysis of cytokines serum levels in the group with gastric cancer versus control groups has shown considerable differences (p < 0.001) in their mean rates. The results indicate that the cytokines interleukin 1beta, interleukin 8 and tumour necrosis factor alpha might perhaps act as diagnostic markers in patients with gastric cancer. Therefore, it is hypothesized that after more extended trials, their use in the screening and prognostic assessment of these patients could be a possibility.

[Endoscopic prosthetic treatment of the esophagojejunal leaks after total gastrectomy: clinical experience]

The Authors, on the basis of their experience on the use of self-expanding prostheses in abdominal surgery, report on the use of these prostheses in two patients who, having undergone a gastrectomy for cancer, developed a fistula of the esophago-jejunal anastomosis. Given recent data from literature, using a prosthesis for an anastomotic fistula may be a valid alternative to a second operation, which, apart from obvious difficulties, has a high mortality rate in patients in weakened general health conditions. In these cases, after the application of a stent, excellent results can be obtained and, after some days, the patients can begin a semi-liquid diet, then proceeding to a semi-solid diet, improving quality of life; in addition, within a reasonable time span, after the healing of the fistula, the prosthesis can easily be removed by endoscopy.

Hemorrhage from primitive rectal varices in patient with idiophatic thrombosis of portal vein: case report

INTRODUCTION

Rectal varices, primitive or secondary to hypertensive or thrombotic disorders of mesenteric-portal circle, represent an uncommon cause of lower digestive bleeding. The presence of rectal varices associated to idiopathic venous portal thrombosis represents a distinct nosologic entity, with important clinical and therapeutic problems related to it.

CASE REPORT

Patient of young age, with positive anamnesis for primitive rectal varices, admitted to our department for a serious recttorragy. The laboratory underlined moderate anaemia and the endoscopy documented the presence of multiple rectal varices, without evident signs of bleeding; the endoscopy documented the presence of two esophageal small varicose cords F1. The hepatobiliary sonography and the portography showed the massive thrombosis of the portal vein. The new serious episode of rectal bleeding induced us to subject the patient to a surgical operation of Hartmann recto-sigmoid resection.

CONCLUSION

Because of the slight number of reported cases of primitive rectal varices and because of the scattering of many dates it is difficult to draw an univocal diagnostic and therapeutic algorithm. Clinical framing and subsequent therapeutic approach rise often up from personal experience rather than well defined guidelines. The treatment is controversial, time by time many therapeutic options are reported either conservative or interventionist. The failure of conservative therapy and the recurrent episodes of bleeding give indication to surgical treatment, that is represented by Hartmann colonic resection and/or the porto-systemic shunts in the cases of portal hypertension; in our case we made colonic resection sec. because of lapsed performing status of the patient.

Cadaveric study on static medial patellar stabilizers: the dynamizing role of the vastus medialis obliquus on medial patellofemoral ligament

Aim of this cadaveric biomechanical study was to describe the detailed anatomy of the static medial patellar stabilizers and further determine the role of each of them in preventing lateral patellar dislocation. Eight cadaver knees, after removing the skin and subcutaneous tissues, were used in the study. The medial patellofemoral ligament (MPFL), the medial retinaculum (MR) the medial patellomeniscal ligament (MPML), and the medial patellotibial ligament (MPTL) were dissected. Their origins, insertions, orientations and sizes were recorded. To the medial stabilizers, a tension of 10 pounds was applied, using a tensiometer held in a semicircular device while the knees were kept in 30 degrees of flexion. Then, the previously described ligaments were dissected and the resultant displacement recorded. The most anatomically distinct structure is the MPFL, whose length varies from 45-50 mm, and its width from 10-20 mm at its origin (medial femoral epicondyle) to 20-30 mm at its insertion to the patella. The "meshing" of the MPFL fibers to the fibers of the vastus medialis obliquus (VMO) close to its patellar insertion was the most interesting and very important finding. The contribution of MPFL to medial stability was more than 50%. Of the remaining ligaments, MPML contributes 24% and the MPTL and MR contribute only 13% respectively. The MPFL is the strongest medial static patellar stabilizer. Its contribution to patellar stability against lateral dislocation is far more than 50%, since its meshing with the VMO, shortens its fibers which thus pulls the patella to the medial part of the femoral groove and keeps it in the trochlea during the initial 20 degrees -30 degrees of flexion.

Acute gallstone cholecystitis in the elderly: treatment with emergency ultrasonographic percutaneous cholecystostomy and interval laparoscopic cholecystectomy

BACKGROUND

The treatment of acute cholecystitis in the elderly is still a subject of debate, particularly with reference to the timing of surgery and the role of laparoscopy.

PATIENTS

From January 1994 to June 2002 we observed 27 patients aged over 70 years with acute calcolous cholecystitis. The patients were submitted to ultrasonographic percutaneous cholecystostomy within 12 h of the acute attack. For two patients (7.4%) at high operative risk, we chose a conservative treatment. Twenty-five patients (92.6%) were submitted, in 15 cases (60%) within 5 days and in 10 patients (40%) within 8 days, to a laparoscopic cholecystectomy. Statistical significance was accepted when the value of p was less than 0.05.

RESULTS

Ultrasonographic percutaneous cholecystostomy was performed successfully in all patients, without major morbidity or mortality, and complete resolution of clinical symptoms was obtained within 48 h. The conversion rate of laparoscopy was 20% (13.3% in patients submitted to surgery within 5 days and 30% in the group submitted within 8 days--p > 0.05). The postoperative morbidity rate was 24%; it was higher (40% versus 15%) in patients converted to laparotomy (p > 0.05); mortality was 4%. The period of hospitalization was 11 days in patients operated laparoscopically and 21 days in those converted to open cholecystectomy (p < 0.001).

CONCLUSIONS

The more rational treatment of acute calcolous cholecystitis in elderly patients is represented by ultrasonographic percutaneous cholecystostomy followed, within 5 days, by laparoscopic cholecystectomy using an abdominal insufflation maximum to 12 mmHg and a limited 10-15 degrees head-up tilt.

Prevalence of blindness and low vision in an Italian population: a comparison with other European studies

AIM

The scientific literature contains recent data on the prevalence of blindness and low vision for a few European countries, but most of these studies have been focused exclusively on the elderly sector of the populations. The purpose of the present study was to provide age-specific estimates of the prevalence and causes of visual loss in an Italian population aged 40 years and over.

METHODS

In total, 847 of the 1,200 citizens >40 years of age (70.6%) in the island community of Ponza underwent complete standardized ophthalmological examinations. Visual acuity (VA) was measured using a standard logarithmic chart. World health organization (WHO) definitions of blindness and low vision were adopted (respectively, VA>1.3 logMAR or a visual field <10 degrees around central fixation, and VA >0.5 to 1.3 logMAR or a visual field <20 degrees around central fixation). Prevalence rates based on presenting VAs were also calculated.

RESULTS

The overall best-corrected prevalence rates were 0.6% (presenting, 0.8%) for better eye blindness, 2.1% (presenting, 6.7%) for better eye low vision, 1.8% (presenting, 2.6%) for monocular blindness, 5.0% (presenting, 11.2%) for monocular low vision. Cataract, glaucoma, degenerative myopia, and AMD were the main causes of better eye visual loss.

CONCLUSION

Age-specific prevalence rates in Ponza are fairly consistent with those for other European countries with similar socio-economic conditions and public healthcare systems. A substantial percentage of visual losses remains uncorrected despite the availability of potentially curative therapy. Greater emphasis needs to be placed on educating the public regarding the importance of good vision.

[Caroli's disease: literature review and characteristics of a clinical case]

The Author's report the case of the simple form of Caroli's disease, a rare malformation, and review literature pointing out the difficulty of an early diagnosis, because disease can be silent for a long time too and it is identified for complication. Today, imaging, endoscopy and interventionist radiology are the most valid tools for a correct diagnosis and treatment, above all in a case of emergency, when other therapeutic solutions are not possible.

Blood loss and transfusion rates in bilateral total knee arthroplasty

From 1994 to 1998, we performed 170 bilateral total knee arthroplasties (TKAs) with cemented, posterior cruciate-substituting prostheses. Blood management included preoperative autologous donation, symptom-based transfusion, and autoreinfusion devices. Perioperative allogeneic transfusion rates for patients who donated 0, 1, 2, 3, or 4 units of blood were 40.00%, 0.00%, 3.70%, 0.00%, and 3.23%, respectively. Preoperative autologous donation >2 units also resulted in lower preoperative hemoglobin levels. For bilateral TKA, a protocol of 2 preoperative autologous donation units and reinfusion of postoperative drainage reduces anemia during the preoperative and postoperative periods.

Combined antegrade and retrograde ureteral stenting: the rendezvous technique

Ureteral stenting is a routine procedure in endourology. To increase the success rate in difficult cases, it may be helpful to use the rendezvous technique, a combined antegrade and retrograde approach. We performed 16 urological rendezvous in 11 patients with ureteral strictures or urologic lesions. The combined approach was successful in all patients, without morbidity or mortality. In our experience the rendezvous technique increased the success rate of antegrade ureteral stenting from 78.6 to 88.09% (p > 0.05). This procedure is a valid option in case of failure of conventional ureteral stenting.

[Diagnostic and therapeutic implications in two cases of pancreatic cystic tumours: mucinous and serous]

Cystic tumours of the pancreas include a pathologically heterogeneous and rare group of tumours, which however have many common clinical features. They represent about 10% of pancreatic cystic lesions and 1% of all forms of neoplasms, thus having a certain relevance in organ surgery. So far two distinct categories of cystic tumours have been identified, the basically benign serous form and the potentially malign mucinous form, which may sometimes show malignant features as early as the diagnostic stage. As neoplasms are very difficult to interpret before operation, it is essential that diagnosis is as accurate as possible in order to streamline surgery, which will have to be carried out after histological tests have been performed on an adequate number of tumour sections. Basing on these two cases of cystic tumours of the pancreas and on current literature, the Authors discuss the effectiveness of imaging techniques, such as contrast echography, dosage of specific tumour markers and histological tests backed up by immunohistochemistry in identifying these neoplasms, in order to study this rare but interesting pathology more accurately.

Blood management in revision total knee arthroplasty

Much attention has been focused on blood management issues in orthopaedic surgery in recent years, but blood management in patients having revision total knee arthroplasty is not well-established. Hematologic values and transfusion records of 100 patients (52 women, 48 men; mean age, 65 years) who had aseptic revision total knee arthroplasty at the authors' institution were evaluated retrospectively. Two- or three-component revisions comprised 66% of the procedures, and 58 patients participated in a preoperative autologous donation program. The mean preoperative hemoglobin level was 12.1 g/dL in the women and 14.1 g/dL in the men, but the men experienced a greater decrease in hemoglobin level (mean largest decrease, 4.2 g/dL versus 3.1 g/dL), possibly caused by the higher allogeneic transfusion rate in women (19.2%) versus men (4.2%). Patient age did not influence hemoglobin level or transfusion rates. Patients who participated in a preoperative autologous donation program had significantly higher hemoglobin levels before donation (14.4 g/dL versus 13.3 g/dL for patients who did not participate in a program) but comparable hemoglobin levels after predonation (12.9 g/dL). Patients with preoperative hemoglobin levels less than 13 g/dL were significantly more likely to have a transfusion. Symptom-based transfusion strategies and blood management approaches such as epoetin alfa that elevate preoperative hemoglobin level therefore may be beneficial in patients having revision total knee arthroplasty.

Assessment of backside wear from the analysis of 55 retrieved tibial inserts

Fifty-five retrieved tibial inserts with four different locking mechanisms were evaluated for evidence for polyethylene wear between the inferior surface of the tibial insert and metal tray. This type of wear will be referred to as backside wear. Backside wear was assessed by evaluating manufacturer's stamped markings on the inferior polyethylene surface. Because these markings are embossed into the polyethylene surface, they were used as indicators of backside wear. Decreases in the depths of markings indicated that backside wear was clearly evident, regardless of design, in 24 (44%) of the inserts. In eight of these 24 inserts, the manufacturer's stamped markings were removed completely. The amount of polyethylene wear was as a high as 591 mg from the inferior surface. This corresponds to a polyethylene wear rate from the backside of the tibial insert of greater than 100 mg per year, which is two to four times higher than wear rates associated with total hip replacements. The current work provides direct evidence of backside wear in all four tibial insert designs. Backside wear of tibial inserts can be a significant contributor to polyethylene wear in total knee arthroplasty. Close attention should be given to the fixation of tibial inserts to metal trays by manufacturers and surgeons.

[Guidelines given by several international documents to the Italian legislation on bioethics in scientific research]

Moving from the most recent progresses in some address international acts on bioethics of the research, the Convention of human rights and biomedicine and La declaration universelle sur le génome humain e les droits de l'homme, this paper describes the legislative acts which regard many aspects of theoretical and practical scientific research, both in the Italian national and supra-national fields. This legislation concerns mainly the following topics: rights of the human subjects of research, informed consent, privacy on the personal data, activity on organ transplantation, research in genetics, activity in the field of treatment of human gametes and embrios. The author here quotes these legislative acts referring briefly to national and international laws.

The vesical granuloma: rare and late complication of laparoscopic cholecystectomy

The spillage of gallstones into the peritoneal cavity from iatrogenic perforation of the gallbladder that occurs during laparoscopic cholecystectomy can result in late and serious complications. We report a case of vesical granuloma with symptoms of dysuria, pollakiuria, and vesical tenesmus that occurred 23 months after a laparoscopic cholecystectomy. Preoperative diagnostic evaluation showed a 3-cm vesical neoformation. A partial cystectomy was performed; macroscopic and histologic examination documented a central nidus of fragmented gallstones and a picture of chronic granulomatous inflammation. Although complications related to unretrieved gallstones that spill into the peritoneal cavity during laparoscopic cholecystectomy are rare, they are being reported with increasing frequency. Therefore, it is important to use tools and techniques that prevent lacerations of the gallbladder and involve retrieval of spilled gallstones.

[Use of mechanical staplers for the solution of proctological problems. Our experience with 122 patients]

The Longo technique using a circular stapler has changed haemorrhoid therapy. Thanks to the advent of this technique for treating haemorrhoids without excision, we can now successfully eliminate the mechanism responsible for their pathogenesis. The aims of circumferential stapled anoplasty are to correct the anodermal prolapse and restore the haemorrhoidal cushions to their anatomical position. Furthermore, with a few variants the technique can be utilised for other proctological problems, such as obstructed defecation in rectocele and incomplete internal prolapse (or rectal intussusception). The authors report on their experience in a consecutive series of 122 cases undergoing circular stapled anoplasty for haemorrhoids, associated in 10 cases with rectocele or rectal intussuscep-tion, analysing early and late complications after an accurate follow-up. The procedure can be performed with local or spinal anaesthesia. The operation lasted on average 19 minutes. There were few complications: early bleeding (4.9%), late bleeding (0.8%), mild stricture (2.5%) and thrombosis of external piles (8.2%). This new surgical technique is effective and rapid, causes only minimal postoperative pain and could be proposed as an alternative to traditional surgery also in the day surgery setting.

The Knee Society Index of Severity for failed total knee arthroplasty: practical application

Previous classifications of severity for total knee arthroplasty revisions have been based largely on bone loss of the femur and tibia. These approaches failed to address the more technically difficult issues in revision surgery such as surgical exposure, contractures, extremity alignment, implant removal, soft tissue stability (in the anteroposterior and in the sagittal planes), extensor mechanism integrity, and patellar revisability. Through the Knee Society, the authors developed a severity index that incorporated these latter factors into one measure. The current authors describe the application of the Knee Society Index of Severity for failed total knee arthroplasty and its method of scoring.

The Knee Society Index of Severity for failed total knee arthroplasty: development and validation

Compared with primary knee replacement, total knee arthroplasty revision surgery is a more complex procedure and accounts for greater expenditures of healthcare resources at each clinical stage. Overall, patients having revision procedures have poorer functional outcomes and higher complication rates than patients having primary arthroplasty. Despite the expanded scope of revision problems and the rapidly emerging technology in revision surgery, the long-term success of any method remains in question. Because there is little consensus on the timing of revision surgery, optimal surgical reconstruction, and the type of prosthesis to be implanted, the Knee Society began development of an Index of Severity for Failed Total Knee Arthroplasty. Fifty-four percent of Knee Society members completed an 82-item questionnaire that determined their clinical impression about potential risk factors for the outcomes of revision surgery for failed total knee replacements. Using these results, a consensus group developed the final version of the index. The result of the nominal group process was the Knee Society Index of Severity, which was based on eight distinct domains. Each domain was divided into attributes and weights based on the questionnaire responses and consensus meeting. Actual case scenarios from five institutions were used to test interrater reliability and validity. The interrater reliability of the average score of all ratings was 0.95; the correlation of the criterion rating with the mean rating was 0.77. When three outliers were not included, the Pearson product correlation increased to 0.92. These data support the application of the Knee Society Index of Severity as a critical component of risk factor studies, effectiveness research, and cost-effectiveness analysis involving revisions of total knee replacements.

A 5-year analysis of organ donors and recipients in Italy

This article describes the improvement of organ donation and transplantation in Italy during 1995-1999. In 1999, the mean number of donors per million population reached 13.7 in Italy. In addition, an analysis regarding major characteristics of donors and recipients is presented, focusing particularly on donor characteristics that have changed in the past 5 years. Despite the encouraging results, further efforts are required to reach the European mean, which still remains higher than the Italian national mean. In particular, an increase of organ donation and procurement in regions with a poor activity in this field is crucial. A 1999 law on donation and transplantation should help in solving problems that continue to affect part of the nation, especially preparing the healthcare staff dedicated to organ retrieval to promote organ procurement.

A review of the Salmonellosis surveillance systems in Italy: evolution during the course of time within the international framework

This paper focuses on the history of the two systems that have been adopted in Italy for the surveillance of Salmonellosis and describes their respective characteristics. Both systems have been subsequently modified: (1) The National Laboratory-based Surveillance System (NLSS) which was created in 1967 for Enteropathogenic Bacteria and subsequently, in 1992, became part of the European computerised Laboratory-based Surveillance System of Salmonellae isolates, the SALM-NET (Salmonella network); (2) The National Infectious Disease Reporting System (NIDRS) which was set up in the 1930s, revised in 1990 and has been used, since 1994, along with the Infectious Disease Informative System (IDIS). The results obtained with the different surveillance systems are presented: (1) The number of isolates from the laboratory surveillance from 1973 to 1997 are described. Total Salmonellae isolates have a slope with an increasing trend from 4372 isolates in 1973 to 15,041 isolates in 1988 drastically dropping to 5479 isolates in 1990 and increasing again to 13,596 isolates in 1993. Attention is given particularly to the epidemiology of S. enteritidis in Italy which increased progressively since 1982 (225 isolates) to 5435 isolates in 1994. S. typhimurium showed a slightly increasing trend in the period 1973-1988 (from 1694 to 3383 isolates) then decreased for reaching again previous levels. S. typhi showed a marked reduction from 573 isolates in 1973 to 33 isolates in 1996. On the contrary, other less frequent serotypes increased. (2) The number of cases of Salmonellosis reported during 1971-1997 are also presented. Other Infections by Salmonellae increased from 12,516 cases in 1976 (renamed Non Typhoidal Salmonellosis in 1990) to more than 20,000 cases in 1992. The number of cases of Typhoid Fever and Infections by S. paratyphi are also described. Particular attention has to be paid to the parallel trends of Salmonellosis using both surveillance systems: number of isolates and number of cases, particularly comparing Other Infections by Salmonellae and total Salmonellae isolates: after the 1992-1993 peak, an initial decrease was observed.

[Combined diagnosis in breast carcinoma: preoperative role of mammoscintigraphy with Tc99m-sestamibi. Our Experience]

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

[Myogenic stromal tumors of the stomach: personal experience]

Myogenic gastric tumours are a rare pathology and present difficulties in terms of nosographic classification, which in most cases can be overcome thanks to improvements in imaging and immunohistochemical techniques. Over the period 1995-1999 we observed 5 patients with aspecific dyspeptic symptoms and occasional epigastric pain, suffering from non-epithelial gastric tumours, associated, in one case, with a carcinoma of the stomach. Histological examination of endoscopic biopsies was inconclusive for a definite histopathological diagnosis, while intraoperative biopsies showed the myogenic origin and the absence of morphostructural abnormalities. In the light of these data, we performed three wedge resections, one distal gastric resection and, in the patient with advanced gastric cancer, a D3 total gastrectomy. Histological examination, immunohistochemistry and cytofluorometry enabled us to diagnose stromal tumours with a low risk of malignancy in all cases. At follow-up after 9-54 months all patients are still alive and free of disease. Though the preoperative diagnosis of stromal tumours is possible with endosonography and CT, only histology, immunohistochemistry and cytofluorometry enable us to define the condition nosographically and establish a prognosis with sufficient accuracy to allow correct surgical treatment. A prolonged follow-up is always necessary to identify eventual relapses and/or metastases, which are particularly frequent in the borderline group or in cases with a high risk of malignancy.

[The Allgrove syndrome]

Allgrove syndrome, rare autosomal recessive pathology, characterized by adrenocortical insufficiency, achalasia and alacrimia, rises usually in pediatric age, while its observation in adults is very rare. A clinical case appeared in an adult, observed by the Authors, is the reason to evaluate the etiopathogenetic mechanisms of this syndrome, with particular attention about potential role of genetic abnormalities and about others factors, again not well known.

Results from the first computerised Italian surveillance of human Salmonella isolates. The Italian SALM-NET Working Group

We report all the first computerised data collected in Italy for the surveillance of Salmonella isolates. Primarily, within the wide framework of the European Community Human Salmonella Surveillance Project (SALM-NET), we report data on the most commonly isolated serotypes in Italy from January 1994 to December 1996. In addition, we report all computerised data historically collected by some Italian regions regarding the period 1980-1993. Total data included in the Italian SALM-NET data base account for 59,336 Salmonella isolates. In the list of the most frequent isolates starting from 1989, S. Enteritidis always ranked first, followed by S. Typhimurium.

Results of the three-year surveillance by the Italian SALM-NET System: human isolates of Salmonella serotypes

Within the wide framework of the European Community Human Salmonella Surveillance Project (SALM-NET), the data on the most commonly isolated serotypes in Italy from January 1994 to December 1996 are reported. The total data included in the Italian SALM-NET data base account for 34,412 Salmonella isolates. In the list of the most frequent isolates, S. enteritidis ranked always first in the years 1994, 1995 and 1996 with 5435 (43.4%), 4589 (37.1%) and 4044 (42.4%), respectively, over the total number of Salmonella isolates. This serotype is followed by S. typhimurium in the list of the top ten isolates, with 2236 (17.9%), 2831 (22.9%) and 2239 (23.5%). The other serotypes included in this list accounted for a much lower number and percentages ranging from 505 isolates of S. derby (4.0%) to 99 isolates of S. brandenburg (0.8%).

Pseudoexfoliation syndrome in a patient with lattice corneal dystrophy

We report the case of a 70-year-old female who presents lattice corneal dystrophy type I in association with pseudoexfoliation syndrome. This association has never been reported in patients not affected by systemic amyloidosis.

The antibiotic resistance patterns of Salmonella Typhi isolates in Italy, 1980-96. The Italian SALM-NET Working Group. Salmonella Network

In this paper we report the distribution of Salmonella Typhi isolates in Italy and their resistance patterns to antibiotics. The data were collected by the Italian SALM-NET surveillance system in a pilot retrospective study of the period 1980-96. Data on drug-resistance were available for 82 isolates out of 176 S. Typhi isolated in Italy. Of these 82 isolates, 32 (39%) were resistant or intermediate to 1 or more antibiotics. Eight isolates were resistant and 7 intermediate to streptomycin; 4 isolates were resistant to ampicillin alone or in association with other antibiotics; only 2 strains (1 isolated in Lombardia in 1993 and the other 1 in Lazio in 1994) were resistant to chloramphenicol, and 2 (isolated in Sardegna and Piemonte in 1995 and 1996, respectively) showed intermediate resistance to chloramphenicol. The strains showing resistance to 3 or more antibiotics were very scarce: 1 (with 5 complete resistances) was isolated in Lazio in 1994, and another 1 (with complete resistance to 10 antibiotics and intermediate resistance to 2 antibiotics) was isolated in Molise in 1988. In conclusion, besides the routine activities to control typhoid fever, an accurate and continuous surveillance is necessary in order to quickly identify multidrug-resistant (MDR) S. Typhi strains and prevent their spread, even though their level, in our country, is still quite low.