Sociodemographic profile, health-related behaviours and experiences of healthcare access in Italian transgender and gender diverse adult population

PURPOSE

Information on the general health of transgender and gender diverse (TGD) individuals continues to be lacking. To bridge this gap, the National Institute of Health in Italy together with the National Office against Racial Discriminations, clinical centres, and TGD organizations carried out a cross-sectional study to define the sociodemographic profile, health-related behaviours, and experiences of healthcare access in Italian TGD adult population.

METHODS

A national survey was conducted by Computer-Assisted Web Interviewing (CAWI) technique. Collected data were compared within the TGD subgroups and between TGD people and the Italian general population (IGP).

RESULTS

TGD respondents were 959: 65% assigned female at birth (AFAB) and 35% assigned male at birth (AMAB). 91.8% and 8.2% were binary and non-binary TGD respondents, respectively. More than 20% of the TGD population reported to be unemployed with the highest rate detectable in AMAB and non-binary people. Cigarette smoking and binge drinking were higher in the TGD population compared with IGP (p < 0.05), affecting TGD subgroups differently. A significant lower percentage of AFAB TGD people reported having had screening for cervical and breast cancer in comparison with AFAB IGP (p < 0.0001, in both cases). Over 40% was the percentage of AFAB and non-binary TGD people accessing healthcare who felt discriminated against because of their gender identity.

CONCLUSIONS

Our results are a first step towards a better understanding of the health needs of TGD people in Italy in order to plan the best policy choices for a more inclusive public health.

Apparent autistic traits in transgender people: a prospective study of the impact of gender-affirming hormonal treatment

PURPOSE

We evaluated differences in Autism Spectrum Quotient (AQ) scores between a sample of hormone-naïve transgender and cisgender people and the impact of gender-affirming hormonal treatment (GAHT) on AQ scores across time. Furthermore, we assessed alexithymia and social anxiety as possible mediators of changes in AQ scores.

METHODS

A cross-sectional comparison between cisgender and transgender people before GAHT and a prospective study on the effects of GAHT over time were performed. Transgender and cisgender people completed several psychometric tests. A total sample of 789 persons (n = 229 cismen; n = 172 ciswomen; n = 206 transmen; n = 182 transwomen) referring to the Florence and Rome Gender Clinics between 2018 and 2020 was enrolled. Of these, 62 participants referring to the Florence Gender Clinic were evaluated in a prospective study at baseline and 12 months after GAHT.

RESULTS

Groups showed significant differences in terms of autistic traits: ciswomen showed lower scores of AQ, while cismen reported higher scores of AQ than all other groups. Transgender individuals showed significant higher levels of Gender Dysphoria (GD), body uneasiness, alexithymia and social anxiety, compared to cisgender ones. No significant differences in general psychopathology were found between groups. Across time, transmen and transwomen showed a significant reduction in AQ scores. The decrease in alexithymia and social anxiety after GAHT did not predict the change in AQ scores.

CONCLUSIONS

The autistic traits in our sample may represent an epiphenomenon of GD rather than being part of an Autism Spectrum Disorder (ASD) condition, since they significantly decreased after 12 months of GAHT.

SIGIS-SIAMS-SIE position statement of gender affirming hormonal treatment in transgender and non-binary people

PURPOSE

Gender Incongruence (GI) is a marked and persistent incongruence between an individual's experienced and the assigned gender at birth. In the recent years, there has been a considerable evolution and change in attitude as regards to gender nonconforming people.

METHODS

According to the Italian Society of Gender, Identity and Health (SIGIS), the Italian Society of Andrology and Sexual Medicine (SIAMS) and the Italian Society of Endocrinology (SIE) rules, a team of experts on the topic has been nominated by a SIGIS-SIAMS-SIE Guideline Board on the basis of their recognized clinical and research expertise in the field, and coordinated by a senior author, has prepared this Position statement. Later on, the present manuscript has been submitted to the Journal of Endocrinological Investigation for the normal process of international peer reviewing after a first internal revision process made by the SIGIS-SIAMS-SIE Guideline Board.

RESULTS

In the present document by the SIGIS-SIAMS-SIE group, we propose experts opinions concerning the psychological functioning, gender affirming hormonal treatment, safety concerns, emerging issues in transgender healthcare (sexual health, fertility issues, elderly trans people), and an Italian law overview aimed to improve gender non-conforming people care.

CONCLUSION

In this Position statement, we propose experts opinions concerning the psychological functioning of transgender people, the gender-affirming hormonal treatment (full/partial masculinization in assigned female at birth trans people, full/partial feminization and de-masculinization in assigned male at birth trans people), the emerging issues in transgender health care aimed to improve patient care. We have also included an overview of Italian law about gender affirming surgery and registry rectification.

MPFL reconstruction and tibial tuberosity transposition in patients with patellar instability: May it troubleshots also trochlear dysplasia?

Purpose

This study aimed to highlight short- and medium-term outcomes of combined medial patello-femoral ligament (MPFL) reconstruction and anterior tibial tuberosity (ATT) transposition surgery in patients with recurrent patellar instability and different degrees of trochlear dysplasia.

Methods

Between January 2014 and May 2019, 25 patients with patellar instability underwent a surgical procedure combining the lowering/transposition of the ATT and the MPFL reconstruction. Each patient were preoperative assessed by Kujala score, International Knee Documentation Committee (IKDC), Tegner activity level scale. The assessment of instability predisposing factors was carried out with patellar height, tibial tuberosity-trochlear groove (TT-TG) distance, trochlear dysplasia, sulcus angle, patellar tilt and MPFL injuries. Functional outcomes were evaluated with Kujala, IKDC and Tegner scores at 3, 6 and 12 months after surgery.

Results

The average age of the patients was 20 years (range 13–43 years). Pre- operative Caton–Deschamps index was pathological in 10 (40%). Sulcus angle was elevated in 13 patients (52%) and TT-TG distance was irregular in 17 patients (68%). Trochlear dysplasia was present in 13 patients (9 type A, 3 type B, 1 type C according to Dejour’s Classification). No re-dislocation occurred during the follow-up. There was a significant increase in the Kujala, IKDC and Lysholm scores after 3, 6 and 12 months, and the results were compared for the different follow-up times and patient’s trochlear dysplasia degree.

Conclusion

This prospective observational longitudinal study identified good clinical outcomes in patients who underwent MPFL reconstruction and ATT transposition for patellar instability. Finally, the different risk factors for patellar instability examined, particularly the presence of trochlear dysplasia, did not significantly influence the final functional results, which range from good to excellent without re-dislocation episodes.

Knee arthroplasty system with medialized keel: Seven-year follow-up of a pioneer cohort

BACKGROUND

In this clinical investigation, a new design with a progressive increased keel medialization according to the size was implanted. The cohort of patients was followed up for seven years.

METHODS

From May 2012 to November 2012, we implanted 70 total knee arthroplasties in 69 patients. The mean age of the patients was 76.2 years. We followed up 56 patients for seven years; we evaluated the patients at six and 60 months after surgery by Patient Reported Outcome Measures score. During the seven-year follow-up, all patients were clinically re-evaluated using the Knee Society Score and the Forgotten Joint Score. All patients underwent a preoperative and postoperative radiographic investigation. At the last follow-up the presence of any radiolucency lines was checked using the Knee Society Total Knee Arthroplasty Radiographic Evaluation and Scoring System.

RESULTS

The patients defined the surgical results as excellent in 66% of the cases, very good in 23%, good in five percent. The analysis of the functional data at seven years, performed by administering the Forgotten Joint Score, showed average values of 70.4. The clinical analysis, performed through the Knee Society Score at the same follow-up, showed average values of 90.4. The seven-year radiological analysis revealed the presence of radiolucency lines in 20 implants. The sum of the line widths never exceeded the critical value of nine millimeters, always remaining below four millimeters. Only one patient was revised.

CONCLUSIONS

The results showed an excellent outcome of this design. The medialization of the tibial keel showed good bone fixation and component alignment at seven-year follow-up.

The role of six biomarkers in diagnosis of hemophilic arthropathy: review of the literature

The aim of our narrative review of the literature is to identify the role of six important biomarkers: synovial fluid thrombomodulin, fibroblast-like synoviocytes, synovial tissue growth factor , vascular endothelial growth factor in synovium and peripheral blood, urinary C-terminal telopeptide of type II collagen, and synovial fluid tumor necrosis factor alpha. These urinary, serum and synovial biomarkers illustrated should be evaluated in patients with hemophilic arthropathy for early diagnosis of hemophilic arthropathy, because they have important implications in the development of arthrofibrosis, altered inflammatory response and bleeding. Moreover, better knowledge of their biological activity is important to identify possible new biological treatment options.

Primary total knee replacement in hemophiliacs: experience of a single institution over fourteen years of surgical procedures

This retrospective study reports clinical and functional orthopedic outcomes and complications after 14 primary total knee replacement (TKR) performed between 2000 and 2014. The mean age at surgery was 42 years (range 26-59), with a removal-free survival of 100% at the end of follow-up (months 109.85). The KSS score was 49.64 pre-operatively (range 31-63) and 78.14 at final follow-up (range 45-90), the KSS function score was 64.64 pre-operatively (range 35-80) and 84.57 at final follow-up (range 45-100). According to this study, there are three main factors that can influence long-term and early surgical outcomes: post-operative fibrosis, a previous synovectomy and presence of inhibitors. Even if our results are slightly suboptimal compared to those obtained in non-hemophilic patients, this study shows that TKR is an effective surgical procedure in hemophiliacs.

Psychological characteristics of Italian gender dysphoric adolescents: a case-control study

PURPOSE

Gender dysphoria (GD) is associated with clinically significant distress and impairment in social, scholastic, and other important areas of functioning, especially when early onset is reported. The aim of the present study is to assess the psychopathological features associated with GD in adolescence, comparing a group of gender dysphoric adolescents (GDs) with a group of non-referred adolescents (NRs), in terms of body uneasiness, suicide risk, psychological functioning, and intensity of GD.

METHODS

A sample of 46 adolescents with GD and 46 age-matched NRs was evaluated (mean ± SD age = 16.00 ± 1.49 and 16.59 ± 1.11 respectively, p > 0.05). Subjects were asked to complete the Body Uneasiness Test (BUT) to explore body uneasiness, the Youth Self Report (YSR) to measure psychological functioning, the Multi-Attitude Suicide Tendency Scale (MAST) for suicide risk, and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA) for GD assessment.

RESULTS

Adolescents with GD reported significantly higher levels of body uneasiness (BUT-GSI, F = 380.13, p < 0.0001), as well as a worse psychological functioning (YSR, F = 13.06 and p < 0.0001 for "total problem scale" and F = 12.53, p = 0.001 for "internalizing" scale) as compared to NRs. When YSR subscales were considered, GDs showed significantly higher scores in the "withdrawal/depression", "anxiety/depression", and "social problems" (all p < 0.0001). In addition, GDs showed significantly higher levels in the "attraction to death" and "repulsion by life" scales and lower scores in the "attraction to life" scale (all p < 0.0001). Finally, GIDYQ-AA score was significantly lower (meaning a higher level of gender dysphoria symptoms) in GDs vs. NRs (p < 0.0001).

CONCLUSIONS

GD adolescents reported significantly higher body dissatisfaction and suicidal risk compared to NRs. In addition, results confirmed a significant impairment in social psychological functioning in adolescents with GD.

Detection of Combined n/γ Fission Signatures Induced by an Epithermal Neutron Source

In this paper, a method is presented for the detection of special nuclear materials (SNMs) in shielded containers, which is both sensitive and applicable under field conditions. The method uses an external pulsed neutron source to induce fission in SNM and subsequent detection of the fast prompt fission neutrons. The detectors surrounding the container under investigation are liquid scintillation detectors able to distinguish gamma rays from fast neutrons by means of pulse shape discrimination method (PSD). One advantage of these detectors, besides the ability for PSD analysis, is that the analog signal from a detection event is of very short duration (typically few tens of nanoseconds). This allows the use of very short coincidence gates for the detection of the prompt fission neutrons in multiple detectors, while benefiting from a low background coincidence rate, yielding a low detection limit. Another principle advantage of this method derives from the fact that the external neutron source is pulsed. By proper time gating, the interrogation can be conducted by epithermal source neutrons only. These neutrons do not appear in the fast neutron signal following the PSD analysis, thus providing a fundamental method for separating the interrogating source neutrons from the sample response in the form of fast fission neutrons. This paper describes laboratory tests with a configuration of eight detectors in the Pulsed Neutron Interrogation Test Assembly (PUNITA). Both the photon and neutron signature for induced fission is observed, and the methods used to isolate these signatures are described and demonstrated.

Who has the worst attitudes toward sexual minorities? Comparison of transphobia and homophobia levels in gender dysphoric individuals, the general population and health care providers

PURPOSE

To date, few studies have addressed attitudes toward transgender individuals. In addition, little is known about health care providers' (HCP) attitudes toward sexual minorities. The aim of the present study is to compare attitudes toward homosexual and transgender individuals between gender dysphoric individuals (GDs), general population controls (C) and HCP.

METHODS

A total of 310 subjects were considered, including 122 GDs (63 transwomen and 59 transmen), 53 heterosexual HCP (26 males and 27 females) and 135 C. Participants completed the Modern Homophobia Scale (MHS) and the Attitudes Toward Transgendered Individuals Scale (ATTI) in order to assess attitudes toward gay men and lesbian women and toward transgender individuals, respectively. In addition, GDs completed the Gender Identity/Gender Dysphoria Questionnaire (GIDYQ-AA) and ATTI to measure, respectively, gender dysphoria levels and internalized transphobia. Religious attitudes were evaluated by means of the Religious Fundamentalism Scale (RFS), and Discrimination and Stigma Scale (DISC-12) was used to measure perceived discrimination.

RESULTS

(1) Men showed significantly higher levels of homophobia and transphobia when compared to women (p < 0.001); (2) perceived discrimination was higher in lesbian women compared to gay men and in transwomen compared to transmen (p < 0.001 and p < 0.05, respectively); and (3) religious fundamentalism was associated with both homophobia and transphobia (both p < 0.001).

CONCLUSIONS

Our results underline the need to promote awareness and acceptance of the sexual minorities, who are more at risk of discriminatory attitudes, which are strongly dependent on religious precepts and dogma.

Inguinal hernia in neonates and ex-preterm: complications, timing and need for routine contralateral exploration

BACKGROUND/PURPOSE

Aim of this study was to present a series of neonates and ex-preterm babies who underwent inguinal hernia repair focusing on complications and possible indication to perform routine contralateral groin exploration.

METHODS

This is a retrospective study of a series of consecutive patients weighing less than 5 kg who underwent inguinal hernia repair between January 2007 and December 2012. Only the affected side was treated. Patients have been routinely followed up postoperatively. We resorted to available outpatients' charts and admission notes to record demographic data, surgical details, complications and the occurrence of metachronous hernias. A questionnaire was administered to all patients' relatives to confirm the long-term outcome.

RESULTS

One hundred fifty-four patients were operated for a total of 184 herniotomies (88 right sided, 36 left sided and 30 bilateral). Median length of follow-up was 42 months (range 6 months-7.5 years). Thirteen patients (13/124 = 10.5 %) developed metachronous hernia that proved to be significantly more frequent in patients weighing less than 1,500 g at birth (p < 0.05). We observed 10 % of complications, including 2.7 % testicular atrophy and 4.5 % recurrence. Atrophy proved to occur more frequently in patients who experienced preoperative incarceration (p < 0.05). No other risk factors were identified.

CONCLUSIONS

The results of our series demonstrated that, though technically demanding, herniotomy in the neonate and ex-preterm is associated with a relatively low incidence of complications. Based on our results and in accordance with literature data, we do not advocate routine contralateral exploration in case of unilateral hernia but surgery to be performed only on the symptomatic side, as soon as possible after initial diagnosis. Very low birth weight patients should be followed with care in the early postoperative period due to the higher likelihood of developing a metachronous hernia.

Medical treatment in gender dysphoric adolescents endorsed by SIAMS-SIE-SIEDP-ONIG

PURPOSE

Despite international guidelines being available, not all gender clinics are able to face gender dysphoric (GD) youth population needs specifically. This is particularly true in Italy. Centers offering specialized support are relatively few and a commonly accepted Italian approach to GD youth has still not been defined. The aim of the present Position Statement is to develop and adhere to Italian guidelines for treatment of GD adolescents, in line with the "Dutch Approach", the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH) guidelines.

METHODS

An in-depth brainstorming on the application of International guidelines in the Italian context was performed by several dedicated professionals.

RESULTS

A staged approach, combining psychological support as well as medical intervention is suggested. In the first phase, individuals requesting medical help will undergo a psycho-diagnostic procedure to assess GD; for eligible adolescents, pubertal suppression should be made available (extended diagnostic phase). Finally, from the age of 16 years, cross-sex hormonal therapy can be added, and from the age of 18 years, surgical sex reassignment can eventually be performed.

CONCLUSIONS

The current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behavior, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.

Online imaging of initial DNA damages at the PTB microbeam

In an inter-disciplinary collaboration of Physikalisch-Technische Bundesanstalt (PTB), German Collection of Microorganisms and Cell Cultures (DSMZ) and Heinrich-Heine University, live-cell imaging has been established at the charged-particle microbeam facility of PTB. Candidate genes participating in DNA strand-break repair pathways such as PARP-1, MRE11, MSH2, MDC1 and p53BP1 have been modified to generate fluorescent fusion proteins. Using multi-cistronic expression vectors, stable genomic integration was achieved in HT-1080 fibroblasts. The aim of this study is to characterise and use these highly reliable cell lines for studying initial steps of DNA damage responses and kinetics of repair after microbeam irradiation with high- and low-linear energy transfer (LET) particles in living cells at physiological conditions.

EULAR/EFORT recommendations for the diagnosis and initial management of patients with acute or recent onset swelling of the knee

Objectives:

The European League Against Rheumatism (EULAR) and the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) have recognised the importance of variation in diagnostic and therapeutic performance across disciplines, have found consensus in starting task forces aiming at achieving diagnostic and therapeutic uniformity, and have identified medical conditions with which representatives of both organisations will frequently be confronted in common clinical practice. The aim of the present work was to establish recommendations for the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Methods:

The EULAR standard operating procedures for the elaboration and implementation of evidence-based recommendations were followed.

Results:

In all, 11 rheumatologists from 11 countries and 12 orthopaedic surgeons from 7 countries met twice under the leadership of 2 conveners, a clinical epidemiologist and a research fellow. After carefully defining the content and procedures of the task force, research questions were developed, a comprehensive literature search was performed and the results were presented to the entire committee. Subsequently, a set of 10 recommendations was formulated based on evidence from the literature if available, and after discussion and consensus building.

Conclusions:

This is the first combined interdisciplinary project of rheumatologists and orthopaedic surgeons, successfully aiming at achieving consensus in the diagnosis and initial management of patients presenting with acute or recent onset swelling of the knee.

Small round blue cell tumours: diagnostic and prognostic usefulness of the expression of B7-H3 surface molecule

Aims:

To assess whether the expression of B7-H3 surface molecule could improve differential diagnosis of small cell round tumours.

Methods and results:

One hundred and one well-characterized paraffin-embedded small round cell tumours, stored in the pathology archive of the Gaslini Institute, were immunohistochemically analysed with the 5B14 monoclonal antibody, which recognizes the surface molecule B7-H3. All lymphoblastic lymphomas and the blastematous component of Wilms’ tumours were completely negative and a few Ewing's sarcoma and Burkitt's lymphoma specimens showed focal positivity, whereas 74% of neuroblastomas, 67% of rhabdomyosarcomas and 100% of medulloblastomas were positive. The pattern of immunoreactivity of 5B14 mAb observed in rhabdomyosarcoma, neuroblastoma and medulloblastoma specimens was limited to the cytoplasmic membrane, and in neuroblastomas areas of rosette formation or of ganglion differentiation were preferentially stained. Interestingly, in neuroblastoma patients high expression of the antigen recognized by the 5B14 mAb was associated with a worse event-free survival.

Conclusions:

The 5B14 mAb represents an additional tool for the differential diagnosis of small round cell tumours and might be useful in identifying neuroblastoma patients at risk of relapse who may take advantage of more careful follow-up.

A phase II trial of dacarbazine (DTIC) and bevacizumab in patients with metastatic melanoma

8579

Background: Dacarbazine (DTIC) has been approved for treating metastatic melanoma in the 1970s, and as a single agent gives a response rate of about 20%. There have been efforts to ameliorate this poor result by using DTIC in different combinations without a significant improvement. In addition, new studies with melanoma cells in vitro show that DTIC causes transcriptional up-regulation of vascular endothelial growth factor (VEGF), suggesting a potential clinical benefit from the concomitant treatment of DTIC and anti-VEGF therapy. The purpose of this study is to determine whether a combination therapy of bevacizumab and DTIC is safe and can increase response rate and progression-free survival in patients (pts) with metastatic melanoma. Methods: From June 2006 to December 2006, 8 chemo-naive pts (1 female and 7 males) with metastatic melanoma were enrolled in the study. The median age was 53 (43–74) and PS was 0–1. Patients received DTIC 800 mg/m2 iv every 4 weeks and bevacizumab 10 mg/kg iv every 2 weeks. A treatment cycle consisted of 28 days. Results: Among 5 evaluable pts there were 1 partial response, 2 stable disease and 2 progressions, 3 pts were not evaluable because it is too early. Median number of administered cycles was 2 (2–6). The toxicity profile was particularly favourable with no G3/G4 haematological toxicity. Other most commonly seen toxicities were: nausea/vomiting (22%), mucositis (13%), diarrhea (9%). Proteinuria 1+ was reported in 3 cycles (13%). One patient with an early progression had also a G2 increase in blood pressure with a dilatative cardiomyopathy. Conclusions: The combination treatment resulted well tolerated and with a sufficient anti-tumor activity to warrant the continuing of enrolment. Updated efficacy and safety data will be presented.

No significant financial relationships to disclose.

Neutron capture cross section measurement of 151Sm at the CERN neutron time of flight facility (n_TOF)

The151Sm(n,gamma)152Sm cross section has been measured at the spallation neutron facility n_TOF at CERN in the energy range from 1 eV to 1 MeV. The new facility combines excellent resolution in neutron time-of-flight, low repetition rates, and an unsurpassed instantaneous luminosity, resulting in rather favorable signal/background ratios. The 151Sm cross section is of importance for characterizing neutron capture nucleosynthesis in asymptotic giant branch stars. At a thermal energy of kT=30 keV the Maxwellian averaged cross section of this unstable isotope (t(1/2)=93 yr) was determined to be 3100+/-160 mb, significantly larger than theoretical predictions.

Muscle transplant in the rabbit's Achilles tendon

Achilles tendinopathy (AT) is a degenerative disorder resulting from functional overload, especially during running and jumping, with some inflammatory features at the insertions, bursae, and paratenon. The Achilles tendon is poorly vascularized, especially in the middle third, and the consequent slow metabolic rate allows it to work at very low oxygen tensions but prevents on the other hand a rapid healing.

PURPOSE

To create an animal model to study a novel surgical technique employed in AT: transplanting some fibers of the soleus muscle into the tendon in order to improve its vascularization and healing and to study the histological appearance of the soleus graft incorporated in the tendon.

METHODS

We operated on 10 white New Zealand rabbits (eight rabbits underwent the procedure, two rabbits the sham operation with incision of the tendon without graft). Two animals were euthanized at 1 wk, 1, 2, and 3 months.

RESULTS

Histology showed that after 3 months the muscle fibers were still viable within the tendons, interspersed within connective tissue fibers. Tendon and muscle tissues were intimately fused.

CONCLUSIONS

The persistence of the soleus muscle pedicle graft within the Achilles tendon tissue is an index of sound blood supply. This surgical model is suitable for application in further studies on tendon healing.

[Fibrocartilaginous dysplasia and tibia vara in young children: presentation of 3 new cases with spontaneous resolution and review of the literature]

Focal fibrocartilaginous dysplasia is a rare and benign condition associated with unilateral tibia vara in toddlers. Three additional cases are reported in children aged 17, 18 and 26 months with spontaneous resolution. The authors discuss, based on a meta-analysis, the natural history of the disorder and review the diagnostic and pathophysiological problems. Since spontaneous remodeling of varus angulation and healing of the bony defect can be expected, biopsy and surgical intervention should be avoided.

Primary cutaneous cryptococcosis in an HIV-negative patient

We report a case of primary cutaneous cryptococcosis in an HIV-negative patient, who presented with painless, ulcerated lesions involving the right forearm (fingers and elbow), which developed over 45 days. On the basis of the clinical appearance, serological and cultural examinations were performed to confirm the diagnosis; the histological evaluation of a skin biopsy showed an acute inflammatory infiltrate containing several PAS + Cryptococci. Subsequently, the patient was treated with fluconazole (400 mg/day for 10 days, then a maintenance therapy of 200 mg/day); after one month, the cutaneous lesions were remarkably improved, but, although a series of further laboratory and clinical examinations was scheduled, the patient repeatedly refused any other re-evaluation, and he was lost from follow-up.

Use of capacitive coupled electric fields in stress fractures in athletes

The authors report the results of an open study on the treatment of stress fracture in athletes by capacitive coupling, a bone healing stimulation method promoting bone formation by application of alternating current in the form of a sinusoidal wave. Twenty-five lower-limb (navicular, 2nd and 5th metatarsal, tibia, fibula, and talus) stress fractures in 21 athletes (mean age, 21.8 years old) were treated. The mean stimulation time was 52 days (navicular fractures, 60 days). Twenty-two fractures were healed, 1 was not healed, and 2 were improved. This preliminary report shows that capacitive coupling can be used safely in the treatment of these stress fractures.