Incidence of traumatic spinal cord injury in Italy during 2013-2014: a population-based study.

STUDY DESIGN: Observational prospective population-based incidence study. OBJECTIVES: The main objective of this study was to assess the incidence of traumatic spinal cord injuries (TSCIs) and incidence rates, in order to provide estimates by age, gender, characteristics and cause. SETTING: This study was conducted at acute-care spinal cord injury (SCI) hospitals and SCI centers from 11 Italian regions, between 1 October 2013 and 30 September 2014. METHODS: Data of all consecutive patients with acute TSCI who met the inclusion criteria were obtained through case reporting by clinicians. The data were collected into a web database. Incidence rates and incidence rate ratios were calculated and stratified by age, gender, cause, level and completeness. RESULTS: From 50% of the entire population of Italy, 445 new cases of TSCI were included. The crude incidence rate of TSCI was 14.7 cases per million per year (95% CI: 13.4-16.4); the overall male to female ratio was 4:1 and the mean age was 54. Complete information was available in 85% of the sample and revealed tetraplegia in 58% and incomplete lesion in 67% of cases. The leading cause of TSCI was falls (40.9%) followed by road traffic accidents (33.5%). The leading cause was falls for patients over 55 and road traffic accidents for patients under 55. CONCLUSION: The changing trend of TSCI epidemiology concerns the increase in the average age of TSCI people and the increase of both cervical and incomplete lesions. The etiology shows the primacy of falls over road traffic accidents and suggests the need for a change in prevention policies.

Observational study of the effectiveness of spinal cord injury rehabilitation using the Spinal Cord Injury-Ability Realization Measurement Index.

STUDY DESIGN: Retrospective observational study. OBJECTIVES: The objective of this study was to determine the rehabilitation potential and the extent to which it is realized in a cohort of spinal cord injury patients using the Spinal Cord Injury-Ability Realization Measurement Index (SCI-ARMI) and to study the clinical factors that influence this realization. SETTING: Two spinal units in Italy. METHODS: Consecutive patients were assessed at the end of an in-patient rehabilitation program using the Spinal Cord Independence Measure and the International Standards for Neurological Classification of Spinal Cord Injury. On the basis of these data and of the age and gender of the patients, we calculated the SCI-ARMI score. Regression analyses were performed to study the relationship between clinical factors and the extent to which rehabilitation potential is realized. RESULTS: We examined the data for 306 patients. Most patients were discharged without having reached their rehabilitation potential, with an SCI-ARMI score <80%. SCI-ARMI scores at discharge were positively influenced by etiology and the lesion level and correlated negatively with lesion severity and the presence of complications during rehabilitation. CONCLUSION: The SCI-ARMI is an effective tool that can be used to measure the achievement of rehabilitation potential in SCI patients and to identify groups of patients who are at risk of not meeting their rehabilitative potential.

Validation of the Italian version of the Spinal Cord Independence Measure (SCIM III) Self-Report.

STUDY DESIGN: Cross-sectional validation study. OBJECTIVES: To validate the Italian version of the Spinal Cord Independence Measure Self-Report (SCIM SR). SETTING: Two spinal cord injury (SCI) rehabilitation facilities in Italy. METHODS: The SCIM III comprises items on 19 daily tasks, grouped into three subscales: 'Self-care,' 'Respiration and sphincter management' and 'Mobility'. The total SCIM score ranges between 0 and 100. The Italian self-reported version (SCIM SR) was translated from the German tool. We studied 116 patients on their first hospitalization for rehabilitation after an SCI. At the time of discharge, patients were evaluated by the rehabilitation team using the SCIM III and self-assessed their independence with regard to activities of daily living using the SCIM SR. Pearson's correlation, Bland-Altman method, and stratified and regression analyses were used to examine the differences between evaluations. RESULTS: On the basis of Pearson's correlation, there was good agreement between the data from the SCIM III and SCIM SR (r=0.918 for 'Self-care,' 0.806 for 'Respiration and sphincter management,' 0.906 for 'Mobility' and 0.934 for total scores). By Bland-Altman analysis, patients rated their functioning nearly the same as professionals-the mean difference between SCIM III and SCIM SR scores was approximately 0 for all subscales and total scores. The stratified and regression analyses failed to identify any specific factor that was associated with differences between SCIM III and SCIM SR scores. CONCLUSIONS: These results support the validity of the Italian version of the SCIM SR, which can facilitate longer-term evaluations of the independence of individuals with SCIs.

The role of surgical treatment in the rehabilitation protocols of thoraco-lumbar spine injuries.

BACKGROUND: Rehabilitation is a crucial issue in the management of spinal cord injuries (SCI) but, in these patients, the primary treatment can bias the outcome of recovery protocols. AIM: Purpose of this paper is to review our case load in the treatment of surgical failures and to define the role of surgery in thoraco-lumbar injuries rehabilitation. PATIENTS AND METHODS: Between 2000 and 2009 seventy patients with post-traumatic paraplegia were referred to Surgical Department as rehabilitation was unfeasible due to inadequate spine injury treatment. Forty-six had had surgery, 24 were treated conservatively Twenty-five patients had a thoracic lesion, 9 a lumbar lesion and 36 a lesion of the thoraco-lumbar junction. A total of 44 surgical procedures were performed (by anterior, posterior or anterior-posterior). RESULTS: On postoperative imaging sagittal alignment was found good in 93% of cases and acceptable in 7%. All patients regained the sitting position within 5 days after surgery. Wound healing problems requiring revision were observed in 4 cases. Major complications were a cerebro spinal fluid (CSF) leakage and a massive pulmonary embolism case in the early post-op. CONCLUSIONS: Wrong primary treatment frequently leads to demanding revision procedures with increased risks for the patient and more than double costs for the health care system. Whatever the technique a stable spine is the target in surgery of SCI allowing a quick and effective rehabilitation without external orthosis.

Comparison of a unidirectional panoramic 3D endoluminal interpretation technique to traditional 2D and bidirectional 3D interpretation techniques at CT colonography: preliminary observations.

AIM: To compare the evaluation times and accuracy of unidirectional panoramic three-dimensional (3D) endoluminal interpretation to traditional two-dimensional (2D) and bidirectional 3D endoluminal techniques. MATERIALS AND METHODS: Sixty-nine patients underwent computed tomography colonography (CTC) after bowel cleansing. Forty-five had no polyps and 24 had at least one polyp > or = 6 mm. Patients underwent same-day colonoscopy with segmental unblinding. Three experienced abdominal radiologists evaluated the data using one of three primary interpretation techniques: (1) 2D; (2) bidirectional 3D; (3) panoramic 3D. Mixed model analysis of variance and logistic regression for correlated data were used to compare techniques with respect to time and sensitivity and specificity. RESULTS: Mean evaluation times were 8.6, 14.6, and 12.1 min, for 2D, 3D, and panoramic, respectively. 2D was faster than either 3D technique (p < 0.0001), and the panoramic technique was faster than bidirectional 3D (p = 0.0139). The overall sensitivity of each technique per polyp and per patient was 68.4 and 76.7% for 2D, 78.9 and 93.3% for 3D; and 78.9 and 86.7% for panoramic 3D. CONCLUSION: 2D interpretation was the fastest overall, the panoramic technique was significantly faster than the bidirectional with similar sensitivity and specificity. The sensitivity for a single reader was significantly lower using the 2D technique. Each reader should select the technique with which they are most successful.

Neuropsychological profiles associated with subcortical white matter alterations and Parkinson's disease: implications for the diagnosis of dementia.

Despite the emergence of a number of new classification systems, the diagnosis of cerebrovascular dementia remains controversial. Also controversial is the significance of periventricular and deep white matter alterations (WMA) as seen on magnetic resonance imaging (MRI). To further clarify this issue, MRI scans were used to regroup patients clinically diagnosed with Alzheimer's disease (AD) or subcortical ischemic vascular dementia (IVD) into cohorts presenting with either little versus significant WMA on MRI. These two groups were then compared to demented patients diagnosed with idiopathic Parkinson's disease (PD) using a comprehensive neuropsychological protocol. Neuropsychological assessment failed to distinguish between patients with PD and significant WMA. By contrast, both of these patient groups exhibited disproportionate impairment on tests of executive systems functioning, whereas patients with little WMA showed greater impairment on tests of declarative memory and semantic knowledge. These findings constitute further evidence that the pattern of cognitive impairment associated with significant WMA is distinctly different when compared to AD. These results are discussed within the context of a growing body of literature suggesting that elements of the underlying neuropathologies in AD and IVD are linked. Implications for the diagnosis of dementia are also discussed.

Ultrasonic assistance in the diagnosis of hand flexor tendon injuries.

In contrast to routine flexor tendon injuries, flexor tendon ruptures following blunt injury or re-ruptures following repair can be difficult to diagnose. The authors investigated the efficacy of using ultrasound to assist in the diagnosis. From 1996 to 1997, 8 patients underwent evaluation of the flexor tendons using an ATL HDI-3000 ultrasound machine with a high-resolution, 5 to 9-MHz hockey stick linear probe. Dynamic evaluation was performed in real time, simulating clinical symptoms. Six patients underwent surgical exploration. Sonographic diagnosis and intraoperative findings were correlated. Ultrasound was used to diagnose 3 patients with ruptured flexor digitorum profundus tendons. Mechanisms of injury included forceful extension, penetrating injury, and delayed rupture 3 weeks after tendon repair. Subsequent surgical exploration confirmed the ruptures and location of the stumps. Five patients had intact flexor tendons by ultrasound after forceful extension, penetrating injury, phalangeal fracture, crush injury, and unknown etiology. In 3 patients who underwent surgery for tenolysis, scar release, or arthrodesis, the flexor tendons were found to be intact, as predicted by ultrasound. The authors found ultrasound to be accurate in diagnosing the integrity of flexor tendons and in localizing the ruptured ends. They conclude that ultrasound is helpful in evaluating equivocal flexor tendon injuries.

Declarative and procedural learning, quantitative measures of the hippocampus, and subcortical white alterations in Alzheimer's disease and ischaemic vascular dementia.

This research investigated whether subjects with Alzheimer's disease (AD) and ischaemic vascular dementia (IVD) associated with periventricular and deep white matter alterations can be dissociated on tests of declarative and procedural memory, as well as on MRI indices of white matter alterations and the size of the hippocampal formation. The California Verbal Learning Test (CVLT) and the Pursuit Rotor Learning Tests (PRLT) were used to measure declarative and procedural memory, respectively. Subjects with IVD obtained a higher score on the CVLT recognition discriminability index; however, on the PRLT total time on target, carry-over between trial blocks, and slope calculated for all test trials was low. Subjects with AD exhibited the opposite profile. MRI studies indicated that subjects with IVD had considerably greater white matter alterations, but larger hippocampal formations than subjects with AD. Higher scores on the CVLT recognition discriminability index were correlated with increased size of the body of the hippocampus and parahippocampal gyrus. By contrast, as the severity of white matter alterations increased the slope on the PRLT declined. In sum, subjects with AD and IVD can be dissociated on the basis of differing patterns of impairment on tests of declarative and procedural memory, and MRI indices of white matter alteration and the integrity of the hippocampal formation.

Dementia associated with periventricular and deep white matter alterations: a subtype of subcortical dementia.

This research examined the neuropsychological functioning of demented patients with periventricular and deep white matter alterations. Thirty-three outpatients with NINCDS-ADRDA probable Alzheimer's disease (AD) and 27 outpatients with probable/ possible ischaemic vascular dementia (IVD, Chui et al., 1992) associated with periventricular and deep white matter alterations matched for age, education, level of dementia, and functional disability were studied. White matter alterations were measured using a 40-point scale previously described by Junque et al. (1990). Subjects with cortical CVAs were excluded. On executive control tests, IVD subjects made more preservations on tests of mental control and response set, and produced fewer responses on phonemic controlled oral word association tests (letters: F,A,S). IVD subjects also made more preservations and graphomotor errors on clock drawings. On the California Verbal Learning Test the IVD group performed better than AD subjects on the short delay free recall test condition, the recognition discriminability index, and made fewer intrusion errors on both free and cued recall conditions. We conclude that neuropsychological assessment can differentiate AD from IVD associated with white matter alterations, and that the neuropsychological profile of demented subjects with significant periventricular and deep white matter alterations is similar to other subcortical dementing illnesses.

Acquired immunodeficiency syndrome and mycotic abdominal aortic aneurysms: a new challenge? Report of a case.

The case of a 64-year-old white man with acquired immunodeficiency syndrome and ruptured abdominal aortic aneurysm infected with Salmonella is presented. Five points related to this case are addressed. It is feared that the vascular surgeon may face patients with acquired immunodeficiency syndrome and abdominal aortic aneurysms infected with Salmonella with increasing frequency in the future. This case raises medical, ethical, and moral questions.

Spontaneous pneumothorax: an uncommon manifestation of Wegener granulomatosis.

Pneumothorax is an unusual manifestation of Wegener granulomatosis. Two cases are presented which illustrate a definite association between the entities. Pneumothorax may be the initial and only pulmonary manifestation, or it may occur in combination with other evidence of the disease.

Shoulder erosions in renal osteodystrophy.

The radiographic manifestations of renal osteodystrophy may be articular as well as osseous. The latter are well recognized, i.e., subperiosteal and subchondral bony resorption. Recently attention has been directed to the occurrence of an erosive arthritis of the hands and wrists in hyperparathyroidism. The authors present six patients with humeral head erosions, all of whom were on chronic long-term hemodialysis. These intra-articular erosions occurred at the "bare" area of the humeral head and thus represent an erosive arthritis and therefore can be distinguished from the usual sites of subchondral and subperiosteal bony resorption seen in hyperparathyroidism.

Hydroxyapatite deposition disease.

Hydroxyapatite crystals are a common cause of periarticular disease, but recent studies have shown that they may also be deposited intra-articularly, either as a primary phenomenon or secondary to another disease. A continuum of abnormalities from monoarticular periarthritis to polyarticular disease and finally joint destruction may occur.

The sonographic appearance of acute pyelonephritis.

Acute pyelonephritis and acute ureteral obstruction often present with similar clinical and urographic findings. Ultrasound, however, can easily detect the presence of obstruction as well as demonstrate characteristic findings suggestive of acute pyelonephritis, and thus allows differentiation. In two patients with acute pyelonephritis, the ultrasonic findings consisted of a large swollen kidney with an increased anechoic corticomedullary area, with multiple scattered low-level echoes. Each of the two cases is discussed in detail.

An analysis of pancreatic sonography in suspected pancreatic disease.

To assess the value of pancreatic sonography in patients suspected of having pancreatic disease, our first 500 pancreatic examinations using gray scale imaging were reviewed in a prospective manner without clinical information. Various parameters of each examination were recorded. The pancreas was localized by its relationships to surrounding vessels and the duodenum. The ability to define the head, body, and tail of the pancreas as well as anterior--posterior size measurements were noted and recorded. A retrospective clinical pathologic follow-up was then carried out and correlated with the ultrasonic findings. Four categories of patients were identified. The features seen in pancreatic ultrasonography of the entire group, as well as those seen in the individual categories, were analyzed. This analysis indicates that pancreatic sonography can be used in patients suspected of having pancreatic disease, defining both normal and abnormal pancreas. A high index of suspicion for the type of abnormality present can be achieved.