Hepatitis C diagnosis and treatment in people who use drugs: mind the gap in the linkage to care.

OBJECTIVE: The objective of this study is to identify a simplified rapid screening and linkage-to-care model for HCV among PWUD. PATIENTS AND METHODS: The study stems from a collaborative project bringing together two local Italian Centers for Drug Addiction and the Hepatology-Infectious Diseases Department of Lazzaro Spallanzani. A research physician analyzed the available medical records seeking to identify HCV and HIV infected patients in care in the addiction centers. Between March 2018 and January 2020 subjects were selected from among a cohort of 720 PWUD in the two Centers' care. The study comprises three steps: first, screening for HCVAb; second, the linkage to care; third, clinical assessment to treatment. The research physician recruited patients for the first two steps directly in their local addiction center. The third step was conducted in the Spallanzani. The characteristics of those subjects who adhered to the three-step study program were then compared to those of the non-adhering PWUD. RESULTS: 194 were known HCVAb positive patients. Of the 505 PWUD in the care of the two Centers eligible for screening, 364 were enrolled in the study. 144 resulted HCVAb positive. 269 were tested for HCVRNA. 101 underwent a full assessment. 96 patients started antiviral therapy with DAA. Patients who refused first step screening were older patients and mainly heroin users; in the second step, almost all the HIV/HCV co-infected patients agreed to a viremia test; in the third step all the HIV/HCV co-infected patients refused HCV treatment. CONCLUSIONS: The study suggests an on-site specialist approach conducted directly in the addiction centers themselves starting from screening; it can bring the goal of HCV PWUD microelimination closer.

Multicentric osteolytic lesion of the middle finger of the hand. Case report.

Giant cell-rich osteolytic lesions may have overlapping clinical, radiologic, and histopathologic features, with an important degree of difficulty of diagnosis and treatment. We report a case of double osteolytic lesion at the middle-finger in a young man without previous history of hand trauma. He underwent en-bloc resection of the bone lesions and reconstruction by graft of hydroxyapatite, resulting in a good morpho-functional result. Histological diagnosis was giant cell reparative granuloma (GCRG), although several features were considered atypical, including the appearance of the giant cells and the areas of the stroma that more closely resembled a giant cell tumor. GCRG is a benign rare intraosseous lesion and the true nature is controversial and unknown. The theories are that it could be a reactive lesion, a developmental anomaly or a benign neoplasm. It appears as an osteolytic lesion that must be considered in the differential diagnosis of other "critical" bone lesions similar in clinical, as well as radiologic and pathological appearance. Further characterization studies are helpful and necessary for the proper management.

Extensive facial trauma caused by dog bites in woman suffering from systemic fluconazole-resistant Candida infection.

INTRODUCTION: Dog bites present a complex problem. Extensive facial trauma is a challenging problem to treat with priority for functional outcome. This paper describes the conservative treatment in a very difficult case of facial trauma with unusual infections due to the bites. CASE REPORT: A 45 year-old woman was admitted in hypovolaemic shock with amputation of nose, upper and lower lips, left cheek and chin caused by dog bites. After vital parameters and volaemy were stabilized, wound toilet was performed, followed by skin and mucosal rotation flaps and anterior nasal tamponade; the lesion has then been covered with a collagen/oxidized regenerated cellulose dressing and sterile gauzes. Culture test highlighted coagulase-negative Staphylococcus and Candida albicans. However after few days, the patient developed septic-undulant hyperpyrexia, retinitis, renal candidiasis, folliculitis. Systemic Candida infection resistant to fluconazole was diagnosed. Amphotericin B was given to the patient and the facial wound was managed conservatively with an active medication because of inoperability conditions. The outcome of the use of active medications was an immediate response with excessive granulation tissue followed by a rapid re-epithelization. CONCLUSION: As our case has shown, conservative treatment can be a valid alternative therapy in the treatment of large wounds with invasive candidosis and candidaemia or other major contraindications to surgery. In fact, in cases where surgical reconstruction is not a feasible option, conservative treatment can allow a rapid repair of the skin barrier.

Posterior interosseous nerve palsy by synovial cyst of proximal radioulnar joint: our experience after 5 years.

AIM: The posterior interosseous nerve palsy is a neuropathy of radial nerve interesting its deep motor branch. The neuropathy can appear with a hollow in the proximal half of the forearm without significant swelling, a complete loss of extension of the fingers with radial deviation of the wrist during extension. In some cases, PIN compression may simulate tendon rupture in rheumatologic diseases, because the pain and the paralysis occur suddenly, so often can be difficult to make a diagnosis. The palsy is caused by compression of the posterior interosseous nerve from soft tissue tumours or tumour-like masses: ganglions, lipomas, rheumatoid synovitis, synovial chondromatosis, fibromas, neurofibromas, bursitis, synovial cysts of the elbow and radioulnar proximal joints. The aim of our research was to individuate the better treatment for the posterior interosseous nerve palsy. METHODS: From 2002 to 2007 we examined 8 patients: 2 female and 6 male. Median age was 43 years. The diagnosis was made by clinical examination, ultrasound, nerve conduction studies and magnetic resonance imaging (MRI). Patients underwent to decompressing posterior interosseous nerve surgery. RESULTS: After the surgical exploration in 8 cases a globular mass of around 2.5 cm to 4.5 cm diameter was discovered. At the histological examination, a synovial cyst of the elbow joint was found in 7 out of 8 patients and an hemangioma tumor in the one remaining patient. 12 months was the median time for a complete recovery after the operation, confirmed by EMG. CONCLUSION: The surgical treatment offers a complete resolution in all cases.

Treatment of persistent radial nerve palsy through "tendon minimal transfer" technique.

Palliative tendon transfer procedures for radial nerve palsy are continuing to evolve. This paper reports outcomes of 10 patients with isolated and traumatic radial nerve palsy underwent "minimal transfer". All patients improved functionally and could attend their routine activities. The flexor carpi ulnaris and palmaris longus tendon transfer has some advantages in terms of simplicity, shorter operative time, less morbidity, better wrist and finger extension and thumb extension and abduction.

Ulnar artery thrombosis and nerve entrapment at Guyon's canal: our diagnostic and therapeutic algorithm.

Hypothenar hammer syndrome is a rare condition of ulnar artery aneurysm or thrombosis, which can be associated with a neuropathy of the ulnar nerve. There is no agreement regarding an optimal diagnosis and treatment for this syndrome. Most authors suggest angiography as the gold standard for diagnosis and recommend observation for the thrombotic type, and reconstructive surgery for the aneurysmal type. We report here our diagnostic and therapeutic algorithm, reviewing 9 patients with ulnar artery thrombosis and nerve entrapment at Guyon's canal; and an evaluation of the type of management including: anamnesis, diagnostic tests, and reconstructive surgery. We consider resection of the arterial thrombotic segment as the treatment of choice, due to the fact that ulnar arterial thrombosis can induce severe chronic inflammation into Guyon's canal and ulnar nerve sufferance. Therefore, we propose a planned approach, including 3 steps: clinical evaluation with Tinel and Allen's tests; magnetic resonance and ultrasound images; ulnar nerve decompression and arterial reconstruction. We believe that this practice is important for the early therapy of ulnar arterio-neuropathy in affected patients.

Traumatic complex wounds, multidisciplinary approach: our experience in a case series.

"Limb-salvage" is a social problem that is rapidly increasing, both in Italy and in the rest of world. Today, as in earlier times, the main causes of open wounds are traumas and such injuries are mainly of II and III stage of Gustilo's classification. Nowadays, the use of modern techniques determined a further dramatic reduction in the infection rates and, above all, in the risk of limb amputation. The most important techniques include: V.A.C. therapy (vacuum assisted closure); PRP gel (platelet-rich plasma gel); hyperbaric oxygen therapy. We treated 4 patients with high energy acute trauma through the combined and innovative use of advanced dressings. The authors report their experience and a brief review of the literature as contribution in regards to treatment of complex wounds of the limbs.

[Surgical treatment of Morton's neuroma: our experience and literature review]. / Il trattamento chirurgico del neuroma di Morton: la nostra esperienza alla luce della letteratura.

OBJECTIVE: Morton's neuroma is a common foot problem associated with pain. MATERIALS AND METHODS: In 52 patients intermetatarsal spaces were operated on for Morton's neuralgia Gautier surgical treatment. The procedure included dorsal incision, division of the deep intermetatarsal ligament, and resection of the common digital nerve including the neuroma. Results. The outcome of the operation was excellent in 47 patients. CONCLUSIONS: The results show the efficacy of the surgical treatment of Morton's neuralgia with a dorsal incision, over a long follow-up period.

[Dupuytren's disease simulated by epithelioid sarcoma with atypical perineural invasion of the median nerve. Case report]. / Malattia di Dupuytren simulata da un sarcoma epitelioide con atipica invasione perineurale del nervo mediano. Caso clinico.

Epithelioid sarcoma is an infrequent tumour, especially in upper limb, which nerve spread is not common. We describe the case of a 27 years old caucasian male with initial diagnosis of Dupuytren's disease. He underwent palmar fascia surgery, but the surgical treatment was followed by recurrence of the deformity in retraction of 4th and 5th finger of the left hand. When he presented himself at our attention, the patient underwent surgical biopsy and new histological examination was made with diagnosis of epithelioid sarcoma. We highlight essentially two aspects of this case: the diagnostic delay of tumour caused by simulation of the Dupuytren's disease and the atypical perineural spread along the median nerve.

The pillar pain in the carpal tunnel's surgery. Neurogenic inflammation? A new therapeutic approach with local anaesthetic.

AIM: After the surgical decompression of the transverse carpal ligament as treatment of the tunnel carpal syndrome, pillar pain manifestation is possible. This is a painful and temporary invaliding syndrome with unknown aetiology. Aim of the study is to demonstrate that pillar pain is based on autonomic irritation that disappears with simple infiltration of local anaesthetic (LA), or rather by neuromodulation. METHODS: Eighty-four patients were enrolled for this study and underwent an open release technique surgery. They were then asked for regular postoperative follow-ups. RESULTS: Thirty-two out of 84 patients (38%) developed pillar pain. Accordingly, injection of LA as pain treatment has since been studied and results compared with the conventional protocol for this painful syndrome. CONCLUSION: Even if the number of the patients considered is not great, there is evidence of a decrement of pillar pain by means of LA injections. Excellent functional outcomes and satisfaction were achieved using LA infiltrations for pillar pain after carpal tunnel decompression. The minimally invasive technique offers a quick, easy, effective, and inexpensive method useful to minimize and cure in a few days the pillar pain.

[Tenosynovial giant cell tumour of the hand and wrist: early diagnosis and surgical treatment]. / Tumore a cellule giganti tenosinoviale della mano e del polso: diagnosi precoce e trattamento chirurgico.

Fourty two patients with tenosynovial giant cell tumour, treated with radical excision, underwent detailed follow-up to evaluate the outcomes and to find early the possible recurrence of disease. Radical excision is the only way to have a complete recovery from disease and total recovery of function. Early diagnosis of recurrence is possible by careful clinical examination, ultrasonography and, in selected cases, magnetic resonance imaging.

[Surgical treatment of painful amputation neuromas with hyaluronic acid gel. Preliminary study of six patients]. / Trattamento chirurgico dei neuromi d'amputazione dolorosi con gel di acido ialuronico. Lavoro preliminare su 6 casi.

Amputation neuroma is the consequence of a traumatic event that interrupt the anatomic structure of a nerve. After the lesion, the nerve begin an plerosis attempt. This condition determines hyposensitivity on its innervation area and a painful syndrome. The pattern's resolution is possible with the neuroma's tissue exeresis and the sinking of proximal stump into closer tissue. This operation reduces or eliminates axonal nerve's flux. The hyaluronic acid (Hyaloglide 0.8-1 ml) use is based on the necessity of proximal stump preservation from mechanical and thermic stimuli that are responsible of typical neuroma's symptoms. In this study we used hyaluronic acid on six painful amputation neuroma patterns on sensitive nerves of upper and lower extremities.

Evaluation of goiter using ultrasound criteria: a survey in a middle schoolchildren population of a mountain area in Central Italy.

Iodine deficiency is still an important health care problem in the world. In Italy, as in most European countries, it is responsible for the development of mild to moderate endemic goiter. In 1995 we conducted a goiter survey in the Gubbio township, an area of Umbria region in Italy, close to the Appenine mountain chain. This study demonstrated a high prevalence of goiter in the middle schoolchildren population, indicating the presence of moderate endemic goiter. Soon after, a goiter prevention campaign aimed at implementing the consumption of iodinated salt was started. In 2001, a second survey was conducted in the middle schoolchildren (age 11-14 yr old) of Gubbio and neighbour townships. Eight hundred thirteen subjects were studied. Data obtained in 240 age-matched children, studied in the same area in 1995, were used for comparison to monitor changes 5 yr after the beginning of iodine prophylaxis. Thyroid volume was measured by ultrasonography. Gland volume was expressed in ml. A large population living in a iodine-sufficient area, previously reported by others, was used as control. Urinary iodine excretion was measured randomly in 20% of the children. The overall prevalence of goiter decreased between 1995 and 2001 from 29 to 8%. Goiter odds ratio (OR), corrected for age, was 4.0 (95% CI 2.8-5.9) for 1995 compared to 2001 (p<0.000). Mean thyroid volume in the matched populations was 7.6+/-2.5 ml in 1995 and 5.7+/-2.1 ml in 2001. Median iodine urinary excretion increased from 72.6 to 93.5 mug/l, at the limit of statistical significance. Living in a rural area, no consumption of iodized salt and familiarity for goiter represented independent risk factors for goiter development. This study was the first conducted in Umbria region and confirmed that an implementation campaign for iodized salt consumption is a simple and useful instrument to prevent endemic goiter and related diseases. A new survey to evaluate goiter prevalence in the same area 10 yr after the beginning of iodine prophylaxis is already planned.

[Complex Regional Pain (CRPS) Syndrome type II. Timing for surgery and therapeutic options: neuromodulation]. / La Sindrome Complessa Dolorosa Regionale (CRPS) tipo II. Timing chirurgico e strategie terapeutiche: la neuromodulazione.

OBJECTIVE: The object of this study is to evaluate the importance of a correct timing for surgery, the different strategies of therapy and the use of the neuromodulation in the Complex Regional Pain Syndrome (CRPS) type II. PATIENTS AND METHODS: The last 2 years we observed 8 patients with the clinical picture of a CPRS type II, due to previous peripheral nerve lesions of the upper extremity. All the patients followed a therapeutic protocol of neuromodulation and reconstructive surgical repair. RESULTS: Six patients out of eight had almost a complete recovery of the symptoms 6 months after the surgery. CONCLUSIONS: Our study demonstrates that the patients who underwent surgical repair followed by neuromodulation didn't present any recurrence of the symptoms.

[Double compression of the ulnar nerve at the elbow and at the wrist (double-crush syndrome). Case report and review of the literature]. / Doppia compressione del nervo ulnare alla doccia epitrocleo-olecranica ed al polso (double-crush syndrome). Descrizione di un caso e revisione della letteratura.

Double compression of a peripheral nerve is not rare in medical practice. This article describes an ulnar neuropathy along the elbow and the wrist segments with electro-diagnostic examination (EDX). The proximal compression was an ulnar entrapment at the olecranon-epitrochlear semi-canal; the distal one was after the canal of Guyon, due to an arthro-synovial cyst arising from the pisohamatum joint. There aren't analogous clinical reports in the literature.

[Neuritis of the sensory branch of the radial nerve: Wartemberg's syndrome. A case report]. / La neurite dei rami terminali del nervo radiale: la sindrome di Wartemberg. Descrizione di un caso e revisione della letteratura.

Wartembergs syndrome is an entrapment of the sensory branch of the radial nerve in the forearm. It is not mentioned with the other peripheral nerve entrapments and it is very rare. Wartemberg's syndrome is too often misdiagnosed as the De Quervain's disease or is not diagnosed at all. The Authors report their experience with a case surgically treated.

[Glomus tumor and neovascular syndrome of the arm: a clinical case]. / Tumore glomico e sindrome neurovascolare dell'arto superiore: caso clinico.

Glomus tumour represents a benign tumor which originates from myoepithelial cells of arteriovenous anastomosis that has a preference for subungual localization with painful and multiform symptomatology. A fifty-year-old female presented a vasospastic symptom with hyperalgesia and cold hypersensitivity in the fourth finger of the right hand. There was a little palpable tumefaction and after an echography, we decided for surgical revision. Differential diagnosis with Raynaud's phenomenon is very important but not simple. The diagnosis is often late. MRI and angio-MR with its typical symptomatology could give the accurate diagnosis. The therapy is only surgical. The excision must be very careful making sure to spare the nervous structures.

Use of vein grafts in emergency in peripheral nerve defect.

Peripheral nerve defects represent a frequent lesion in emergency. The vein graft is the alternative to nerve graft in cases where the nerve defect does not allow a direct approximation. Our experience on the use of venous graft has brought about excellent functional results that, together with a simple execution of the methodology, are at the bottom of our study. During the last 6 months we have treated 3 cases of peripheral nerve defect with nerve gap >2 cm; 1 lesion of ulnar nerve, 1 lesion of median nerve treated with vein graft and in 1 case an association of the median and ulnar nerve treated with reversed vein graft. An immediate resolution of the pain was observed in all patients already during the first 36/48 hrs. The clinical and electrophysiological evaluations at 3 and 6 months have demonstrated encouraging data regarding functional reparation and re-innervation. Even in consideration of the limited number of cases, comparison with data related to the autologous nerve graft shows a slightly slower recovery, but certainly overlapping to the classical methodology; moreover, excellent clinical results appear from the use of reversed vein graft. The advantage of vein grafts are multiple. There is an overlapping of the functional recovery, that represents the condition sine qua non of each new surgical experimental procedure. The simplicity of the technical execution and the possibility to cover missing nerves without sensory damage is advantageous both for the patient and for the structure, reducing operating time and related costs.

[Cutaneous Merkel cell carcinoma: case report]. / Carcinoma cutaneo di Merkel: caso clinico.

Merkel cell carcinoma is an unusual cutaneous malignancy with a propensity for spreading to regional lymph nodes, with recurrence at original site or/and in lymph node. Occurring most often on the head and neck of the elderly patients. Complete surgical resection is the mainstay of treatment of the primary tumor. A case is here described of an old patient with more than one local relapse and in regional lymph nodes too, complete surgical resected, actually in good state of health, treated with radiotherapy.