3-dimensional computer tomography is more accurate than traditional long-leg radiographs in the planning and evaluation of coronal alignment in total knee arthroplasty: a prospective study on 121 knees.

BACKGROUND AND PURPOSE: Accurate measuring tools are essential in preoperative planning and for the study of the association between postoperative alignment and clinical outcome in total knee arthroplasty (TKA). We aimed to describe a simple method to measure preoperative hip-knee-femoral shaft (HKFS) angle and postoperative coronal alignment in TKA with the use of standard 3D CT and to compare preoperative HKFS angles and postoperative coronal alignment measured with the 3D CT technique and with standing long-leg hip-knee-ankle (HKA) radiographs. PATIENTS AND METHODS: HKA radiographs and 3D CT were taken preoperatively and 3 months after the operation in 121 knees. The interrater reliability for the 3D CT method was calculated with intra-class correlation coefficient (ICC). The preoperative HKFS angles and the postoperative deformity measured with the 2 methods were compared and illustrated on Bland-Altman plots, frequency tables, and by Cohen's kappa coefficients (k). RESULTS: The 3D CT method was feasible in all knees and the ICC was excellent. Mean (SD, range) difference in HKFS angle measured on HKA radiographs and on 3D CT was -0.3° (0.9°, -4.1° to 2.4°). Mean (SD, range) difference in postoperative deformity was 0.1° (1.6°, -5° to 6°). The 95% limits of agreement were 1.4° and -2° for HKFS and ±3° for postoperative alignment. The agreement in outlier (≥ 3°) identification was moderate with a k (95% confidence interval) of 0.48 (0.32-0.64). CONCLUSION: 3-dimensional computer tomography was feasible and was shown to be more accurate than traditional long-leg radiographs.

Fusion rate and influence of surgery-related factors in lumbar interbody arthrodesis for degenerative spine diseases: a meta-analysis and systematic review.

The aim of this meta-analysis and systematic review is to summarize and critically analyze the influence of surgery-related factors in lumbar interbody fusion for degenerative spine diseases. A systematic review of the literature was carried out with a primary search being performed on Medline through PubMed. The 2009 PRISMA flowchart and checklist were taken into account. Sixty-seven articles were included in the analysis: 48 studies were level IV of evidence, whereas 19 were level III. All interbody fusion techniques analyzed have proved to reach a good fusion rate. An overall mean fusion rate of 93% (95% CI 92-95%, p < 0.001) was estimated pooling the selected studies. The influence of sagittal parameters and cages features in fusion rate was not clear. Autograft is considered the gold standard material. The use of synthetic bone substitutes and biological factors alone or combined with bone graft have shown conflicting results. Low level of evidence studies and high heterogeneity (χ2 = 271.4, df = 72, p < 0.001; I2 = 73.5%, τ2 = 0.05) in data analysis could result in the risk of bias. Further high-quality studies would better clarify these results in the future.

Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO Study).

BACKGROUND: Laparoscopic lavage was proposed in the 1990s to treat purulent peritonitis in patients with perforated acute diverticulitis. Prospective randomized trials had mixed results. The aim of this study was to determine the success rate of laparoscopic lavage in sepsis control and to identify a group of patients that could potentially benefit from this treatment. METHODS: This retrospective multicentre international study included consecutive patients from 24 centres who underwent laparoscopic lavage from 2005 to 2015. RESULTS: A total of 404 patients were included, 231 of whom had Hinchey III acute diverticulitis. Sepsis control was achieved in 172 patients (74·5 per cent), and was associated with lower Mannheim Peritonitis Index score and ASA grade, no evidence of free perforation, absence of extensive adhesiolysis and previous episodes of diverticulitis. The operation was immediately converted to open surgery in 19 patients. Among 212 patients who underwent laparoscopic lavage, the morbidity rate was 33·0 per cent; the reoperation rate was 13·7 per cent and the 30-day mortality rate 1·9 per cent. Twenty-one patients required readmission for early complications, of whom 11 underwent further surgery and one died. Of the 172 patients discharged uneventfully after laparoscopic lavage, a recurrent episode of acute diverticulitis was registered in 46 (26·7 per cent), at a mean of 11 (range 2-108) months. Relapse was associated with younger age, female sex and previous episodes of acute diverticulitis. CONCLUSION: Laparoscopic lavage showed a high rate of successful sepsis control in selected patients with perforated Hinchey III acute diverticulitis affected by peritonitis, with low rates of operative mortality, reoperation and stoma formation.

Approval rating and opinion of outpatients and general practitioners toward generic drugs: a questionnaire-based real-world study.

PURPOSE: Generic drugs use in the Liguria region is higher than the Italian average, but lower than in other European countries. No data exist about real-life prescription and level of awareness of generic drugs. In this study, we analyzed demographic, social, economic and cultural factors that may affect the level of awareness of generic drugs and their effective use. METHODS: We conducted a population survey using a structured questionnaire, administered to a sample of 8 outpatient clinics of general practitioners located in different districts of Genoa (Liguria, Italy). Multivariate logistic modeling was adopted to study the relationship between awareness/use of generic drugs and characteristics of subjects. RESULTS: Out of 2,000 outpatients surveyed, 95% were aware of generic drugs: these were mostly females (OR =2.2, 95% CI: 1.4-3.6), >35 years old (OR >6.0 vs 18-35 years), with a high level of education (OR >4.4 vs "elementary sch"), living in the west side of the city (OR =1.9 vs center); of these, only 59% declared that they effectively use generic drugs. Users were younger (OR =3.1, 18-35 years vs >65 years), with a high level of education (high school/university degree vs no title/elementary/secondary school OR =1.7), and were aware of the lower cost compared with branded drugs, and were mainly informed by pharmacists and physicians. CONCLUSIONS: Although subjects were substantially aware of the existence of generic drugs, ~40% still did not use them; doubts about their efficacy seem to be mainly driven by the idea that cheaper drugs lead to lower product quality, in terms of efficacy, safety and tolerability. New education policies on generic drugs are needed.

Itch and motivation to scratch: an investigation of the central and peripheral correlates of allergen- and histamine-induced itch in humans.

Intense itch and urge to scratch are the major symptoms of many chronic skin ailments, which are increasingly common. Vicious itch-scratch cycles are readily established and may diminish quality of life for those afflicted. We investigated peripheral and central processing of two types of itch sensation elicited by skin-prick tests of histamine and allergen solutions. Itch-related skin blood flow changes were measured by laser Doppler in 14 subjects responsive to type I allergens and 14 nonatopic subjects. In addition, this study examined central processing of both types of itch using functional magnetic resonance imaging (fMRI). Itch perception and blood flow changes were significantly greater when itch was induced by allergens compared with histamine. Both types of itch correlated significantly with activity in the genual anterior cingulate, striatum, and thalamus. Moreover, itch elicited by allergens activated orbitofrontal, supplementary motor, and posterior parietal areas. Histamine-induced itch also significantly correlated with activation in the insula bilaterally. The identification of limbic and ventral prefrontal activation in two types of itch processing likely reflects the subjects' desire to relieve the itch sensation by scratching, and these regions have been repeatedly associated with motivation processing. A dysfunction of the striato-thalamo-orbitofrontal circuit is believed to underlie the failure to regulate motivational drive in disorders associated with strong urges, e.g., addiction and obsessive compulsive disorder. The patterns of itch-induced activation reported here may help explain why chronic itch sufferers frequently self-harm through uncontrollable itch-scratch cycles.

[The methods of using the echocardiogram in outpatients. The role of the cardiologist for more appropriate use of the procedure. The Ligurian Group of the Italian Society of Cardiovascular Echocardiography]. / Modalità di utilizzazione dell'ecocardiogramma in pazienti ambulatoriali. Ruolo del cardiologo per l'appropriatezza della prescrizione. Gruppo Ligure della Società Italiana di Ecografia Cardiovascolare.

Concerns about the increasing medical care costs are causing the medical community to focus its attention on the appropriate of diagnostic tests such as echocardiography. Prerequisite to a better utilization of the limited economic resources assigned to our health care system is an analysis of how, why, and with which results diagnostic tests with a widespread use and relevant cost, like echocardiography, are requested. During the last 2 weeks of September 1994, a transversal, observational study was carried out at 13 hospital echocardiographic laboratories. Ordering physician characteristics, reasons for ordering the test, cardiological diagnostic tests previously performed and their relationship with the test results, were evaluated with a questionnaire completed by the physician who performed the test, in all the out-patients undergoing echocardiogram in that fortnight. Five hundred and sixteen consecutive questionnaires were successfully completed. Fourty-five percent of the echocardiograms were ordered by cardiologists, 35% by general practitioners, 10% by internists, and 10% by other specialists. Hypertension (16.4%) and ischemic heart disease (14.8%) were the most common indications for the test, followed by palpitations or arrhythmias (7.5%), mitral valve prolapse or mitral valve disease (7.3%), chest pain or angina pectoris (6.3%), cardiac murmur (5.5%), dyspnea or heart failure (5.2%), aortic valve disease (5%), prosthetic heart valve evaluation (4.6%), others (27%). Before undergoing the echocardiogram, 433 (84%) patients underwent an electrocardiogram, 242 (47%) a cardiological clinical evaluation, 196 (38%) a chest X-ray, and 191 (37%) had had a previous echocardiogram. The most common echocardiographic diagnosis was normal (29.2%) followed by hypertensive heart disease (16.2%), mitral valve disease (12.3%), aortic valve disease (10.5%), ischemic heart disease (9.3%), cardiomyopathy (4.9%) normal prosthetic heart valve function (4.5%), pericardial effusion (3.8%), others (11.3%). Among the echocardiograms ordered by cardiologists, 21.8% were normal in comparison with 35.4% of those ordered by general practitioners (p < 0.004), 35.3% of those ordered by internists (p = 0.04), 35.3% of those ordered by other specialists (p = 0.04). Among the 284 patients whose echocardiograms were not requested by a cardiologist, only 215 (76%) had undergone an electrocardiogram and only 68 (24%) a clinical evaluation by a cardiologist. In these patients, the frequency of normal echocardiograms was not influenced by having undergone a previous electrocardiogram or a chest X-ray. Conversely, patients in whom the echocardiogram was ordered after a cardiology consult showed a significant lower frequency of normal results compared to patients not evaluated by a cardiologist (23% vs 39%; p < 0.05). More than 50% of the echocardiograms performed in out-patients are ordered by physicians who are not cardiologists. Among these echocardiograms, about 1 out of 3 results normal. This finding suggests an improper use of echocardiogram as a screening tool by non-cardiologists in out-patients. A preceding clinical evaluation by a cardiologist, but not an electrocardiogram or a chest X-ray alone, may determine a more appropriate use of the test being associated with a reduced frequency of normal results.

Isonymy and the genetic structure of Sicily.

The genetic structure of Sicily was analysed through the distribution of surnames of 758,793 users registered in the Italian Telephone Company, corresponding to 371 communes of the island. Estimates of the coefficient of consanguinity due to random isonymy, of Fisher's a, an indicator of abundance of surnames, and of Karlin-McGregor's v, an indicator of immigration rates, were obtained for each commune. Four different estimates of genetic distance between all possible pairs of communes within each province were also obtained, and their relationship with geographic distance was studied. The logarithmic transformation of Lasker's coefficient of relationship showed correlations with the log of geographic distance which range between -0.78 and -0.40; the strongest, for the province of Catania, was attributed to the presence of Mount Etna, and the weakest, for Palermo, to the high population density of this province.

[Peritoneal splenosis. Report of a case and pathogenetic considerations]. / Splenosi peritoneale. Segnalazione di un caso e considerazioni patogenetiche.

A clinical case of splenosis recently observed in a young man subjected at the age of 8 to splenectomy for rupture of the spleen and operated at 19 for intestinal occlusion is reported. The pathogenetic aspects of the condition, characterised by the presence of nodules of splenic tissue in the abdominal cavity, are examined through a review of the literature.

[Value of transduodenoscopic wirsungography in the diagnosis of pancreatic pseudocysts]. / Valore della wirsungrafia transduodenoscopica nella diagnosi delle pseudocisti pancreatiche.

The radiographic pictures obtained by endoscopic wirsungraphy in a group of 24 patients suffering from pancreatic pseudocysts and subsequently examined intraoperatively by wirsungraphy and cystography are analysed and commented. Pre-operative endoscopic visualisation of the lesion was obtained in 70% of the cases. In 55% of the cases there were co-existing alterations of calibre and trend of the main pancreatic duct, chiefly attributable to chronic basic pancreatitis and to a very small extent to the pseudocystic lesion. The following are discussed: a) the diagnostic value of the endoscopic procedure, which reaches absolute values in the direct visualisation of the sac, with a power of resolution that is difficult to reach with other methods; b) the probable prognostic significance with reference to the not absolutely precluded possibilities of spontaneous regression; c) the notable usefulness of the procedure, combined with intra-operative wirsungraphy and cystography, for anatomo-topographical definition of the lesion and its relations with the ductal system, indispensable for a correct formulation of the surgical tactic.

[Rare non-functioning insular tumor of the pancreas]. / Raro tumore insulare non funzionante del pancreas

A case of cystic neoplasia with a cephalopancreatic localization, arising in a young woman aged 26 and derived from the beta-insular elements, is presented. The tumour had invaded the porto-mesenteric tract, and hence duodenopancreatic demolition had to be followed by venous repair by prosthesis. On the basis of the literature the biological complexity of this exceptional tumour is disscussed (especially in relation to prognosis), as well as the surgical treatment adopted in this patient, who is in excellent conditions more than three years later.