Change in major amputation rate in a center dedicated to diabetic foot care during the 1980s: prognostic determinants for major amputation.

From 1990 to 1993, 115 diabetic patients were consecutively hospitalized in our diabetologic unit for foot ulcer and 27 (23.5%) major amputations were carried out. The major amputation rate of this series of cases was compared with that occurring in diabetic subjects taken into our hospital for foot ulcer in two previous periods: 1979-1981 (17 major amputations in 42 inpatients or 40.5%) and 1986-1989 (26 major amputations in 78 inpatients or 33.3%). The comparison shows a progressive reduction in major amputation rate [Odds ratio 0.66, 95% confidence interval (CI) 0.46-0.96]. Univariate and multivariate analysis, carried out in the population of the 1990-1993 period, in order to detect the independent factors associated with major amputation show the following prognostic determinants of major amputation: Wagner grade (odds ratio 7.69, CI 1.58-37.53), prior stroke (odds ratio 35.05, CI 3.14-390.53), prior major amputation (odds ratio 3.49, CI 1.26-9.38), transcutaneous oxygen level (odds ratio 1.06, CI 1.01-1.12), and ankle-brachial blood pressure index (odds ratio 4.35, CI 1.58-12.05), while an independent protective role was attributed to hyperbaric oxygen treatment (odds ratio 0.15, CI 0.03-0.64). In accordance with other studies, we, therefore, conclude that a comprehensive protocol as well as a multidisciplinary approach in a dedicated center can assure a decrease in major amputation rate. The parameters of limb perfusion were the modifiable prognostic determinants most strongly predictive for amputation.

[Carotid stenosis with contralateral occlusion. Surgical indications and results]. / Stenosi carotidea con occlusione controlaterale. Indicazioni chirurgiche e risultati.

Recent American and European trials have clearly defined that surgery provides best treatment for unilateral critical stenosis of internal carotid artery. Isolated reports seem to confirm this trend also in cases with carotid critical stenosis with controlateral occlusion, even if a major surgical risk may be expected. In our experience in the last two years, out of 96 carotid enderterectomies 20 presented a controlateral occlusion. After routine pre-operative assessment, with particular regard to DSA "cross-filling" study, intervention has been performed under general anesthesia with BP+EEG cerebral monitoring in both groups of patients. In the non occluded group temporary shunt has been used in 19.7% of cases, in occluded the incident of shunting was 40%. Operative morbidity and mortality in the second group was surprisingly absent, with cumulative 4.1% complication rate. Our experience confirms that risks and results in carotid endoarterectomy are similar in both groups of patients.

[Results of revascularization and amputation of the gangrenous diabetic foot. Importance of a multidisciplinary approach]. / Risultati della rivascolarizzazione ed amputazione nella gangrena diabetica del piede. Importanza dell'approccio multidisciplinare.

A total of 89 diabetic patients with foot lesions were treated using amputation during the past 5 years at Niguarda-Ca' Grande Hospital. All patients suffered from gangrene which in 76% of cases was classified as Wagner's stage IV. The lesion was infected in 67 patients. Emergency surgical cleansing was performed in order to drain abscesses and remove necrotic tissue, taking care not to damage healthy tissue. An accurate multidisciplinary study was performed in all cases which included neurological, oculistic and vascular assessment. 83% of patients presented retinopathy and 62.5% were nephropathic. Angiographic tests revealed the presence of distal vascular lesions in 90% of cases. A femoro-distal by-pass was used in 17 cases and the limb was salvaged in 13 patients; ileal-femoral PTA was performed in 10 cases and the limb was salvaged in 7 patients. Amputations were limited wherever possible to distal segments: toes (55 cases), transmetatarsal (12 case), leg (12 cases), thigh (5 cases), atypical resections or ample cleansing of the foot (5 cases). This approach allowed us to record: 1) a low operative mortality (1 case); 2) higher quality of life; 3) the possibility of reoperating on more proximal portions of the limb in the event of immediate or long-term failure. This was necessary in 19 cases which can be classified as follows: reamputation of toe (11 cases), transmetatarsal (4 cases), amputation of leg (4 cases).

Ultrasound guided fineneedle aspiration of impalpable breast nodules.

AIMS: This study was designed in an attempt to improve the sensitivity of cytologic examination of fineneedle aspiration biopsies. METHODS AND RESULTS: A prospective study was carried out on 79 patients with breast lesions less than 1 cm in diameter and clinically impalpable who were referred to the Radiodiagnostics Section of the Ca' Granda Hospital of Milan in 1990 and 1991 for mammographic and ultrasound verification. The examination was carried out using a high frequency (10 MHz) ultrasound probe to which an aspiration needle had been soldered. This made it possible to quickly and accurately reach the target nodule and thus gave a high sensitivity of the examination (93%). However, attachment of the needle to the probe prevented sampling from other points of the nodule and was responsible for the slight increase in number of inadequate samplesfi which in turn worsened the specificity of the test (86%). To check the gold standard of the examination, all the patients with positive or doubtful aspirations underwent surgical biopsy, whereas strict radiologic controls were performed in the negative cases. CONCLUSIONS: Ultrasound-guided fineneedle aspiration may have advantages over needle aspiration performed with the stereotactic radiologic technique. The needle can be monitored even if the patient moves; even deep, peripheral nodules as well as those near a prosthesis can be reached; repeated samples can be taken, and costs are limited.

[Hemorrhages of the upper gastrointestinal tract. A comparison of the diagnostic accuracy between endoscopic and radiological examinations]. / Le emorragie del tubo gastroenterico superiore. Raffronto dell'accuratezza diagnostica fra esame endoscopico e radiologico.

One hundred and forty-eight patients admitted for upper gastrointestinal hemorrhage, but excluding esophageal varices, underwent optic fibre gastroscopy at the time of admission and were then examined using a barium meal after a 24-48 h interval. The aim of the study was to compare the sensitivity, specificity and diagnostic accuracy of the two tests. A correct diagnosis was obtained using both procedures in 58.2% of cases. Endoscopy provided an accurate diagnosis in 35.1% of patients, whereas gastrointestinal x-rays showed the exact site of the lesion in only 6.7% of cases. Endoscopy had a sensitivity of 92.5% compared with 60.7% for the barium meal. Endoscopy also had a higher level of specificity (100%) versus the barium meal (33.3%). The results obtained from the pathological examination of specimens confirmed the accuracy of endoscopy. In conclusion, early endoscopy is a reliable procedure in the emergency assessment of the hemorrhaging patient; routine x-ray examination does not appear to add additional information and may be reserved for subsequent use if endoscopy gives doubtful or misleading indications of the site of bleeding.

[Mesenteric venous hypertension in an adolescent with common ileocolic mesentery]. / Ipertensione venosa mesenterica in un adolescente con mesentere ileocolico comune.

The case of a twelve year-old boy suffering from "common ileocolic mesentery" with surgical finding of very serious splanchnic venous dilatation is presented. Mesenteric arteriography was the most useful test for diagnosis. The surgical technique has been compared with that described by other Authors.

Primary adenocarcinoma of terminal ileum with clinical and gross morphologic features simulating Crohn's disease. A case report.

We report a case of primary adenocarcinoma of the terminal ileum, which presented with clinical, radiologic and surgical findings indistinguishable from Crohn's disease. The age of the patient and the rapidly progressing symptoms were the only preoperative clues to the diagnosis of an occult malignancy. Frozen sections of an intraoperative biopsy established the correct diagnosis and led to a radical change in the treatment. This is the third report of adenocarcinoma of the small bowel simulating Crohn's disease.

Surgery versus combined therapies for cancer of the anterior floor of the mouth.

We report the results of treatment in a consecutive series of 75 patients operated on at the Istituto Nazionale Tumori of Milan, from January 1965 to December 1979, for cancer of the anterior floor of the mouth. Most of the tumors were advanced: 39 were treated with simple resection, and 36 underwent combined treatment, consisting of surgery associated with either chemotherapy or surgery. Three- and five-year observed survival rates of the whole series were good (41% and 25%, respectively), considering the tumor stage of these patients, but the determined survival rates were particularly high (56% and 46%, respectively). No real advantage was found in the use of multiple planned sequential therapies over surgery alone, and deaths from intercurrent diseases seemed to be more frequent in the patients who underwent combined therapies. We conclude that for patients in poor general condition, such as those with carcinomas of the anterior floor of the mouth, aggressive and complex treatments should be considered with caution in controlled clinical trials.