Use of ceramic bearings in hip arthroplasty: correct implantation and review of clinical and radiographic results.

Ceramic materials are widely used in hip prosthetic surgery. Faced with important developments in the design and characteristics of the materials, ceramic-on-ceramic (CoC) are today the bearings in Total Hip Replacement (THR) showing the minimal wear rate. Moreover, ceramic wear debris demonstrated the absence of local and systemic toxicity. This makes ceramic bearing particularly suitable for active patients, whatever their age. The results show excellent survival rates of THRs with ceramic components and excellent clinical and radiographic scores with follow-up close to 20 years. However, the excellent outcomes of THRs with ceramic bearings are depending on appropriate and correctly performed surgical technique.

The effects of collagenase of Clostridium Histolitycum (CCH) in Dupuytren's disease: a histological study on cell mediated mechanisms that allow enzymatic fasciotomy.

Dupuytren Disease is a benign fibromatosis of palmar fascia of the hand, whose pathophysiology is not completely understood. The present study is intended to provide a description of the effects of Collagenase of Clostridium Hystoliticum (CCH) into an injected cord of Dupuytren. Our experimental study wanted to evaluate the histological effects of injection of CCH in the first 24 hours, without manipulating the specimens. MATERIALS AND METHODS: Surgical specimens were injected with CCH, and then fixed in formalin every six hours, up to 24 hours. Those specimens were compared to control specimen (non-injected), fixed and analyzed at the same times. RESULTS: In the injected specimens, the number of CD68 positive cells increased into and outside the cords compared to non injected specimens, within the same time from the surgical removal. CONCLUSION: CCH has a proinflammatory activity and provokes a short ray chemotactic action on white blood cells. The lysis of the cord induced by CCH stimulates the inflammatory response. The role of the inflammatory infiltration deserves to be investigated in a more accurate way, preferably by using in vivo studies.

Innovations in prevention of infections in oncological megaprostheses: a narrative review.

Infection is a significant complication in oncological megaprostheses. The purpose of our study is to indagate the innovations and new trend about the prevention of infection in this kind of surgery. The research focused on the use of antimicrobic prophylaxis, the defensive antibacterial coating and the use of silver coated.

Arthroscopy in osteochondral pathology of the elbow: indications, treatment and complications.

The arthroscopic technique has revolutionized orthopaedic surgery in the last forty years, due to the improvement in surgical technique and innovations in technologies. Actually, knee and shoulder arthroscopy are commonly used to treat the most frequent pathologies with mini-invasive approaches demonstrate recovery of function and outcomes. Not the same thing can be said for other joints such as ankle, elbow and hip, where the narrowness of the space makes the technique more challenging. In this study, a brief review of the literature and the history of elbow arthroscopy are described. Indications, surgical technique, risks and complication, tip and tricks, advices and notes to avoid complications are reported. Elbow arthroscopic surgery is a difficult technique that requires a long learning curve, but in an experienced surgeon's hands, it is a safe and successful methodology when applied with correct indications and cautions.

Risk factors for failure of two-stage revision arthroplasty for infected hip prosthesis: review of the literature and single centre cohort analysis.

OBJECTIVE: Periprosthetic joint infections (PJI) are one of the most dangerous complications in hip surgery. "Two-stage" revision surgery is the treatment of choice. Nevertheless, 5-10% of failures are reported. The aim of this study is to evaluate which factors determine the failure of the two-stage revision in patients affected by hip PJI. PATIENTS AND METHODS: We retrospectively enrolled 21 patients treated for hip PJI who had undergone two-stage revision surgery. The diagnosis had been made using criteria established by the Musculoskeletal Infection Society (MSIS) and readapted by the Philadelphia Consensus Conference group. The patients underwent periodic clinical and laboratory controls after the surgical procedure. The two-stage revision treatment was considered unsuccessful in the event of re-infection or in case of severe complications occurring within one year from the treatment. RESULTS: At a mean follow-up of 23.8 months 57% healed with no complications. The reinfection rate was 19% and, after the 3rd stage, the final failure rate was 9.5%. The study has shown, with statistical significance, that a greater number of previous surgical procedures (p<0.05, OR=22) and BMI>25 (p<0.05, OR=4) represent increased risk factors in predicting the failure of two-stage revision surgery. Age, CRP, ESR and a shorter lapse (<60 days) between 1st and 2nd stage were recorded in the failure cases, and have to be considered, even if not statistically significant. CONCLUSIONS: Knowing the factors responsible for the increased failure of two-stage revision could lead to closer monitoring and more aggressive management in those patients expected to be at greater risk of reinfection. Obesity and multiple surgeries are risk factors for failure.

Relationship between primary headache and nutrition: a questionnaire about dietary habits of patients with headache.

The role of food associated with the headache has been the subject of scientific research since 1900, especially for migraine patients. A substantial proportion of patients (ranging from 12 to 60 %) report that their migraine attacks may be precipitated by dietary elements, certain eating habits (fasting) and abuse (caffeine and alcoholic beverages abuse and withdrawal). The biological mechanism by means of triggers in general and food in particular precipitate migraine attacks remains obscure. Based on the data in the literature, we performed an osservational study searching for possible correlations between nutrition and primary headaches. We enrolled 50 consecutive patients from the Headache Center of the Neurology Department of Hospital "Cardinal Massaia" of Asti and submitted them a 14-item questionnaire for the assessment of relationship between primary headache and food. Our preliminary data, although the follow up is still in progress, show that there are strong associations between the onset of the headache and dietary habits. It will be necessary to analyze a larger sample in order to draw more precise conclusions on this topic.

Sensitization and pain.

Migraine is often accompanied with signs of increased intracranial and extracranial mechanical sensitivities. The prevailing view today is that migraine headache is a neurovascular disorder with intracranial origin and involvement of meningeal blood vessels and their pain nerve fibers. Allodynia, defined as perception of pain following not painful stimulation, is a common clinical feature in various pain syndromes, and as part of migraine pain, it can be considered an indicator of trigeminal neural network sensitization. The cutaneous allodynia that accompanies the migraine headache in a large percentage of patients may be considered the clinical expression of central nervous system sensitization and is characterized by pain provoked by stimulation of the skin that would ordinarily not produce pain. An altered codification process of sensory impulses in the brainstem, in particular by the nucleus caudalis trigeminalis, may justify the temporal aspects and symptoms in the course of migraine attack.

Primary headache and epilepsy: a multicenter cross-sectional study.

The prevalence and characteristics of interictal headache, epilepsy and headache/epilepsy comorbidity were assessed in 858 women and 309 men aged 18-81 years from headache and epilepsy centers in Italy. The research hypothesis was that comorbidity among patients with either disorder would be expected to be higher than in the general population. Interictal headache was diagnosed in 675 cases (migraine 482; tension-type headache 168; other types 25), epilepsy in 336 (partial 171; generalized 165) and comorbidity in 156 (1.6% from headache centers; 30.0% from epilepsy centers). Patients with epilepsy, headache and comorbidity differed in a number of demographic and clinical aspects. However, for both headache and epilepsy, a family history of the same clinical condition was equally prevalent in patients with and without comorbidity. These findings do not support the purported association between headache and epilepsy.

Sleep and primary headaches.

The relationship between sleep and primary headaches has been known for over a century, particularly for headaches occurring during the night or early morning. Migraine, tension-tyre headache, and cluster headache may cause sleep fragmentation, insomnia, and hypersomnia, causing considerable social and economical costs and several familial problems. By contrast, sleep disorders may themselves trigger headache attacks. Finally, headaches and sleep disorders can also be symptoms of other underlying pathologies. Despite this background, there is still no clarity about the mechanism that links these two entities and their interdependence remains to be defined. Patients with primary headache should undergo a careful assessment of sleep habits.

Pathophysiology of migraine chronification.

Migraine is a prevalent, disabling, undiagnosed and undertreated disease in neurological practice. It is a chronic, recurrent disorder with episodic manifestations that are progressive in some individuals with clinical, physiological and anatomical bases. Progression may be due to mechanisms generating the migraine attacks or to the activation generated by the attacks. Potentially remediable risk factors for chronification include frequency of migraine attacks, obesity, excessive use of medications, caffeine overuse, stressful life events, depression, sleep disorders and cutaneous allodynia.

Study on the possible role of the -174G>C IL-6 promoter polymorphism in predicting response to rituximab in rheumatoid arthritis.

OBJECTIVE: Identification of genetic biomarkers of response to biologics in rheumatoid arthritis (RA) is a relevant issue. The -174G>C interleukin-6 (IL-6) promoter polymorphism was investigated in RA patients treated with rituximab (RTX), being IL-6 a key cytokine for B cell survival and proliferation, thus possibly implicated in rituximab efficacy. METHODS: The study was conducted in a real-life retrospective cohort of 142 unselected RA patients (120F/22M) treated with RTX and referred to 7 rheumatologic centres in the north of Italy. One hundred and thirteen (79.6%) patients were rheumatoid factor (RF)-positive and 112 (78.9%) were anti-CCP antibodies positive. The response to therapy was evaluated at the end of the sixth month after the first RTX infusion, by using both the EULAR criteria (DAS28) and the ACR criteria. The IL-6 -174G>C promoter polymorphism was analyzed by RFLP following previously reported methods. RESULTS: Lack of response to RTX at month +6 by EULAR criteria was more prevalent in RA patients with the IL-6 -174 CC genotypes (9/21, 42.8%), than in the GC/GG patients (23/121, 19.0%) (OR 3.196, 95% CI=1.204-8.485; p=0.0234). Similar results were found when evaluating the response by ACR criteria. No differences were found in RA duration, baseline DAS28, baseline HAQ, RF status, anti-CCP status according to the different IL-6 -174 genotypes. CONCLUSION: IL-6 promoter genotyping may be useful to better plan treatment with RTX in RA. Larger replication studies are in course to confirm these preliminary results.

[Rheumatoid factor positivity rather than anti-CCP positivity, a lower disability and a lower number of anti-TNFalpha agents failed are associated with response to rituximab in rheumatoid arthritis]. / La presenza del fattore reumatoide, la disabilità ed il numero di precedenti anti-TNFalpha falliti predicono la risposta clinica a rituximab nell'artrite reumatoide.

OBJECTIVE: Predictors of response to biologics in rheumatoid arthritis (RA) is an important issue in the current era. Rituximab (RTX) has been demonstrated effective and safe in active RA, resistant to traditional or biologic DMARDs. METHODS: Fifty-seven patients with active longstanding RA were treated with RTX after traditional DMARD or anti-TNF alpha therapy failure. RESULTS: Number of anti-TNF treatment previously failed (p=0.005), HAQ (p=0.013), rheumatoid factor (RF) (p=0.0002) and anti-CCP (p=0.006) were associated with an ACR response > or =50 at the end of 6th month by univariate analysis. Multivariate analysis confirmed that the number of anti-TNF previously failed, baseline HAQ and RF, but not anti-CCP were associated with an ACR response > or =50. EULAR moderate/good response was associated with ESR value (p=0.036), HAQ (p=0.032), and RF (p=0.01) by univariate analysis, while only RF positivity was associated with EULAR moderate/good response by multivariate analysis. CONCLUSIONS: RF positivity rather than anti-CCP positivity is a predictor of response to RTX, suggesting that RF-positive patients with low disability may obtain a clinical response when treated to RTX after the first anti-TNF agent failure or after traditional DMARD therapies. Larger studies are required to confirm these results.

Detection of bovine viral diarrhea virus (BVDV) in seropositive cattle.

Detection of bovine virus diarrhoea virus (BVDV) in one vaccinated beef cattle and three non-vaccinated dairy herds was investigated on peripheral blood leukocytes (PBL) with or without previous treatment followed by a capture ELISA (cELISA). Using the combination of PHA and polycation treatment, PBL from 229 seropositive cattle were studied and could be classified in four different states of BVDV infection. Lysed PBL from four animals were directly positive in cELISA (Category I), PBL of 17 animals were positive after PHA stimulation (Category II), 15 animals were positive only after PHA stimulation plus polycation treatment (Category III), while virus could not be detected in 193 seropositive cattle. Wild-type BVDV strains were isolated by co-culture on polycation-treated MDBK cells from 11 of these seropositive animals. BVDV antibodies of these same animals were able to neutralize their own virus, indicating that virus persists in PBL in spite of strain-specific antibodies. No apparent change of leukocyte subpopulations could be detected in any category of virus-positive animals. Thus, BVDV may be present in the PBL of some cattle, even in the presence of a specific active immune response.

A randomized, controlled, phase II trial comparing escalating doses of subcutaneous interleukin-2 plus antiretrovirals versus antiretrovirals alone in human immunodeficiency virus-infected patients with CD4+ cell counts >/=350/mm3.

A total of 73 patients with baseline CD4+ cell counts >/=350 cells/mm3 who were receiving combination antiretroviral therapy (ART) were randomized to receive subcutaneous interleukin-2 (IL-2; n=36) in addition to ART or to continue ART alone (n=37). Subcutaneous IL-2 was delivered at 1 of 3 doses (1.5 million international units ¿MIU, 4.5 MIU, and 7.5 MIU per dose) by twice-daily injection for 5 consecutive days every 8 weeks. After 24 weeks, the time-weighted mean change from baseline CD4+ cell count was 210 cells/mm3 for recipients of subcutaneous IL-2, compared with 29 cells/mm3 for recipients of ART alone (P<.001). There were no significant differences between treatment groups for measures of plasma human immunodeficiency virus RNA (P=.851). Subcutaneous IL-2 delivered at doses of 4.5 MIU and 7.5 MIU resulted in significant increases in CD4+ cell count (P=.006 and P<.001, respectively), compared with that seen in control patients. These changes were not significant in the 1.5 MIU dose group compared with that in the control patients (P=.105). Side effects that occurred from subcutaneous IL-2 administration were generally low grade, of short duration, and readily managed in an outpatient environment.

Interactions of dendritic cells with fibronectin and endothelial cells.

We studied the phenotypic characteristics of spontaneously migrated skin dendritic cells (sDC) and monocyte-derived dendritic cells (moDC), generated under different culture conditions, and their interactions with fibronectin (FN) and endothelial cells. Monocyte-derived dendritic cells were obtained after culturing monocytes with granulocyte-macrophage colony-stimulating factor (GM-CSF) (800 U/ml) and interleukin-4 (IL-4) (500 U/ml) with either 10% fetal bovine serum (FBS) or 10% allogeneic human serum (HS). Regardless of the type of serum used, the majority of moDC expressed human leucocyte antigen-DR (HLA-DR) and CD86. On day 5 of incubation, 20-67% of moDC cultured in the presence of HS (HS-moDC) expressed CD1a, b and c versus 94-97% when cultured in the presence of FBS (FBS-moDC). DC showed a differential gradient of adhesion to FN: FBS-moDC>HS-moDC>sDC approximately monocytes. Both FBS-moDC and HS-moDC were strongly positive for CD49e (alpha5-integrin) and CD29 (beta1-integrin) but negative for CD49d (alpha4-integrin). A monoclonal antibody (mAb) against CD49e blocked the adhesion of both types of moDC to FN. Although both FBS-moDC and HS-moDC attached to endothelium (a 76% and 63% increase, respectively), only HS-moDC were able to migrate through non-activated endothelium. Overall, these results suggest that spontaneously migrated sDC are less adherent to FN than moDC, that HS and FBS induce differences in CD1 expression, that HS-moDC are less adhesive to FN and endothelial cells but more motile than FBS-moDC, and that alpha5beta1-integrin is the molecule involved in moDC adhesion to FN.

Psychiatric symptoms in male cannabis users not using other illicit drugs.

AIM: To assess the prevalence of DSM-III-R axes I and II disorders and the severity of psychiatric symptoms in cannabis users who did not use other illicit drugs. DESIGN: Cross-sectional psychiatric examination of subjects with different patterns of cannabis use: cannabis dependence, abuse and occasional use. PARTICIPANTS: One hundred and thirty-three cannabis users identified through random urine testing of draftees to the Italian army and interviewed after 2-5 days of abstinence from drug use. MEASUREMENTS: The subjects completed the Beck Depression Inventory, the Spielberger State-Trait Anxiety Index and the 20-item revised Toronto Alexithymia Scale and were then interviewed with the Structured Clinical Interview for DSM-III-R. FINDINGS: The prevalence of co-morbid psychiatric disorders varied with the pattern of cannabis use: 83% of subjects with DSM-III-R cannabis dependence, 46% of those with DSM-III-R cannabis abuse and 29% of occasional users received at least one DSM-III-R psychiatric diagnosis. The severity of depressive, anxious and alexithymic symptoms increased progressively with the degree of involvement with cannabis. CONCLUSIONS: In this sample of young men, the risk of associated psychiatric disabilities varied with the pattern of cannabis use. Chronic use of cannabis was associated with a high prevalence of co-morbid psychiatric disorders.

[Diverticular disease and its treatment]. / La malattia diverticolare e il suo trattamento.

Diverticular disease of the colon is being seen with increasing frequency. Not infrequently, the first attack of diverticulitis may result in serious and potentially fatal complications. A period of observation and conservative management is necessary to determine the outcome of a particular attack. Approximately 30% of symptomatic patients require surgical intervention. Controversy still surrounds the appropriate operative approach to be employed in the management of diverticular disease, moreover when it presents with a complication. In general, resection is the procedure of choice for perforating diverticulitis. There is an emerging role for down-staging interventions in the recent literature; with few exception, there is no role for three-stages procedure for diverticular disease. In the setting of stage I or stage II disease (Hinchey classification) primary resection with anastomosis is safe and should be performed. Proximal colostomy formation may be carried out at the discretion of the surgeon if warranted by such local circumstances as contiguous inflammation or macroscopic contamination. For patients with stage III and stage IV disease endcolostomy with Hartmann closure of the rectum is the procedure of choice, although anastomosis with proximal stoma may prove to be an acceptable alternative. We reviewed the changing patterns in the operative treatment in 46 patients admitted to our Division for perforated diverticulitis. We performed the resection with anastomosis in 39 patients with perforation at the II stage; in 7 patients with generalized peritonitis (stage III-IV by Hinchey) we preferred Hartmann intervention in 4 cases and the three-stages procedure in 3 cases. We had no death at all. From 1979 to 1994 we noticed an increasing use of down-staging procedures.

Symptom profile, Axis II comorbidity and suicidal behaviour in young males with DSM-III-R depressive illnesses.

We assessed the descriptive validity of DSM-III-R major depression (MDD), dysthymia (DD) and adjustment disorder with depressed mood (ADDM) by comparing the clinical profiles of 176 young male patients. The severity of depression increased progressively across the three diagnostic groups (ADDM < DD < MDD). Symptom presentation did not distinguish clearly between the diagnostic groups, even though somatic symptoms were more frequent among MDD patients. The prevalence of personality disorders was much higher (43%) among DD patients than among MDD (22%) and ADDM (15%) patients. The lifetime prevalence of suicide attempts differed in the three diagnostic groups (MDD 27%, DD 17%, ADDM 4%). Assessment of Axis II comorbidity and suicidal behavior can improve the diagnostic distinction between these DSM-III-R depressive illnesses.

[Acute biliary pancreatitis. Therapeutic approach]. / Le pancreatiti acute biliari. Approccio terapeutico.

Those forms of acute pancreatitis with a biliary etiology necessitate the choice of surgical techniques whose main objective is to obviate the cause of lithiasis and remove the necrotic and hemorrhagic areas of the gland. While probably overestimated from an epidemiological point of view, acute biliary pancreatitis still causes an overall mortality rate of 10% and has hardly been affected by the development of intensive care units and the routine use of somatostatin. By comparing the various approaches reported in the literature the Authors attempt to match the surgical concept of "timing" and the type of operation to be performed with the anatomopathological stage of disease. The paper reports the preliminary results of a treatment protocol in use since 1988 in group of 35 patients in whom the preoperative diagnosis of acute biliary pancreatitis was confirmed by computerised tomography.