Interobserver and intraobserver reliability of a new radiological classification for femoroacetabular impingement syndrome.

PURPOSE: Radiological evaluation of femoroacetabular impingement is based on single-plane parameters such as the alpha angle or the center edge angle, or complex software reconstruction. A new simple classification for cam and pincer morphologies, based on a two-plane radiological evaluation, is presented in this study. The determination of the intraobserver and interobserver reliability of this new classification is the purpose of this study. METHODS: We retrospectively reviewed the three-view hip study in patient undergoing hip arthroscopy for FAI syndrome between October 2015 and April 2016. Any case having protrusio acetabuli, coxa profunda or which has undergone previous osteotomic surgery was excluded. Five observers used our proposed classification to identify three different stages for the cam and pincer morphologies. Inter- and intraobserver agreement of classification was determined using average pairwise Cohen's kappa coefficient. RESULTS: The interobserver agreement for the pincer and cam morphologies was excellent. For the pincer morphology classification, the average Kappa agreement was 0.838 (range 0.764-0.944). For the cam morphology, the average pairwise Cohen's kappa coefficient was 0.846 (range 0.734-0.929). The intraobserver agreement was excellent as well. The average percent pairwise agreement was 0.870 and 0.845 for pincer and cam type, respectively. CONCLUSIONS: The new classification system shows excellent levels of inter- and intraobserver agreement for both deformities. This classification is demonstrated to be a useful tool in planning hip arthroscopy. Further studies are needed to correlate the classification itself with specific intraoperative findings.

Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy.

BACKGROUND: The need to dissect axillary nodes in patients with early breast cancer and clinically negative axilla remains controversial. The aim of the study was to assess the role of axillary radiotherapy (RT) in reducing axillary metastases in patients with early breast cancer who did not receive axillary dissection. PATIENTS AND METHODS: From 1995 to 1998, 435 patients over 45 years old with breast cancer up to 1.2 cm and no palpable axillary nodes were randomized 214 to breast conservation without axillary treatment and 221 to breast conservation plus axillary RT. RESULTS: After a median follow-up of 63 months, overt axillary metastases were fewer than expected: three cases in the no axillary treatment group (1.5%) and one in the RT group (0.5%). Expected cases were 43 in the no axillary treatment group and 10 in the RT group. Rates of distant metastases and local failures were low, and 5-year disease free survival was 96.0% (95% confidence interval, 94.1%-97.9%) without significant differences between the two arms. CONCLUSIONS: This study suggests that occult axillary metastases might never become clinically overt and axillary dissection might be avoided in patients with small carcinomas and a clinically negative axilla. Axillary RT seems to protect the patients from axillary recurrence almost completely.

Prevalence of numeric anomalies in the permanent dentition of patients with Down syndrome.

The purpose of this study was to evaluate the prevalence of numeric anomalies in the permanent dentition of patients with Down syndrome by means of panoramic radiographs. The sample consisted of panoramic radiographs from 70 subjects. We examined the radiographs to detect hypodontia as well as supernumerary teeth. Our results confirm the high prevalence of hypodontia among patients with Down syndrome (60%), mostly with mild expression. The teeth most often missing were the upper lateral incisors, usually bilaterally, followed by the lower second premolars and upper second premolars. Supernumerary teeth were seen in 6% of the subjects, and the concomitant occurrence of hypodontia and supernumerary teeth occurred in one patient.

Long-term results of aggressive surgical treatment of primary and recurrent retroperitoneal liposarcomas.

The aim of this study was to establish the role of surgery in the treatment of retroperitoneal liposarcomas. Data concerning 28 patients submitted to surgery for retroperitoneal liposarcoma in our department over the period from 1972 to 1999 were reviewed retrospectively and analysed. Seventy-four operations were performed; in 54% of the operations it was necessary to resect contiguous organs (kidney 60%, colon 50%, adrenal gland 35%). In 89%, grossly curative resection was achieved at the first operation; 20 patients had at least one local recurrence after first operation (median time interval: 22 months). The mean follow-up was 80 months; median survival time was 51 months and 5-year actuarial survival time 51%. Patients with low-grade liposarcoma showed a statistically significant improvement (P < 0.001) in median survival (153 months) versus those with medium- (37 months) and high-grade sarcomas (8 months). At present surgery is still the treatment of choice in the treatment of primary and recurrent liposarcoma; in the case of low-grade liposarcomas especially, an aggressive surgical approach can result in long-term survival.

[Hepatobiliopancreatic surgery in patients over 70 years old: which anesthesia?]. / Chirurgia epatobiliopancreatica nei pazienti oltre i 70 anni: quale anestesia?

In the last years the criteria of operability have been extended to elderly patients with hepato-pancreatic-biliary diseases. We selected 46 patients (in the seventies or older, class 3 or 4 of ASA score, affected by hepato-pancreatic-biliary neoplasms) in order to evaluate the behavior of these patients undergoing to different anaesthesiological techniques. Randomly, we treated 24 patients (group A) in general anaesthesia, and 22 patients (group B) in peridural anaesthesia. We considered mortality rate, morbidity rate, as sepsis, wound infection, pleuritis, and pneumonias. The data were analyzed by chi2-test and Fisher's exact test (p < 0.05). Mortality rate was similar in the two groups (A = 4.1, B = 4.5) (p = ns), and no complications were determined by the different anesthesiologic procedures. Pleuritis was present in 44% of group A vs 45% of group B (p = ns). Atelectasis areas were present in 58% of group A vs 27% of group B (p = ns), pneumonia was present in 33% of group A vs 9% of group B: this value was significant (p = 0.049). There were no differences between the two groups regarding wound infection rate (only one case in group B). We think that pulmonary diseases can be determined by intubation and mechanical ventilation. We show a significant reduction of pneumonia in the patients that underwent peridural anaesthesia. For this reason, peridural technique can be safely extended to elderly patients with hepato-pancreatic-biliary diseases.

[Role of surgical splanchnicectomy in the treatment of pancreatic carcinoma]. / Il ruolo della splancnicectomia chirurgica nel trattamento del carcinoma pancreatico.

Palliative surgical procedures offer considerable benefit for the patients with unresectable pancreatic cancer: surgical splanchnicectomy performed in conjunction with biliary-enteric by-pass offers good results as regard pain relief without increased morbidity and mortality. We treated 25 patients with unresectable pancreatic cancer by mean of biliary-enteric by-pass plus bilateral splanchnicectomy performed through different surgical approaches. In this series of patients postoperative mortality was nil, mean survival time was 7.2 months (range 3-14 months). Preoperatively, we assessed all patients as affected by visceral pain: Scott-Huskisson 10 mark-scale value in quantitative assessment of pain was equal or above the 7th mark in 87.5% of patients. One month later in the postoperative follow-up, 96% of the patients had a significant reduction in pain intensity from a preoperative median of 7 mark to a postoperative median of 1.5 mark (p = 0.0001). The mean period free of pain recurrence was 4.8 months. However, after 6 months only 46% of survivors were pain-free with such rate decreasing further to a 10% of survivors after 8 months. Nevertheless, the patients had around 70% of their survival span free of pain. We strongly believe that failure in relief of pain is due to a mistake in preoperative evaluation of the type of pain (somatic and not visceral, or both) and to the onset of somatic pain in the course of the disease rather than to surgical technical errors. Recurrence of pain has been considered inevitable in the biological progression of unresected cancer, and would be treated by combination of therapies, such as non steroidal anti-inflammatory drugs, transaortic coeliac plexus block, narcotics and cervical cordotomy.

[Anatomo-surgical notes on splanchnicectomy: original research on 15 autopsy observations]. / Premesse anatomo-chirurgiche alla splancnicectomia: ricerca originale su 15 osservazioni autoptiche.

Surgical splanchnicectomy for the relief of neoplastic pain is a palliative strategy in cases of unremovable pancreatic cancer. The first step in the achievement of satisfactory and long-lasting relief of pain is the correct identification of semilunar ganglia and splanchnic nerves during laparotomy. In this light, we tried to estimate the exact location, number, shape, and length of splanchnic nerves and ganglia in 15 corpses (mean age 39.9 years, range 21-74, F/M/ = 5/10). Right and left splanchnic nerves always pierce the diaphragm laterally to the crus. On the right side, the splanchnic nerve always enters the abdomen posterior to the inferior vena cava, on the right edge in 10%, on the middle in 73%, on the left in 17% of the cases. On the left side, the splanchnic nerve pierces the diaphragm strictly thickened to the left edge of the aorta in 66.6% of the cases, close to the left edge in 26.6%, and close to the right edge of the left adrenal gland in 6.8%. The right splanchnic nerve slides almost horizontally on the diaphragmatic bundles, and reaches an area delimited by the coeliac trunk and the superior mesenteric artery. The length of the right splanchnic nerve is 41 mm of the mean (range 20 to 55 mm): the thickness is between 4 and 6 mm. The left splanchnic nerve is shorter (mean 24 mm, range 15; 30 mm). The right splanchnic nerve varies from 2 to 6 ganglionar bodies and varies in size from 4.5 mm to 30 mm; the left nerve varies form 2 to 4 (sizes between 4 mm to 26 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

[Postoperative ischemic ileocolitis in the elderly. Suggested therapy with intraluminal administration of oxygen and glutamine]. / Ileocolite ischemica post-operatoria nell'anziano. Proposta di terapia con somministrazione endoluminale di ossigeno e glutamina.

Ischaemic ileocolitis in postoperative course of major abdominal surgery is a great challenge for the surgeon: the mortality rate is very high, and therapeutic choices are poor. In the elderly patients ischaemic bleeding ileocolitis is often determined by low flow: sepsis and cytologic damage are primed by activation of endotoxins and chemical mediators, and bacterial translocation could develop across intestinal wall. In our case the patient (male, caucasian, 68 years old) underwent bilio-hepatic resection for hilar cholangiocarcinoma. In the postoperative period continuous enteric haemorrhage was determined by an ischaemic ileocolitis demonstrated by colonoscopy. Abdominal angiography did not show stenosis or occlusion of mesenteric vessels. We administered dopamine and dobutamine as vasodilator drugs for splanchnic circulation without any positive response. Surgical removal of the colon was unsuccessful to stop bleeding. ileostomy and sigmostomy were performed. Histologic samples of the specimen showed ischaemic ileocolitis. After a few days the patient bled again. As last therapeutic choice, we bubbled oxygen in a solution of L-glutamin 500 mml (3 liters/min for 5 min). We administered 500 mml of this solution three times a day by enteral sond, and 100 mml twice a day by sigmoidostomy and endoluminal oxygenation was performed twice a day (1l/min for 1-2 minutes) under continuous control. Bleeding was reducing during the next five days, until stopping. If glutamine and O2 can be considered the fuel of enterocytes, we hypothesized endoluminal oxygenation and glutamine enteral supply of the small intestine could feeding enterocytes, until a complete restoration of enteral mucosa and stopping of the haemorrhage.

[Terminal ballistics. 1]. / Balistica terminale. 1a parte.

We have chosen to conceive of terminal ballistics as a violent and extremely rapid confrontation between two forms of resistance before the final state of rest is reached. This definition, which cannot help but don the admittedly loud and outlandish garb of physics, is the most promising for the purposes of biological interpretation. The main characters on this stage are two, but only one of these really plays the lead, namely the human target, which acts out the basic roles inherent in its physical make-up; the other, the bullet, remains a background figure, frozen in its walk-on part, and ready for the next performance. This modus operandi, which is no simplification, but rather an academic necessity, enables us to focus on images which stand out more clearly as a result of an intensive macroscopic spotlight which brings out the features of the individual phenomena, broken down into a succession of close-ups, and subtracts them from the cold physical nature of this or that form of inert matter, which here is merely an occasional, disagreeable witness, or even more, a standing from time to time for but one of the infinite facets of the biological composite being. Here, then, faced with a kind of exploded macrophotograph of a complex kaleidoscope, we see the animal universe, of which we capture so far the plasticity, the subdivisibility, the anisotropy and the cavitation.