Postoperative imaging of orthopaedic hardware in the hand and wrist: is there an added value for tomosynthesis?

AIM: To prospectively investigate digital tomosynthesis (DTS) as an alternative to digital radiography (DR) for postoperative imaging of orthopaedic hardware after trauma or arthrodesis in the hand and wrist. MATERIALS AND METHODS: Thirty-six consecutive patients (12 female, median age 36 years, range 19-86 years) were included in this institutional review board approved clinical trial. Imaging was performed with DTS in dorso-palmar projection and DR was performed in dorso-palmar, lateral, and oblique views. Images were evaluated by two independent radiologists for qualitative and diagnosis-related imaging parameters using a four-point Likert scale (1=excellent, 4not diagnostic) and nominal scale. Interobserver agreement between the two readers was assessed with Cohen's kappa (k). Differences between DTS and CR were tested with Wilcoxon's signed-rank test. A p-value <0.05 was considered statistically significant. RESULTS: Regarding image quality, interobserver agreement was higher for DTS compared to DR, especially for fracture-related parameters (delineation osteosynthesis material [OSM]: KDTS0.96 versus KDR0.45; delineation fracture margins: KDTS0.78 versus KDR0.35). Delineation of fracture margins and delineation of adjacent joint spaces scored significant better for DTS compared to DR (delineation fracture margins: DTS1.54, DR2.28, p0.001; delineation adjacent joint spaces: DTS1.31, DR2.24, p0.001). Regarding diagnosis-related findings, interobserver agreement was almost equal. DTS showed a significant higher sharpness of fracture margins (DTS1.94, DR2.33, p0.04). Mean dose area product (DAP) for DTS was significant higher compared to DR (mean DR0.219 Gy·cm2, mean DTS0.903 Gy·cm2, p0.001). CONCLUSION: Fracture healing is more visible and interobserver agreement is higher for DTS compared to DR in the postoperative assessment of orthopaedic hardware in the hand and wrist.

Chronic critical limb ischemia: European experiences.

Chronic critical limb ischemia still poses a substantial threat to both limb and life of the affected patients since these patients suffer typically also from associated cardiac and cerebrovascular disease and other severe comorbidities. Due to improved secondary prevention strategies and dedicated technical innovation, however, clinical outcomes have improved in the recent years. Purpose of this article is to provide a balanced discussion of contemporary treatment concepts for patients with critical limb ischemia with a focus on arterial revascularization.

The Oceanus statue of the Fontana di Trevi (Rome): The analysis of black crust as a tool to investigate the urban air pollution and its impact on the stone degradation.

This paper deals with the analysis of black crust coming from the statue of Oceanus belonging to the Fontana di Trevi (Rome). This monument is undoubtedly one of the main touristic attractions of Rome. During the restoration held between 2014 and 2015, some diagnostic analyses had been carried out. It has been highlighted that the sheltered surfaces suffer the formation of black crust, especially on the marble statues. The possibility to sample those degradation products, together with the unaltered substrate, represented an excellent opportunity to characterize the marble itself, to assess the impact of the urban air pollution on the stone material, and to detect the pollutant on a precise timescale. In fact, it is known that the previous restoration of the fountain had been carried out between 1989 and 1991 then, information about the air pollution over the last 25years can be highlighted, because it has been proved that black crusts act as passive samplers of pollution. In order to fully characterize those samples, several techniques were used, including optical and scanning electron microscopy, X-ray diffraction, laser ablation inductively coupled plasma mass spectrometry, infrared spectroscopy and ion chromatography. Furthermore, a new methodology based on CHN (Carbon, Hydrogen, Nitrogen) analysis has been developed for the quantification of the two main constituents of the carbonaceous fraction present in the black crusts, i.e. OC (organic carbon) and EC (elemental carbon). This integrated approach proposed in the present study allowed us to gain information about the mineralogical phases and the elements within the crusts and at the crust-substrate interface, giving the possibility to identify the pollution sources causing the stone decay within the monument.

Incidence of hospital-acquired infections in Italian long-term-care facilities: a prospective six-month surveillance.

This study presents results from a six-month prospective surveillance of hospital-acquired infections in four Italian long-term-care facilities (LTCFs). Eight hundred and fifty-nine patients were enrolled and 21 503 person-days were observed. Two hundred and fifty-four hospital-acquired infections (HAIs) occurred in 188 patients. The overall infection rate was 11.8 per 1000 person-days. The most frequent infections were urinary tract infections (3.2 per 1000 person-days), lower respiratory tract infections (2.7 per 1000 person-days) and skin infections (2.5 per 1000 person-days). Risks related to HAI in a multi-variate regression model were: length of stay >or=28 days [odds ratio (OR) 3.5, 95% confidence intervals (CI) 2.4-5.0]; presence of a device (OR 2.0, 95%CI 1.3-3.0); Norton scale <12 (OR 1.8, 95%CI 1.2-2.6); and being bedridden (OR 1.7, 95%CI 1.08-2.6). The presence of HAI increased the median length of stay (31 days vs 20 days, P<0.01) without a significant influence on fatal outcome (OR 1.4, 95%CI 0.7-2.7).

The inducible trimethylamine-N-oxide reductase of Escherichia coli K12: biochemical and immunological studies.

The inducible trimethylamine-N-oxide reductase which migrates on non-denaturing polyacrylamide gels with an RF of 0.22, has been purified from the soluble fraction of wild-type E. coli K12. The molecular weight of the purified enzyme estimated by molecular-sieve chromatography is about 230,000. It is composed of two subunits of molecular weight 110,000. Antiserum specific for the enzyme has been produced. Gel filtration on Sephadex G-200 of the soluble fraction gave two peaks of trimethylamine-N-oxide reductase, one with an Mr of 230,000 and an RF of 0.22, and another with an Mr of 120,000 and an RF of 0.36. Since the anti-trimethylamine-N-oxide reductase serum recognises the two forms and shows a single subunit with an Mr of 110,000, we conclude that in E. coli there is a single inducible trimethylamine-N-oxide reductase which can exist as a dimer or a monomer. Other immunological studies with anti-trimethylamine-N-oxide reductase serum on crude extracts prepared from cells grown in the absence of inducer showed that the constitutive trimethylamine-N-oxide reductase was not recognised by the antiserum. The same analyses carried out on a tor mutant (defective in the structural gene of the inducible enzyme) confirmed without ambiguity that the constitutive enzyme is immunologically distinct from the inducible enzyme. In the same way, using the anti-trimethylamine-N-oxide reductase serum, rocket immunoelectrophoresis analyses were able to show that the inducible apoenzyme is not regulated by the fnr gene product and that molybdate does not seem necessary for the synthesis or stabilisation of this enzyme.

Molybdenum cofactor: a compound in the in vitro activation of both nitrate reductase and trimethylamine-N-oxide reductase activities in Escherichia coli K12.

Nitrate reductase (nitrite: (acceptor) oxidoreductase, EC 1.7.99.4) and trimethylamine N-oxide reductase (NADH : trimethylamine-N-oxide oxidoreductase, EC 1.6.6.9) activities were reconstituted by incubation of the association factor FA (the putative product of the chlB gene) with the soluble extract of the chlB mutant grown anaerobically in the presence of trimethylamine N-oxide. When soluble extracts of the chlB mutant grown on 10 mM sodium tungstate, a molybdenum competitor, were used in complementation systems, no enzymatic reactivation was observed. Heated extracts of the parental strain 541 were shown to contain a thermoresistant molybdenum cofactor by their ability to reactivate NADPH-nitrate reductase activity in the nit1 mutant of Neurospora crassa. By complementation of parental strain heated extract with association factor FA and soluble extract of the chlB mutant grown in the presence of sodium tungstate, we were able to show for the first time that the molybdenum cofactor is an activator common to the in vitro reconstitution of both nitrate reductase and trimethylamine-N-oxide reductase activities.

The inducible trimethylamine N-oxide reductase of Escherichia coli K12: its localization and inducers.

We used an anti-trimethylamine-N-oxide reductase (EC 1.6.6.9) serum and different immunological techniques (Ouchterlony, rocket immunoelectrophoresis, immunoblotting) to show that dimethylsulphoxide (DMSO), tetrahydrothiophene 1-oxide (THTO) and pyridine N-oxide (PNO) were effective inducers of the inducible form of trimethylamine N-oxide reductase. We confirmed this genetically and biochemically using a strain in which phage MudII 1734 carrying lacZ was inserted into torA, the structural gene for inducible trimethylamine-N-oxide reductase. By subcellular fractionation and quantitation with rocket immunoelectrophoresis, we showed that the enzyme was principally localized in the periplasmic fraction. Constitutive trimethylamine-N-oxide reductase was localized in the membrane fraction and, like the inducible enzyme showed a broad specificity with respect to various compounds such as DMSO, THTO and PNO. Apart from their immunological properties, the two enzymes could be clearly differentiated by their temperature stability.

Automated software supported versus manual aorto-iliac diameter measurements in CT angiography of patients with abdominal aortic aneurysms: assessment of inter- and intraobserver variation.

BACKGROUND: Open surgical or endovascular abdominal aortic aneurysm (AAA) relies on precise preprocedual imaging. Purpose of this study was to assess inter- and intraobserver variation of software-supported automated and manual multi row detector CT angiography (MDCTA) in aortoiliac diameter measurements before AAA repair. PATIENTS AND METHODS: Thirty original MDCTA data sets (4 x 2mm collimation) of patients scheduled for endovascular AAA repair were studied on a dedicated software capable of creating two-dimensional reformatted planes orthogonal to the aortoiliac center-line. Measurements were performed twice with afour-week interval between readings. Data were analysed by two blinded readers at random order Two different measurement methods were performed: reader-assisted freehand wall-to-wall measurement and semi-automatic measurement. RESULTS: Aortoiliac diameters were significantly underestimated by the semi-automatic method as compared to reader-assisted measurements (p < 0.0031). Intraobserver variability of AAA diameter calculation was not significant (p > 0. 15) for reader-assisted measurements except for the diameter of the left common iliac artery in reader 2 (p = 0.0045) and it was not significant (p > 0. 14) using the semi-automatic method. Interobserver variability was not significant for AAA diameter measurements using the reader-assisted method and for proximal neck analysis with the semiautomatic method (p > 0.27). Relevant interobserver variation was observed for semi-automatic measurement of maximum AAA (p = 0.0007) and iliac artery diameters (p = 0.024). CONCLUSIONS: Dedicated MDCTA software provides a useful tool to minimize aortoiliac diameter measurement variation and to improve imaging precision before AAA repair. For reliable AAA diameter analysis the reader-assisted freehand measurement method is recommended to be applied to a set of reformatted CT data as provided by the software used in this study.

An analysis of the black crusts from the Seville Cathedral: a challenge to deepen the understanding of the relationships among microstructure, microchemical features and pollution sources.

The Cathedral of Seville is one of the most important buildings in the whole of southern Spain. It suffers, like most of the historical buildings located in urban environments, from several degradation phenomena related to the high pollution level. Undoubtedly, the formation of black crusts plays a crucial role in the decay of the stone materials belonging to the church. Their formation occurs mainly on carbonate building materials, whose interaction with a sulfur oxide-enriched atmosphere leads to the transformation of calcium carbonate (calcite) into calcium sulfate dihydrate (gypsum) which, together with embedded carbonaceous particles, forms the black crusts on the stone surface. To better understand the composition and the formation dynamics of this degradation product and to identify the pollutant sources and evaluate their impact on the stone material, an analytical study was carried out on the black crust samples collected from different areas of the building. For a complete characterization of the black crusts, several techniques were used, including laser ablation inductively coupled plasma mass spectrometry, Fourier transform infrared spectroscopy, micro infrared spectroscopy, optical and scanning electron microscopy. This battery of tests provided information about the nature and distribution of the mineralogical phases and the elements within the crusts and the crust-substrate interface, contributing to the identification of the major pollution sources responsible for the deterioration of the monument over time. In addition, the results revealed a relation among the height of sampling, the surface exposure and the concentration of heavy metals. Finally, information has been provided about the origin of the concentration gradients of some metals.

High levels of adhesion molecules are associated with impaired endothelium-dependent vasodilation in patients with peripheral arterial disease.

Soluble intercellular adhesion molecule-1 (sICAM-1) and vascular cellular adhesion molecule-1 (sVCAM-1) were measured alongside flow-mediated vasodilation (FMD) in 34 patients with intermittent claudication and 14 control subjects. Patients with plasma sICAM-1 >253 ng/mL (median value) showed lower FMD than those with sICAM-1 < 253 ng/mL (5.6 +/- 1.8% vs 9.6 +/- 4.2%, p < 0.01). Similarly, in the 17 patients with plasma sVCAM-1 > 414 ng/mL, FMD was lower than in the remaining 17 patients (6.1 +/- 1.9% vs 9.2 +/- 4.5%, p < 0.05). Additionally, when endothelial dysfunction was defined as FMD < or = 5.5%, patients with FMD below this value had higher plasma concentrations of sICAM-1 and sVCAM-1 than those with FMD > 5.5%. Therefore, our findings indicate a close association between elevated plasma levels of adhesion molecules and endothelial dysfunction. As impaired endothelial function is one of the first steps in atherogenesis, our findings have clinical relevance since they serve as the basis for further evaluation of sICAM-1 and sVCAM-1 as potential plasma markers for progression of atherosclerosis in a population at high risk.

Retinoic acid differentiated SH-SY5Y human neuroblastoma cells: an in vitro model to assess drug neurotoxicity.

PURPOSE: To evaluate whether retinoic acid (RA) differentiated human neuroblastoma (HN) SH-SY5Y cells are a suitable and reliable model to test the neurotoxicity of chemotherapic drugs without the confusing effects of the neurotrophic factors commonly used to induce neuronal differentiation. METHODS: Cultures of the SH-SY5Y cell line were exposed to RA to induce neuronal differentiation which was assessed by measuring the neurite length. The effect of increasing concentrations of cisplatin (CDDP) on neurite outgrowth was determined. Cyclophosphamide (CTX) was used as negative control. RESULTS: CDDP induced a significant reduction in the mean neurite length in a dose dependent manner. The neurotoxic effect of CDDP was reversible. Cyclophosphamide did not induce changes in RA differentiated HN cells. CONCLUSIONS: RA differentiated HN cells are sensitive to the neurotoxic effect of CDDP and the course of the changes is similar to that observed in clinical practice and in in vivo experimental models. Therefore, this model is proposed as a screening method to test the neurotoxicity of chemotherapy drugs and the possible effect of neuroprotectant molecules and drugs.

Spinal-cord compression due to extradural amyloidosis of the cervico-occipital hinge, in a hemodialysed patient. A case report.

Long-term dialysed patients can develop an arthropathy, called dialysis arthropathy, due to the deposition and transformation of the beta2 microglobulin into amyloid. The involvement of the spine, called destructive spondyloarthropathy (DSA), occurs between 10 and 25 percent; of these patients, and sometimes causes neurological damage. The disc space narrowing, vertebral body erosion and pseudocystis, in presence of polyarthropathy, chronic renal failure, and carpal tunnel syndrome, allows to make a diagnosis of DSA, which is proved by histological finding of beta2 microglobulin-amyloid. We report a rare case of spinal cord compression due to beta2 microglobulin-amyloid deposit in extradural space of cervico-occipital hinge.

Microcirculation and tissue metabolism in peripheral arterial disease.

It is now clear that different pathophysiologic mechanisms have a profound influence on the extent of the functional impairment in intermittent claudication. In particular, metabolic derangements, including impaired oxygen delivery and/or extraction, reduced nitric oxide synthesis, reduced glucose oxidation, accumulation of toxic metabolites and reduction in carnitine availability are correlated with disease severity. Therefore, metabolic interventions aimed at counteracting these alterations may represent a valid therapeutic approach to the treatment of this condition. To date, verapamil and L-arginine efficacy has been proven in few patients; a large scale clinical trial, conversely, reports that propionyl-L-carnitine appears to be an effective and well tolerated drug for the treatment of intermittent claudication.

Exercise increases soluble adhesion molecules ICAM-1 and VCAM-1 in patients with intermittent claudication.

Adhesion molecules play a relevant role in the pathogenesis of vascular diseases. In 21 patients with intermittent claudication and 18 sex- and age-matched control subjects, we measured plasma levels of the circulating form of the adhesion molecules E-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) alongside von Willebrand factor (vWF), at rest, at maximally tolerated exercise and 5, 15 and 30 min after exercise. In controls, plasma sICAM-1 levels did not change with exercise, while in claudicants they increased from 285+/-15 to 317+/-16 ng/ml (p<0.01). Also for sVCAM-1 exercise did not modify plasma levels of sVCAM-1 in controls but increased it in claudicants from 671+/-45 to 751+/-47 ng/ml (p<0.05). Similarly, vWF did not change with exercise in controls, but increased in claudicants from 100+/-9% to 111+/-8% of value for pooled normal plasma (p<0.05). Exercise-induced changes in sICAM-1 negatively correlated with the maximal tolerated walking time, which is an index of disease severity. These findings indicate that, in claudicants, exercise is associated with increase in plasma levels of sICAM-1 and sVCAM-1.

[A new questionnaire for assessing the quality of life of patients with intermittent claudication]. / Un nuovo questionario per la valutazione della qualità della vita nel paziente affetto da claudicatio intermittens.

BACKGROUND: Quality of life assessment is becoming increasingly relevant for evaluating the impact of disease and treatments and for deciding priorities when allocating resources. This is especially true in intermittent claudication where the goal of therapy is not the cure of the disease but rather to alleviate its symptoms and improve the patient's functional capabilities. At present, however, no generic scale fits all criteria for the ideal quality of life measuring in intermittent claudication. METHODS: We developed a questionnaire aimed at evaluating the specific limitations encountered by claudicants in the physical activity and in the social and emotional functioning. The present study evaluated the questionnaire for validity, reliability, and sensitivity to change, attributes considered to be essential for a questionnaire to be useful. RESULTS: In 30 patients with intermittent claudication, the scores of the four sections of the questionnaire significantly correlated with the scores of the corresponding sections of the Nottingham Health Profile. This indicates that the questionnaire is valid. For each of the four subscales, the intraclass correlation coefficient was > 0.75, thus showing a high test re-test reliability. Also the internal consistency is strong with alpha coefficient ranging from 0.79 to 0.89. Finally, the questionnaire was administered to 9 patients before and 4 weeks after percutaneous transluminal angioplasty for claudication. After the intervention, the improvement in walking performance paralleled the improvement in quality of life. This indicates that the questionnaire is sensitive to change. CONCLUSIONS: Our questionnaire appears to be a valid and reliable quality of life measure in intermittent claudication.

[Nurses' perception of specific nursing activities that can be delegated to other health care personnel]. / Le attività delegabili ad altre figure: la percezione degli infermieri.

In order to understand the nurses' perception of the activities specific to nursing care, and to assess what they are ready to delegate to other health care workers, a complex activity of analysis was started. Head nurses and nurses representative of the different NHS hospital and district services (hospital wards, home care and district, preventive services, psychiatric services and first aid services in the district, operating theatre and clinics) of the Medio Friuli area (North of Italy) were asked to identify a. the main activities performed in the patients' care, b. the nature of the activities (whether administrative, hotel, health, support-non health), c. their level of standardization (i.e. whether their performance required discretionality and the tailoring of the activity to the patient's situation) and d. if they considered it delegable and to whom (doctors, support personnel, secretary, other health care personnel). Final aim of the work was to acquire elements in order to reorganize the nursing care. In order to leave the nurses free to identify areas that better allowed the description of their activities, (and due to the large and different numbers of sectors and areas involved), no strict instructions were given. Therefore the model used and level of detail in the description of activities and processes varied from group to group. Sixty nurses participated in the work. On average, from 38.9% (Operating Theatre and clinics) to 55.7% (Psychiatric services) of the activities identified were perceived as delegable to nurses aids and/or secretaries. The 89.2% of delegable activities (183/205) were considered highly standardized. Up to 23.4% (39/166) were classified as health care activities (i.e. prevention of pressure sores with mobilization, risk assessment with standardized scales, application of ointments, the care for patients during mobilization etc.). The remaining were classified as administrative or support activities. Although this does not necessarily imply that with the introduction in the health care team of a secretary and of the nurse-aid half of the time of the nurse could be freed, nurses perceive that on average half of their routine and basic activities could be well delegated to other figures.

Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity.

OBJECTIVES: Arteriographic lesions of diabetic subjects with critical limb ischemia (CLI) and ischemic foot ulcer were reviewed retrospectively, to provide new criteria for stratification of these patients on the basis of their vascular involvement. PATIENTS: In 417 consecutive CLI diabetic subjects with ischemic foot ulcer undergoing lower limb angiography, lesions were defined as stenosis or occlusion, localization, and length (<5 cm, 5-10 cm, >10 cm). In a subgroup of 389 subjects, foot arteries also were evaluated. Patients then were categorized into 7 classes of progressive vascular involvement based on angiographic findings. RESULTS: Of the 2893 found lesions (55% occlusions) 1% were in the iliac arteries, whereas 74% were in below-the-knee (BTK) arteries. Sixty-six % of all BTK lesions were occlusions, and 50% were occlusions >10 cm (p<0.001 vs proximal segments). Occlusions of all BTK were present in 28% of patients, although there was patency of at least one foot artery in 55% of patients. The morphologic Class 4 (two arteries occluded and multiple stenoses of tibial/peroneal and/or femoral/popliteal vessels) was the most common (36%). An inverse correlation between morphologic class and TcPO2 was observed (r=-0.187, p=0.003). CONCLUSIONS: In CLI diabetic subjects with ischemic foot ulcer, the vascular involvement is extremely diffuse and particularly severe in tibial arteries, with high prevalence of long occlusions. A new morphologic categorization of these patients is proposed.