Disease activity assessment for juvenile idiopathic arthritis in transitional care.

OBJECTIVE: The indices to measure disease activity of chronic arthritis in adulthood and childhood are different. Therefore, assessing the status of the disease in young patients with juvenile idiopathic arthritis (JIA) can be tricky, especially when the transition to adult care is ongoing. The aim of our study was to assess the level of correlation between adult and juvenile scores in the measurement of disease activity in JIA patients during transitional care. METHODS: We estimated the disease activity by using the Juvenile Arthritis Disease Activity Score 71 (JADAS71), clinical JADAS, adult Disease Activity Score (DAS28), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI) in JIA patients in transitional care. We enrolled patients older than 16 years at the time of the first transition visit, and disease activity was assessed at baseline and 12 months. Regression analyses were carried out to estimate the level of agreement among the different indices. RESULTS: We recruited 26 patients with JIA; 11 patients were polyarticular (42.3%) and 15 patients were oligoarticular (53.1%). The mean age at diagnosis was 7.7±3.9 years and the age at the first evaluation was 20.9±3.7 years. The correlation between JADAS71 and DAS28 was r2=0.69, r2=0.86 between JADAS71 and SDAI, and r2=0.81 between JADAS71 and CDAI. CONCLUSIONS: SDAI and JADAS71 showed the best correlation, but a few patients were not captured at the same level of disease activity. New prospective studies with a larger number of patients will be needed in this field.

[Translated article] Nautilus Flap and Bullfighter Crutch Flap for the Repair of Periorificial Surgical Defects of the Face.

BACKGROUND: Reconstruction of surgical defects located close to eyelid edges, nostrils, or the mouth is challenging, as tension generated by direct closure or skin flaps in these sensitive regions tends to cause distortion. New repair techniques that prevent retraction may significantly improve outcomes. PATIENTS AND METHODS: Retrospective study of the use of 2 novel flap designs-the nautilus flap and the bullfighter crutch flap-to repair surgical defects in the peripalpebral, perivestibular, nasal, and perioral areas. The nautilus flap was used to repair 4 peripalpebral defects and 2 perioral defects, and the bullfighter crutch flap to repair 14 nasal ala defects. RESULTS: Cosmetic and functional outcomes were very satisfactory in all 20 patients, with no cases of ectropion, nasal vestibule collapse, or labial asymmetry. Necrosis did not occur in any of the cases. CONCLUSIONS: The nautilus and bullfighter crutch flaps appear to be excellent choices for reconstructing surgical defects in periorificial areas.

Nautilus Flap and Bullfighter Crutch Flap for the Repair of Periorificial Surgical Defects of the Face. / Colgajo nautilus y colgajo en muleta taurina para defectos quirúrgicos faciales periorificiales.

BACKGROUND: Reconstruction of surgical defects located close to eyelid edges, nostrils, or the mouth is challenging, as tension generated by direct closure or skin flaps in these sensitive regions tends to cause distortion. New repair techniques that prevent retraction may significantly improve outcomes. PATIENTS AND METHODS: Retrospective study of the use of 2 novel flap designs-the nautilus flap and the bullfighter crutch flap-to repair surgical defects in the peripalpebral, perivestibular, nasal, and perioral areas. The nautilus flap was used to repair 4 peripalpebral defects and 2 perioral defects, and the bullfighter crutch flap to repair 14 nasal ala defects. RESULTS: Cosmetic and functional outcomes were very satisfactory in all 20 patients, with no cases of ectropion, nasal vestibule collapse, or labial asymmetry. Necrosis did not occur in any of the cases. CONCLUSIONS: The nautilus and bullfighter crutch flaps appear to be excellent choices for reconstructing surgical defects in periorificial areas.

Bishop Flap and Sigma Flap to Repair Surgical Defects in High-Tension Anatomical Regions. / Colgajo obispo y colgajo sigma para defectos quirúrgicos en zonas anatómicas de elevada tensión.

BACKGROUND: The reconstruction of surgical defects in high-tension anatomical regions is challenging due to the ischemia and subsequent necrosis associated with tension closure. Research on new flaps capable of closing these defects exerting less tension would be a tremendous advancement in dermatological surgery. PATIENTS AND METHODS: We conducted a multicenter, retrospective study that used 2 new flaps-the bishop and the sigma ones-to repair surgical defects in high-tension regions such as the scalp, lower extremities, and the nasal pyramid. The bishop flap was used in 9 patients, 5 of whom exhibited their lesion in the nasal pyramid, 2 in the legs and another 2 in the scalp. The sigma flap was used in 6 patients, 5 of whom exhibited scalp lesions and 1 leg lesion. RESULTS: Uneventful and excellent results were obtained in all 15 patients due to infection, dehiscence, or necrosis. CONCLUSIONS: Both the bishop and the sigma flaps are a good alternative to repair surgical defects in high-tension regions such as the scalp, lower extremities, or the nasal pyramid.

Percutaneous cementoplasty of periprosthetic loosening: can interventional radiologists offer an alternative to revision surgery?

OBJECTIVE: To evaluate feasibility and validate both safety and efficiency of radiological percutaneous periprosthetic bone cementoplasty (RPPBC) performed under local anesthesia as an alternative minimally invasive treatment of aseptic implant loosening. METHODS: In this case series, seven patients (mean age 81 years, range 73 to 89 years, 2 men and 5 women) were enrolled between February 2011 and January 2020 with confirmed aseptic loosening of orthopedic implants. One patient presented with tibial component loosening of an unicompartmental knee arthroplasty, one with glenoid component loosening from a reverse shoulder arthroplasty, one femoral gamma nail, and four presented with pedicle screw loosening after staged posterior lumbar interbody fusion. All patients underwent clinical, biochemical, and imaging assessments to confirm the diagnosis of aseptic loosening. All benefited from RPPBC under dual CT and fluoroscopic guidance. All procedures were performed under local anesthesia by an experienced radiologist. Preprocedural, immediate and 6-month post-cementoplasty pain levels on a visual analogue scale (VAS), and functional outcomes were evaluated. Immediate and 6-month postprocedural CTs were performed to evaluate the treated region. RESULTS: All RPPBC were well tolerated by patients throughout the procedure. None of the patients suffered from local or systemic infection post-RPPBC, or periprosthetic fractures. No recurrent implant loosening was observed. Six patients were pain free at 6 months. All patients expressed functional improvements during validated outcome score evaluations. CONCLUSION: RPPBC appears to be an efficient and reliable treatment strategy for aseptic loosening of orthopedic implants in elderly patients deemed unfit for revision surgery. KEY POINTS: • Radiological percutaneous periprosthetic bone cementoplasty offers immediate and long-lasting pain relief in elderly frail patients, or those deemed unfit for revision surgery despite presenting with symptomatic aseptic loosening of orthopedic implants. • Radiological percutaneous periprosthetic bone cementoplasty brings quick and long-lasting improvements in clinical functional outcomes and offer effective pain reduction, thereby improving the overall quality of life. • Radiological percutaneous periprosthetic bone cementoplasty is a safe, quick, reliable, and well-tolerated minimally invasive procedure which can be easily performed under simple locoregional anesthesia and requires short-term hospital stay.

Effects of oral contraceptives on thyroid function and vice versa.

BACKGROUND: Thyroid gland dysfunction represents an epidemiologically relevant disease in the female gender, where treatment with oral contraceptives (OCs) is frequently prescribed. Although OCs are able to impact the thyroid gland function, scanty data have been released on this matter so far. AIM: The aim of this article was to review how hormonal OCs, including estrogen- or progesterone-only containing medications, interact with the hepatic production of thyroid-binding globulin (TBG) and, consequently, their effects on serum levels of thyroxine (T4) and triiodothyronine (T3). We also reviewed the effect of Levo-T4 (LT4) administration in women taking OCs and how they influence the thyroid function in both euthyroid women and in those receiving LT4. REVIEW: The estrogenic component of the pills is capable of increasing various liver proteins, such as TBG, sex hormone-binding protein (SHBG) and coagulation factors. On the other hand, the role of progestogens is to modulate estrogen-dependent effects mainly through their anti-androgenic action. In fact, a reduction in the effects of androgens is useful to keep the thromboembolic and cardiovascular risks low, whereas OCs increase it especially in women with subclinical hypothyroidism or in those treated with LT4. Accordingly, subclinical hypothyroidism is known to be associated with a higher mean platelet volume than normal and this increases cardiovascular risk due to platelet hyperactivity caused by incomplete thrombocytopoietic maturation.

Multicentre randomized clinical trial of colonic J pouch or straight stapled colorectal reconstruction after low anterior resection for rectal cancer.

BACKGROUND: Colonic J pouch reconstruction has been found to be associated with a lower incidence of anastomotic leakage than straight anastomosis. However, studies on this topic are underpowered and retrospective. This randomized trial evaluated whether the incidence of anastomotic leakage was reduced after colonic J pouch reconstruction compared with straight colorectal anastomosis following anterior resection for rectal cancer. METHODS: This multicentre RCT included patients with rectal carcinoma who underwent low anterior resection followed by colorectal anastomosis. Patients were assigned randomly to receive a colonic J pouch or straight colorectal anastomosis. The main outcome measure was the occurrence of major anastomotic leakage. The incidence of global (major plus minor) anastomotic leakage and general complications were secondary outcomes. Risk factors for anastomotic leakage were identified by regression analysis. RESULTS: Of 457 patients enrolled, 379 were evaluable (colonic J pouch arm 190, straight colorectal arm 189). The incidence of major and global anastomotic leakage, and general complications was 14·2, 19·5 and 34·2 per cent respectively in the colonic J pouch group, and 12·2, 19·0 and 27·0 per cent in the straight colorectal anastomosis group. No statistically significant differences were observed between the two arms. In multivariable logistic regression analysis, male sex (odds ratio 1·79, 95 per cent c.i. 1·02 to 3·15; P = 0·042) and high ASA fitness grade (odds ratio 2·06, 1·15 to 3·71; P = 0·015) were independently associated with the occurrence of anastomotic leakage. CONCLUSION: Colonic J pouch reconstruction does not reduce the incidence of anastomotic leakage and postoperative complications compared with conventional straight colorectal anastomosis. Registration number NCT01110798 (http://www.clinicaltrials.gov).

Pelvic floor rehabilitation for defecation disorders.

Pelvic floor rehabilitation is frequently recommended for defecation disorders, in both constipation and fecal incontinence. However, the lack of patient selection, together with the variety of rehabilitation methods and protocols, often jeopardize the results of this approach, causing difficulty in evaluating outcomes and addressing proper management, and above all, in obtaining scientific evidence for the efficacy of these methods for specific indications. The authors represent different gastroenterological and surgical scientific societies in Italy, and their aim was to identify the indications and agree on treatment protocols for pelvic floor rehabilitation of patients with defecation disorders. This was achieved by means of a modified Delphi method, utilizing a working team (10 members) which developed the statements and a consensus group (15 members, different from the previous ones) which voted twice also suggesting modifications of the statements.

Randomized clinical trial of percutaneous tibial nerve stimulation versus sham electrical stimulation in patients with faecal incontinence.

BACKGROUND: The aim was to assess the effects of percutaneous tibial nerve stimulation (PTNS) in the treatment of faecal incontinence (FI) by means of an RCT. METHODS: Patients aged over 18 years with FI were included in a multicentre, single-blinded RCT. The primary endpoint was reduction in the median or mean number of FI episodes per week. Secondary endpoints were changes in measures of FI severity, and disease-specific and generic quality of life. Outcomes were compared between PTNS and sham stimulation after 9 weeks of treatment. RESULTS: A higher proportion of patients in the PTNS (13 of 29) than in the sham (6 of 30) group showed a reduction of at least 50 per cent in the median number of FI episodes/week (incidence rate ratio (IRR) 2·40, 95 per cent c.i. 1·10 to 5·24; P = 0·028), but not in the mean number of episodes/week (10 of 29 versus 8 of 30; IRR 1·42, 0·69 to 2·92; P = 0·347). The absolute median number of FI episodes per week decreased in the PTNS but not in the sham group (IRR 0·66, 0·44 to 0·98; P = 0·041), as did the mean number (IRR 0·65 (0·45 to 0·97); P = 0·034). Scores on the Cleveland Clinic Florida faecal incontinence scale decreased significantly in both groups, but more steeply in the PTNS group (mean difference -1·3, 95 per cent c.i. -2·6 to 0·0; P = 0·049). The aggregated mental component score of Short Form 36 improved in the PTNS but not in the sham group (mean difference 5·1, 0·5 to 9·6; P = 0·028). CONCLUSION: PTNS may offer a small advantage in the clinical management of FI that is insufficiently responsive to conservative treatment. The key challenge will be to identify patients who may benefit most from this minimally invasive surgical procedure. Registration number: NCT00974909 (http://www.clinicaltrials.gov).

Comparison of two diagnostic techniques, skin-prick test and component resolved diagnosis in the follow-up of a cohort of paediatric patients with pollinosis. Multicentre pilot study in a highly exposed allergenic area.

BACKGROUND: Over the last years, different works have been published about the importance of incorporating new diagnosis techniques in allergic patients such as component-resolved diagnosis (CRD). The objective of this study is to compare the evolution of allergic sensitisation profiles by means of CRD and cutaneous tests (SPT) on pollen-allergic patients. METHODS: A total of 123 patients aged between 2 and 14 years were included in an open, prospective, multicentre study. All the children had symptoms suggestive of seasonal respiratory allergic disease, with the diagnosis confirmed by cutaneous tests. Specific-IgE to major pollen-allergens (CRD) and SPT were performed at basal and after three years of follow-up. RESULTS: Out of 123 patients included, a total of 85 were analysed. The mean age was 8±3 years. Significant changes in the allergic sensitisation profiles were observed for the most prevalent allergens (Olea and grass) but it is in grass, the most relevant allergen in terms of allergen pressure, where changes in both absolute and relative frequencies between SPT and CRD were more evident. CONCLUSION: CRD seems to be an essential tool to carry out an appropriate follow-up of patients with allergic respiratory disease, as well as to decide on the immunotherapy composition that best matches the allergic sensitisation profile of patients.

T1 colon cancer in the era of screening: risk factors and treatment.

BACKGROUND: The aim of this study was to identify risk factors for lymph node positivity in T1 colon cancer and to carry out a surgical quality assurance audit. METHODS: The sample consisted of consecutive patients treated for early-stage colon lesions in 15 colorectal referral centres between 2011 and 2014. The study investigated 38 factors grouped into four categories: demographic information, preoperative data, indications for surgery and post-operative data. A univariate and multivariate logistic regression analysis was performed to analyze the significance of each factor both in terms of lymph node (LN) harvesting and LN metastases. RESULTS: Out of 507 patients enrolled, 394 patients were considered for analysis. Thirty-five (8.91%) patients had positive LN. Statistically significant differences related to total LN harvesting were found in relation to central vessel ligation and segmental resections. Cumulative distribution demonstrated that the rate of positive LN increased starting at 12 LN harvested and reached a plateau at 25 LN. CONCLUSIONS: Some factors associated with an increase in detection of positive LN were identified. However, further studies are needed to identify more sensitive markers and avoid surgical overtreatment. There is a need to raise the minimum LN count and to use the LN count as an indicator of surgical quality.

Repair of transperineal recto-urethral fistula using a fibrin sealant haemostatic patch.

AIM: Recto-urethral fistula (RUF) is a rare complication of radical prostatectomy. We report a transperineal approach using a fibrin sealant haemostatic patch. METHOD: Five consecutive patients who developed RUF following radical prostatectomy had a direct transperineal repair with a haemostatic patch (TachoSil®) and were assessed at a median follow-up of 35.5 (21-45) months. RESULTS: There were no early postoperative complications. The average length of hospital stay was 5 (4-7) days. One patient developed recurrence 4 weeks after removal of the urethral catheter. Following healing in four patients the stoma was reversed at a median interval of 3 months, and 9.5 (7-10) months following the prostatic surgery. In the four patients with successful closure there was no case of recurrence or anorectal or urinary dysfunction at a median follow-up of 35.5 (21-45) months. CONCLUSION: Direct transperineal repair of RUF reinforced with a fibrin haemostatic patch of TachoSil is safe and effective.

Long-term evaluation of bulking agents for the treatment of fecal incontinence: clinical outcomes and ultrasound evidence.

BACKGROUND: The injection of bulking agents into the anal canal has been reported to help patients with fecal incontinence. Although it has been advocated as a safe and effective option, substantial data concerning long-term efficacy are still lacking, and the resorption process of the implants has not yet been carefully studied. The aim of our study was to investigate the long-term outcomes of bulking agents for the treatment of fecal incontinence and the behavior of implanted materials in the anorectum. METHODS: At a median follow-up of 7 years, 19 patients with idiopathic fecal incontinence who had received bulking agent implants were evaluated. Clinical, manometric and ultrasound assessments were carried out. RESULTS: The clinical improvements that were achieved in the short term were not maintained over time. For each patient, the number of implants that could no longer be identified on ultrasound was significantly correlated with poorer clinical long-term outcomes. On average, only 14% of the originally injected volume was still detectable. CONCLUSIONS: In the long term, perianally injected bulking agents seem to lose effectiveness. The ultrasound assessment suggests that the process of resorption is almost complete, and the implants are no longer effective in treating incontinence.

Renal tuberculosis: a case report.

Tuberculosis or TB (tubercle bacillus) remains a major public health problem in developing countries. Over the last decades extrapulmonary locations of the disease have become more frequent due to the increased prevalence of acquired immune deficiency syndrome and the increase number of organ transplants. The urogenital localization represents about 27% of all extra-pulmonary localizations of TB and may be due either to a disseminated infection or to a primitive genitourinary localization. The majority of patients, has pyuria, sometimes with hematuria. The diagnosis of urinary tuberculosis is based on the finding of pyuria in the absence of infection by common bacteria. The initial medical treatment includes isoniazide, rifampicin, pyrazinamide, ethambutol and streptomycin. This disease should be suspected in patients with unexplained urinary tract infections, especially if immunocompromised and/or coming from endemic areas.