Paraplegia in a patient with Von Hippel Lindau syndrome: surgical and reconstructive treatment of Marjolin's ulcer. A case report.

STUDY DESIGN: Marjolin's ulcer is a squamous cell carcinoma that develops in posttraumatic scars and chronic wounds. Suspicion of such lesions should be raised in chronic wounds demonstrating characteristic changes. We have reported the peculiar phenomenon of malignant transformation of chronic pressure sores that occurred in a paraplegic patient. OBJECTIVES: The aim of this study was to cover the extensive defects by a last resort reconstructive option. SETTING: Department of Plastic and Reconstructive Surgery, Università Politecnica delle Marche, Ancona, Italy. METHODS AND RESULTS: A 40-year-old paraplegic man, with multiple hemangioblastomas of the brain and spinal cord due to Von Hippel Lindau syndrome developed pressure ulcers with unstable healing over the sacral, trochanteric, bilateral, and ischiatic areas after 15 years from neurosurgery. The biopsy result showed an invasive squamous carcinoma. Carcinomas in pressure sores are highly aggressive, and they need to be treated more radically. In our case we opted for a demolitive surgical treatment including musculocutaneous rotational flap harvested from total left thigh to cover the extensive defects. The limb was previously disarticulated. CONCLUSION: In Marjolin's ulcer, multiple biopsies are the first-line modality for the early diagnosis as they are a safe method with high rate of accuracy. First-line treatment is surgery consisting of radical excision with lymph node dissection, if they are involved. Adjuvant radiation therapy may be used in selected patients. Management of massive pelvic defects can be a challenging problem. The pedicled lower limb flap offers a technique that can be considered as a last resort procedure for extensive defects where other options are insufficient or not available anymore. In our case the patient is disease-free after 2 years of follow-up.

Patient satisfaction with hospital rehabilitation: validation of the SAT-16 questionnaire through Rasch analysis.

AIM: The SAT-16 is a 16-item self-administered questionnaire measuring patient satisfaction with the quality of care during stay in a rehabilitation unit. A comprehensive psychometric analysis of SAT-16 was performed using both classical test theory and Rasch analysis (RA) to examine its validity and metric properties, and provide further insights for its clinical use in rehabilitation settings. METHODS: A sample of 9458 patients, consecutively admitted to two Rehabilitation Centres, was examined with SAT-16. Factor (both explorative and confirmatory) analysis and RA were used to process the data in order to examine validity and metric properties of SAT-16. Dimensionality, item fit to the model, response category performance and internal construct validity were assessed. RESULTS: Two subscales were identified by factor analysis and expert review, respectively related to satisfaction with clinical care (items 1-9), and satisfaction with hospital organization and facilities ("hotel" aspects of care, items 10-16). Each subscale underwent a separate RA. Response categories were revised in both subscales of SAT-16, obtaining a new 3-level rating scale. Both subscales showed high internal consistency and internal validity. CONCLUSION: RA confirmed the appropriateness of SAT-16 and its usefulness in identifying areas for quality improvement. Overall, the questionnaire allows to assess patient satisfaction with the services through: 1) two sub-scores respectively specific for satisfaction with "clinical care" and "hotel aspects of care"; 2) additional information gathered in the optional open-ended questions.

[Oncoplastic surgery for the treatment of breast cancer]. / Chirurgia oncoplastica nel trattamento dei tumori della mammella.

Surgery is still the gold standard in breast cancer. Also if the elective treatment, thanks to the adjuvant therapy, ha became more conservative than once was, breast surgery remains, in the mind of the woman affected by breast cancer, a demolitive surgery. The collaboration bet-ween the breast surgeon and the plastic surgeon has to be closer than it is, in order to obtain the total asportation of the tumor and an esthetic result that limits the psychological trauma to the woman. Oncoplastic surgery is the answer to these human and medical necessities, giving the correct approaches about breast volume, tumor volume, radicality of the treatment and esthetic outcome. This review will focus on different oncoplastic approaches, to help improving both the esthetic outcome of breast cancer resection and the likelihood of surgeons obtaining wide surgical margins in preparation for breast-conserving radiotherapy.

Difficulties In Emotion Regulation During Rehabilitation For Alcohol Addiction: Correlations With Metacognitive Beliefs About Alcohol Use And Relapse Risk.

PURPOSE: Understanding how difficulties in emotion regulation can be related to metacognitive beliefs during early abstinence, identifying which factors are associated with craving and relapse risk may be useful in residential rehabilitation treatment of alcohol addiction. METHODS: Sixty-five patients underwent a 28-day rehabilitation program for alcohol addiction. They underwent a brief semi-structured interview at admission and completed a battery of five self-report questionnaires between days 7 and 10 of alcohol abstinence (T0) and 3 days prior to discharge (T1). RESULTS: After rehabilitation program, all symptoms of psychological distress decreased. We found a significant improvement in all emotional, cognitive and metacognitive scales except for "Cognitive harm" (NAM), "Awareness" (DERS) and a small effect size (low statistical power) for "Emotional clarity" (DERS). Compared to those still abstinent at 1 month from discharge, we found more difficulties in "Emotional clarity" in those who had an early relapse. Difficulties in "Emotional clarity" were observed also in patients with a high level of craving at discharge. CONCLUSION: Significant differences were observed between the groups "abstinence vs non-abstinence" at 1 month from discharge concerning difficulties in emotion regulation. In particular, we found difficulty in the awareness and understanding of emotion, precisely to identify correctly the emotions. The "Emotional Clarity" seems to be the emotional difficulty that characterized also the group with a high level of craving at discharge and the individuals with early relapse, suggesting the importance of this function as a preliminary factor in emotion regulation.

Cognitive-behavioral interventions in rheumatic diseases.

Rheumatic diseases, like many other chronic diseases, represent an important public health burden. To reduce the social and economic impact of these pathologies, an appropriate management of these conditions should be encouraged based on the use of established intervention strategies. The aim of this article is to describe the content of Cognitive-Behavioural Therapies (CBTs) for patients with rheumatic diseases aimed at managing pain, disability and quality of life. These interventions involve education, training in various types of relaxation approaches and other coping skills, and the application of these skills in the patient's home and work environment. CBT include the teaching of life and coping skills that can assist the patient in productive problem solving and prevention or minimization of future pain episodes and stressful events. Moreover, several studies suggest that the cognitive-behavioural approach is efficacious in rheumatoid arthritis, osteoarthritis and fibromyalgia in improving not only the psychological adjustment during the course of the disease but also physical function.

The influence of comorbidities and complications on discharge function in stroke rehabilitation inpatients.

AIM: The aims of this prospective study were: 1) to assess the frequency, type and severity of comorbidities (COMs) and complications (COMPLs) in acute stroke patients, according to the weighted comorbidity index (w-CI) of Liu et al. and 2 new indices, respectively COM severity index (COM-SI) and COMPL severity index (COMPL-SI); 2) to separately analyse the interference of COMs and COMPLs with functional status and recovery during stroke rehabilitation treatment; 3) to compare the ability of COM-SI and COMPL-SI to predict functional independence at discharge with that of w-CI. METHODS: Eighty-five stroke rehabilitation inpatients participated in the study. The type, incidence and severity of COM at admission and of COMPL during the whole hospital stay were studied prospectively. The Functional Independence Measure (FIM) scale was administered at both admission and discharge. RESULTS: About 1/3 suffered from some significant COM and another 1/3 developed COMPLs needing specific medical treatment and/or clinical monitoring. The most frequent COMs and COMPLs were cardiovascular and psychiatric/psychological diseases. The odds of having a high efficiency in the daily functional gain (FIM score) were greater for patients without any COM (3.5) and/or COMPL (4.6). Similarly, the odds of having a high FIM score at discharge were greater (3.5) for patients without COM or COMPL. The COM-SI demonstrated a higher predictive capacity of the FIM score at discharge (5%) than w-CI (4%), and COMPL-SI (1%). CONCLUSIONS: COM-SI resulted as the most interesting predictive index of functional outcome at discharge, after accounting for the functional status at admission.

Falls in a rehabilitation setting: functional independence and fall risk.

AIM: With this study we wanted to determine the incidence, characteristics and consequences of falls in our rehabilitation setting. METHODS: An observational study was carried out in a rehabilitation setting for postacute orthopedic and neurological inpatients. Three-hundred and twenty patients were enrolled. Falls risk factors (Downton index [DI] and other known parameters), disability (functional independence measure [FIM]) and balance (Berg balance scale [BBS]) were assessed at admission. Falls that occurred during the rehabilitation stay were prospectively classified (St. Louis Older Adult Service and Information System [OASIS] system) and analyzed. RESULTS: Forty patients experienced a fall (12.5%). The faller group was characterized by a major clinical complexity; 70% of fallers were neurological patients and 30% presented cognitive impairment (mini mental state examination [MMSE] <24). They presented a statistically significant worse score on FIM (motor and cognitive), BBS and DI at admission, with 74% predictability of falls as measured by total FIM score and age. Falls recorded with the OASIS classification showed a prevalence (52.5%) for not bipedal (wheelchair transfer) and self-generated falls; 35% were intrinsic falls (caused by subject-specific factors) and 12.5% extrinsic falls (caused by environmental factors). Falls resulted in only minor clinical consequences, except for one rib fracture, but led to a significant increase in length of stay. CONCLUSIONS: In a rehabilitation centre, for good management of resources and safe prescriptions of a patient's independence in activities of daily living, fall risk is better evaluated with appropriate scales.

[Assessment of a patient satisfaction scale in rehabilitation]. / Validazione di una scala di soddisfazione del paziente in degenza riabilitativa.

BACKGROUND: A new scale is presented, measuring patients' satisfaction with respect to the quality of care during stay in a rehabilitation unit. The questionnaire is self-administered and anonymous, and it includes 15 items, scored 1 to 4. The cumulative score may thus range 15-60; the higher the score, the higher the patient's satisfaction. MATERIALS AND METHODS: The instrument was proposed to 175 disabled patients, admitted to a free-standing Centre for rehabilitation following neurological or orthopedic impairments. RESULTS: One hundred and forty questionnaires were completed. Of these, 131 could be analyzed. The mean score was > 3 in every item. Factor analysis disclosed that the questionnaire comprises 5 factors, which may be defined as "medical care", "physiotherapy", "nursing care", "food" and "physical environment and facilities". A satisfactory internal consistency of the items was found (item-remainder correlations > 0.5, Cronbach alpha > 0.9). This suggests that the scale is sufficiently unidimensional to permit cumulative summing of the item scores. CONCLUSIONS: The results suggest the content and construct validity of the scale. The questionnaire thus merits further psychometric investigation.

[Validity and reliability of a new questionnaire on patient satisfaction in rehabilitative therapy]. / Validità ed affidabilità di un nuovo questionario sulla soddisfazione del paziente in degenza riabilitativa.

BACKGROUND: The aim of this study was to examine some psychometric properties of a new questionnaire measuring patients' satisfaction with respect to the quality of care during stay in a rehabilitation unit. The instrument (called SAT-16) is composed of 16 four-level items and 2 open-ended questions. The construct validity of the 16-item section was already demonstrated in a previous study based on factorial analysis. In this study the concurrent validity, further aspects of the construct validity and test-retest reliability were analyzed. METHODS: The SAT-16 was administered to 339 inpatients, admitted consecutively to a Rehabilitation Center. RESULTS: 262 questionnaires (77%) were returned, of which 221 with all items filled in. The SAT-16 correlated well with two other measures of satisfaction (CSQ-8 and global satisfaction regarding the hospital stay). The answers to two open-ended questions came out to be consistent with those to the 16 closed-ended questions. The high values for the indices of test-retest reliability (ICC and kappa) are evidence of the stability of the scores in two repeated administrations. CONCLUSIONS: The SAT-16 was found to be provided with good psychometric characteristics. It can be proposed as a valid instrument for use in clinical practice for the continuous quality improvement of inpatient medical rehabilitation programmes.

[Anesthesia in videolaparoscopic cholecystectomy. Our experience]. / Anestesia in videolaparocolecistectomia. Nostra esperienza.

In this work authors describe physiopathological problems and possible complications relative to intraperitoneal insufflation in videolaparoscopic-surgery. Furthermore they illustrate the anesthesiologic protocol executed by themselves in videolaparoscopic cholecystectomy, and they describe results obtained following their anesthesiologic technique of the grounds of a retrospective study on 88 patients treated by videolaparoscopic cholecystectomy.

[Caudal anesthesia in proctological surgery]. / L'anestesia caudale in chirurgia proctologica.

The technique and advantages of caudal peridural anesthesia for proctology surgery are reported. The scarce invasivity of this methodology, the scarce or lack of interference with respiratory and cardiocirculatory functionality, the good analgesic effect postoperatively in our patients operated for proctology pathology, established the reason why we consider caudal analgesia particularly indicated for proctology surgery.

[Intestinal angiodysplasia: diagnosis and therapy]. / Angiodisplasia intestinale. Diagnosi e terapia.

On the basis of two personal cases of angiodysplasia authors describe this rare pathology and its relative diagnostic difficulties. On the grounds of their experience and the international literature on this pathology, authors considered the angiography as the selected method for the diagnosis of intestinal angiodysplasia, and they consider surgical therapy as the best curative method for this pathology.

[Malignant schwannoma of the omentum. Considerations in a clinical case]. / Schwannoma maligno omentale. Considerazioni su un caso clinico.

Authors describe a rare case of malignant schwannoma of the omentum. The diagnosis of schwannomas is often late because of the absence of early clinical signs. Clinical, diagnostic and histopathological considerations of these neoplasias are described in this work.

[Malignant neoplasms of the male breast. Our clinical contribution]. / Le neoplasie maligne della mammella maschile. Nostro contributo clinico.

A survey of literature data on male breast cancer is reported: on this basis the authors report their experience of five cases observed between 1980 and 1989 at Ospedale "S. Corona" Pietra Ligure, out of 500 female breast cancers treated in the same period. Epidemiological data and follow-up records are analysed, reporting survival rate similar to that of larger series.

[Mechanical obstruction of the small intestine due to phytobezoars]. / Occlusione meccanica dell'intestino tenue da fitobezoari.

The authors report 3 cases of small bowel obstruction due to phytobezoar, and they describe various aetiological factors of this pathology. The surgical treatment of choice is the removal of phytobezoar by enterotomy. Particularly important is the intraoperative exploration of gastrointestinal tract to localize other phytobezoars.

[Nuclear DNA content in tumors of the colon and rectum. Relationship between ploidy and site of the neoplasm]. / Contenuto nucleare di DNA nei tumori del colon-retto. Rapporto tra ploidia e sede della neoplasia.

The DNA distribution pattern was determined 30 colo-rectal carcinomas. The DNA content in individual cells was measured according to a cytophotometric method based on light transmission measurement of Feulgen-stained nuclei. The DNA non diploid carcinomas were significantly more common from the left (descending and sigmoid) colon and rectum (P = 0.0002). No relationship existed between DNA pattern and age, sex, Dukes' stage, tumor grade.

[Selection criteria of mobile lifters in the hospital setting]. / Criteri per la selezione di sollevatori mobili in ambito ospedaliero.

The manual handling of patients with limited mobility represents the major cause of musculoskeletal injury to the spine in paramedical health care workers. Within the hospital, the more complex procedures of patient transfer often require the use of mobile hoists. The aim of this paper is to describe the basic criteria for the selection of such hoists. The main characteristics of a hoist are its stability, the sling attachment, the speed of operation, range of movement of the spreader bar, safety of the operation being performed, patient comfort, the physical effort required on the part of the health care worker, manoeuvrability and simplicity of use. Important organizational-structural features to evaluate include: the type of patient normally present in the unit concerned, the specific movement to be performed, the structural characteristics of the environment, and the work organization of the personnel.

[The reliability of the grading assessment of the biopsy samples in malignant colorectal neoplasms]. / Attendibilità della valutazione del grading sui prelievi bioptici per le neoplasie maligne colo-rettali.

The authors evaluate the results of preoperative bioptic grading compared with those obtained from postoperative specimens. Altogether, there was nonagreement in 45% of cases; therefore there is the risk of underestimating the biological aggressiveness of the disease. In fact, 68% of patients who were assessed as G1 in preoperative staging were found to have a higher degree of neoplastic dedifferentiation.

Bibliometric indicators: a snapshot of the scientific productivity of leading European PRM researchers.

AIM: The aim of this paper was to explore the validity and practical usefulness of a set of bibliometric indicators with a focus on the scientific production of influential European researchers in Physical and Rehabilitation Medicine (PRM). METHODS: We randomly selected 24 European PRM specialists from the list of invited lecturers or chairpersons at the 17th ESPRM Congress in 2010. Using the time window 1996-2010, we recorded the number of papers published, total number of citations, and h-index from Web of Science (WoS) and Publish or Perish (PoP) databases. We also noted the journals in which the papers were published. Ranking the 24 authors into two groups according to higher vs. lower research productivity, we compared the frequency of Editorial Board membership of at least one of the 5 most influential journals in PRM. RESULTS: Median values (WoS, PoP) for papers, citations, and h-index were respectively: (31, 46); (171, 317); and (6.5, 8.5). High correlations were found among different indicators, and also between the same indicators calculated in the two different databases. However, the Bland-Altman plot indicated that the two databases could not be considered interchangeable. Twelve PRM specialists were Editorial Board members: 11 of them were in the first 10 ranking positions for at least one of the 6 indicators analysed. CONCLUSION: There is need to better understand the characteristics of bibliometric indicators and we retain that the information they provide is insufficiently valid to justify their use as the sole objective criterion for career assessment.

Hyperhidrosis treatment with bornaprine in the acute phase of spinal cord-injured patients.

STUDY DESIGN: Original article. OBJECTIVE: To test the use of bornaprine in the hyperhidrosis treatment in the acute phase of spinal cord-injured patients. SETTING: Patients with acute spinal cord lesions in the Spinal Unit of Pietra Ligure, Savona, Italy. METHOD: In 4 years, 12 patients have been treated, for a maximum period of 75 days, with dosages ranging from 2 to 4 mg day(-1). RESULTS: All of them reported long-lasting subjective benefits, without side effects, even after the interruption of the therapy. CONCLUSION: The bornaprine treatment, at 2 or 4 mg day(-1) dosage, has been effective and safe to contrast hyperhidrosis, in the acute phase of spinal cord-injured patients. This positive experience would require additional trials and a larger number of cases to gain a more solid support.