Difference between forensic patients with schizophrenia spectrum disorders in Italy and other European countries: Results of the EU-VIORMED project.

BACKGROUND: There has been a substantial change in the law on the provision of secure health services for offender-patients in Italy, a country currently with the lowest general psychiatry bed availability per head of the population in Europe, raising questions about possible differences in offender-patient admissions between European countries. AIMS: In this multicentre case-control study, our aim was to compare the socio-demographic, clinical and criminological characteristics of a sample of Italian forensic in-patients with schizophrenia or similar psychosis with patients in a similar diagnostic range in specialist in-patient services elsewhere in Europe. METHODS: Secure hospital unit in-patients with psychosis were recruited across five European countries (Italy, Austria, Germany, Poland and England). Consenting patients were interviewed by researchers and assessed using a multidimensional standardised process. Within country similarities between Austria, Germany, Poland and England were confirmed. RESULTS: Overall, 39 Italian participants had had fewer years of education than the 182 patients in the other countries and were less likely to have ever had skilled or professional employment. The Italian patients had been older at first contact with any mental health services than the other Europeans. Diagnosed comorbidity rates were similar, but the Italian group reported higher levels of disability. Although the other European forensic patients were more likely to be undergoing treatment at the time of their index offence, they were also more likely to have been poorly compliant with treatment. The rate of suicide-related behaviours was significantly lower among the Italian patients than among the others. CONCLUSIONS: Notwithstanding similar diagnoses, important differences emerged between patients in Italian forensic mental health resident services and those in four other European countries, some possibly reflecting less access to earlier relevant services in Italy. Others, including lower disability ratings among the Italian patients and a lower rate of suicide-related behaviours, may indicate that the Italian reforms carry benefits. This is worthy of further evaluation.

Chronic Achilles Tendon Rupture Treated with Allograft: A Case Report.

In clinical practice, chronic Achilles tendon ruptures are uncommon. Usually, these lesions are discovered four to six weeks after injuries. More frequently, Achilles tendon ruptures are acute and treated with tendon sutures.1 Many surgical techniques are available to treat chronic lesions such as sutures or V-Y elongation with or without augments.2-3 Our case is about a chronic Achilles tendon rupture discovered two years after injury. Our patient came to our attention with a 6 cm tendon gap. We performed tendon repair with cadaver allograft. After four years of follow-up, our patient has a complete functional recovery and he can normally perform daily and working tasks without pain.

Percutaneous Hallux Valgus Correction: Modified Reverdin-Isham Osteotomy, Preliminary Results.

BACKGROUND: Hallux valgus (HV) is a metatarsophalangeal joint deformity that can be classified as mild, moderate, or severe. Treatment is recommended for pain or severe deformities. Recently, operative percutaneous correction techniques have been performed to treat mild deformities. MATERIALS AND METHODS: A retrospective, single-surgeon, single-center study of 49 HV percutaneous correction using a modified Reverdin-Isham osteotomy was conducted. HV, intermetatarsal angle (IM), proximal articular set angles (PASA), and American foot and ankle functional score (AOFAS) were assessed pre- and postoperatively by a single operator. Statistical analysis was performed using a Wilcoxon rank test. Medium time of follow-up was 34 months. RESULTS: HV mean value decreased from a preoperative medium value of 35.18° to 14.3° postoperatively, IM mean value decreased from 15.5° to 8.7°, and PASA from 7.2° to 5.25°(p<0.001 for HV and IM, p<0.125 for PASA reduction). Postoperatively AOFAS medium score was 95. DISCUSSION: In our series, functional and clinical results of percutaneous osteotomy without osteosynthesis were comparable to other percutaneous and conventional techniques, both in clinical and radiological findings. High level of patient's satisfaction and improvement on pain-related symptoms are even better referred to traditional techniques. Modified Reverdin-Isham osteotomy technique differs from the others for translation of metatarsal head after osteotomy; we do not correct PASA angles, but we can obtain more HV and IM correction and include some severe HV. Our results suggest that translation of metatarsal head could give higher HV angle correction.

Peroneal Tubercle Hypertrophy: A Case Report.

The peroneal tubercle is an osseous prominence present on the calcaneus bone at the junction between the middle and the anterior third of its lateral surface. It is a bony septum which divides the tendons of the peroneus brevis and the peroneus longus and offers insertion to the inferior peroneal retinaculum. A hypertrophy of this prominence causes pain in the lateral and the posterior part of the foot while wearing shoes, rarely peroneal tenosynovitis can even cause it to break. In the following pages, we will describe a case of peroneal tubercle hypertrophy, visible even at clinical examination, in a 26-year-old male patient without apparent causes nor previous trauma.

RISK aversion in Italian forensic and non-forensic patients with schizophrenia spectrum disorders.

BACKGROUND: Goal-directed decision-making is a central component of the broader reward and motivation system, and requires the ability to dynamically integrate both positive and negative feedback from the environment in order to maximize rewards and minimize losses over time. Altered decision-making processes, in which individuals fail to consider the negative consequences of their decisions on both themselves and others, may play a role in driving antisocial behaviour. AIM: The main study aim was to investigate possible differences in loss and risk aversion across matched patients, all with a schizophrenia spectrum disorder (SSD), but who varied according to whether they had a history of serious interpersonal violence or not, and a sample of healthy controls with no history of violence. RESULTS: The sample included 14 forensic and 21 non-forensic patients with SSD, and 41 healthy controls. Among the three decision-making variables under investigation, risk aversion was the only significant predictor of membership of the three groups, with greater risk aversion among non-forensic patients with SSD compared to healthy controls. No differences were observed across groups in loss aversion and choice consistency. CONCLUSIONS: This evidence suggests a new potential treatment target for rehabilitative measures aimed at achieving functional improvements in patients with SSD by selectively leveraging the neuro-cognitive processing of reward.

Percutaneous Foot Surgery without Osteosynthesis in Hallux Valgus and Outcomes.

BACKGROUND: Several procedures and types of osteotomies have been described for hallux valgus (HV) correction. Percutaneous techniques may lead to an early regain of function reducing morbidity and recovery time. In this study, we aimed to evaluate the clinical and radiographic outcomes of percutaneous hallux valgus (HV) correction. METHODS: One hundred and twenty-four feet treated with the percutaneous technique between May 2011 and December 2015 were included in our study. All patients underwent resection of the medial metatarsal exostosis, complete first metatarsal distal osteotomy, adductor hallucis tendon release and Akin osteotomy of the proximal phalanx. Pre- and postoperative X-rays were clinically assessed. RESULTS: The mean hallux valgus angle (HVA) and the intermetatarsal angle (IMA) decreased significantly from the preoperative assessment to the final follow-up. The AOFAS score improved from a mean preoperative value of 70.2 to 93.8 at the final follow-up. CONCLUSION: Percutaneous complete distal osteotomy in hallux valgus correction is a safe, reliable and effective procedure for the correction of symptomatic mild hallux valgus. Nevertheless, it requires appropriate surgical experience and patient aftercare in order to achieve the best result.

First metatarsophalangeal fusion with dorsal plate: clinical outcomes.

BACKGROUND: First metatarsophalangeal joint (MTPJ) fusion is the most effective technique for the treatment of MTPJ primary arthritis, severe hallux valgus and failure of primary corrective surgery of these conditions. It can be achieved through different techniques. We evaluated the outcomes in a cohort of patients treated with dorsal plate arthrodesis. MATERIALS AND METHODS: We treated 30 feet for 28 patients; the mean follow-up was 35 months. For each foot, we collected radiological and clinical assessment, with the visual analogue scale (VAS) for pain and the Manchester and Oxford Foot questionnaire (MOFQ). The technique consisted in a cup and cone arthrodesis with the application of a low profile dorsal plate. Patients were allowed for immediate weight bearing. RESULTS: Consolidation was achieved in all cases; in 29 cases, radiographic union was recorded within 6 months from surgery, in one case after 9 months. Comparison between the preoperative and postoperative of VAS and MOXFQ values showed a statistically significant difference (p < 0.05). Only one case developed wound dehiscence as complication. CONCLUSIONS: Even if there is still a debate regarding the best system for MTPJ fusion, we believe cup and cone fusion with dorsal plating is an effective method. Moreover, the stability of the osteosynthesis obtained allows for immediate post-operative weight bearing, making patients able to return soon to their normal life. TRIAL REGISTRATION: We present a retrospective study; all patients enrolled were retrospectively registered.

What's the resolutive surgery for pseudo-ainhum in Vohwinkel syndrome? A case report and review of the literature.

Vohwinkel Syndrome, also known as Keratoderma Hereditarium Mutilans, is an extremely rare dominant autosomal keratosis. It typically presents with "starfish" keratoses on the knuckles, palmoplantar keratoderma (PPK), hearing impairment and mutilating digital constriction bands (pseudoainhum) that cause strangulation, often leading to autoamputation of the affected digit. Both medical and surgical treatment haven't shown to date consistent results, in the treatment of pseudoainhum. In this study we present the case of a woman with Vohwinkel syndrome who showed constriction bands causing ischemic changes of the 5th digit of the right hand for which she was treated with surgery. We also present a review of the literature for the management of this disease.

Sociodemographic, clinical and criminological characteristics of a sample of Italian Volterra REMS patients.

BACKGROUND: In Italy the Law 9/2012 prescribed the total closure of forensic psychiatric hospitals (OPGs) and the conversion to a care model based on residential units in the community employing only clinical personnel (Residenze per l'Esecuzione delle Misure di Sicurezza - REMS) and fully integrated in public mental health services. The aim of this study is to report sociodemographic, clinical and criminological characteristics of patients admitted in Volterra REMS since it opened on 01/12/15 up to 31/12/17. METHODS: Sociodemographic and clinical information was collected from official documents (clinical files, ward reports) and from patients' personal health records. Psychiatric diagnoses were made by REMS psychiatrists according to the DSM-5 criteria. Criminological information was obtained from patients' criminal records. RESULTS: Volterra REMS patients' characteristics are similar to those of samples of OPGs patients (unmarried socially disadvantaged males with an average age of 40, no offsprings, low education, high rates of Schizophrenia Spectrum Disorders and medical comorbidity). However, the REMS model presents a very high turnover rate: during the study period 61 patients were admitted while 32 were discharged. Being assisted by public mental health services before committing the crime increased the probability of discharge. In non-EU patients long acting injectable antipsychotics were used more frequently than in community ones. Substance-Related Disorders are the main psychiatric comorbidity and resulted as being more frequent in bipolar patients than in other patients. CONCLUSIONS: Due to the high patients' turnover, we expect a progressive change in sociodemographic, clinical and criminological features of the REMS population. The REMS model provides a return for mentally disordered criminals to the care of local public mental health services which are recovering after many years some of their most challenging patients ensuring their deinstitutionalization and reintegration into society.