Improving diagnosis of early inflammatory arthritis : results of a novel triage system.

OBJECTIVES: Early treatment of inflammatory arthritis (IA) leads to reduced disease activity, reduced joint damage, decreased functional impairment and increased chance of remission. However, delay often occurs from referral to rheumatology appointment. This survey evaluated whether a preliminary triage carried out by healthcare workers without formal medical training could be effective in identifying patients with or without early IA. METHODS: Patients were recruited during their first call to our centre, before their first visit. A simple questionnaire, including three questions and aimed at investigating the presence of sign and symptoms of IA was developed. The same survey was administered twice: the first time, during patient's first call to our centre (telephone survey), and the second time, during their first visit with the rheumatologist (Ambulatory visit survey). We compared the outcomes of the survey with the actual diagnosis made by the rheumatologist following standard medical examination. RESULTS: In total 484 patients were included in the study, and 34/484 (7.02%) were confirmed to have early IA. The telephone survey was able to detect the non-early IA patients in 99.5% of cases; the same result was reported for the ambulatory visit survey. The median time required to complete the questionnaire was 1 minute in both surveys. CONCLUSIONS: The adoption of a simple survey, also administered by non-medical personnel, may effectively contribute to the early detection of IA.

Comparison between two different reconstruction techniques after pancreatic head resection. Technical feasibility and clinical benefits.

BACKGROUND: The study aim was to evaluate if diverting drainage of bile and pancreatic secretions with an isolated Roux loop technique helps to decrease the rate of postoperative morbidity and mortality, in particular postoperative pancreatic fistula (POPF). METHODS: A prospectively maintained database between 2006 and 2018 was reviewed. Patients who underwent primary elective pancreaticoduodenectomy were included. Two types of reconstruction methods were compared: single loop (SJL) reconstruction (28 patients) and isolated Roux-en-Y (DJL) reconstruction (36 patients). Demographic characteristics and perioperative results were compared between the two groups. RESULTS: This study includes 64 patients. The average duration of surgery was 308 mins; it was longer for DJL (P<0.0001). Major postoperative complications were seen in 24 patients (9 in SJL; 15 in DJL) without statistically significant difference. The most frequent complication that occurred was PJ anastomosis failure (4 in SJL; 6 in DJL). The choice of postoperative complication management was not related to surgical reconstruction technique (P=0.389). Length of hospital stay in DJL was significantly longer than in SJL (P=0.04). CONCLUSIONS: No significant advantage of one technique over the other was found. In our opinion, surgeons should choose the approach with which they have the most experience and ease.

Effectiveness and Tolerability of Repeated Courses of Viscosupplementation in Symptomatic Hip Osteoarthritis: A Retrospective Observational Cohort Study of High Molecular Weight vs. Medium Molecular Weight Hyaluronic Acid vs. No Viscosupplementation.

Background: Nonsurgical management of symptomatic hip osteoarthritis needs real-world evidence. We evaluated the effectiveness and tolerability of US-guided intra-articular treatment of two hyaluronic acids (HAs) commercially available in Italy and investigated predictors of response. Methods: Outpatient records including three cohorts: 122 subjects treated with medium (1,500-3,200 kDa; Hyalubrix®) molecular weight (MW) or high (hylan G-F20; Synvisc®) MW HAs and 20 controls taking NSAIDs/analgesics on demand were retrospectively analyzed. Pain VAS score, WOMAC, NSAID/analgesic consumption, and causes of suspension were available at 1, 6, 12, and 24 months after first administration. As selection bias usually affects observational retrospective studies, a quasi-randomization process was attained by performing propensity score approach. Results: Propensity score adjustment successfully allowed comparisons among balanced groups of treatments. VAS and WOMAC considerably decreased over time in treated groups independently of the radiological grade (p<0.001). On the other hand, the control group showed only a slight and rather uneven variation in VAS. Mean score changes were comparable in both HA cohorts from the earliest stages (ΔVAS(HA1,500-3,200kDa)T1vsT0 = -20%; ΔVAS(hylan G-F20)T1vsT0 = -23%/ΔWOMAC(HA1,500-3,200kDa)T1vsT0 = -17%; ΔWOMAC(hylan G-F20)T1vsT0 = -19%), reaching a further substantial reduction after 12 months (ΔVAS(HA1,500-3,200kDa)T12vsT0 = -52%; ΔVAS(hylan G-F20)T12vsT0 = -53%/ΔWOMAC(HA1,500-3,200kDa)T12vsT0 = -45%; and ΔWOMAC(hylan G-F20)T12vsT0 = -47%). Almost 11% (=13/122) of ineffectiveness and few moderate local side effects 3% (=4/122) were detected. Conclusions: Viscosupplementation in a real-life setting seems to provide a sound alternative in pain management in comparison to oral NSAIDs/analgesics, guaranteeing a reduced intake of pain killer medications. Analgesic effectiveness, functional recovery, and reduced joint stiffness extend and improve over 12 and 24 months, suggesting that repeated administrations achieve an additive effect.

[F.A.S.T. Ultrasound for emergency surgeon]. / Ecografia FAST per il chirurgo di pronto soccorso.

INTRODUCTION: FA.S. T (Focused Assessment with Sonography for Trauma) is an ultrasound investigation that can discover presence of peritoneal fluid. The availability of an investigation that can be used directly at the patient bed optimizes the Emergency Room Service. The learning curve is short and all doctors working in Emergency Room can use it. AIM OF THE STUDY: End point of the study was to evaluate the applicability of fast to our hospital, to study it's efficacy when compared to other investigations and to produce a flow chart for patients with abdominal trauma. MATERIAL AND METHODS: From July 2002 we evaluate 400 consecutive patients with medium - high grade abdominal trauma. After ATLS we investigate the patient with FAST Ultrasound. Patients with indication to immediate laparotomy (ATLS Flow Chart) where evaluated only with FAST and send to the operating theatre. All others patients follows the normal abdomial trauma flow chart as in use in our Emergency Room. RESULTS: We performed 2 immediate laparotomy (0.5%) and 8 (2%) after the results of investigations. In group of immediately laparotomy FAST ultrasound confirmed the presence of haemoperitoneum (Sensibility and Specificity of 100%). In the other group (not immediately laparotomy) in 6 over 8 cases FAST Ultrasiound was in accord with other conventional radiological investigations (Sensibility 75%, Specificity 100%). In 2 over 8 patients only TC permitted to evidence intrabdominal damage not seen by FAST (MesoColon Haemathom and Gastric Rupture). CONCLUSIONS: FAST ultrasound resulted an effective and reliable investigation to evidence abdominal fluid when compared with other radiological investigations. We hope this tipe of investigation will be adopted in all Emergency Room.

[Post-traumatic acute appendicitis. A case report]. / Appendicite acuta post traumatica. Descrizione di un caso.

Acute appendicitis is a frequent abdominal pathology, more frequent in the childhood. The pathophysiology of acute appendicitis is obstruction of the appendix lumen and distension due to continued mucosal secretion. The second step is a rapid multiplication of resident bacteria, excretion of toxine and wall inflammation. Causes of this processes are different: in most of cases there is an hyperplasia of intrinsic lymphoid tissue (60%) or hard stool. Another cause may be foreign body. But is there a relationship between abdominal trauma and appendicitis?

Gastric outlet obstruction due to inflammatory fibroid polyp.

INTRODUCTION: Inflammatory fibroid polyp (IFP) is a rare mesenchymal tumor of the gastrointestinal tract. The lesion is characterized by spindle-shaped stromal cells and an inflammatory infiltrate rich in eosinophils. CASE REPORT: The AA. present a case of the IFP of the stomach. A 85-year-old woman was admitted to the hospital for early vomiting and epigastric pain. The patient underwent a gastroduodenoscopy that revealed a polypoid lesion mimicking cancer of the antrum and subtotal obstruction of the gastric transit. CONCLUSIONS: The Endoscopic Ultrasound Sonography suggested the presence of a lesion of the submucosal layer such as lymphoma or other type of malignancy like gastrointestinal stromal tumor (G.I.S.T).

Plasma cholecystokinin levels after vertical banded gastroplasty: effects of an acidified meal.

BACKGROUND: Although cholecystokinin (CCK) is involved in the short-term regulation of satiety, it has not been investigated in obese patients subjected to bariatric restrictive operations. METHODS: 8 morbidly obese patients (BMI 49.1 +/- 6.9), 7F and 1M, were investigated before and after vertical banded gastroplasty (VBG). 6 healthy lean volunteers served as the control group. CCK was determined (RIA) after an overnight fast and after the administration of an acidified (pH 3) liquid meal. Blood samples were taken 45 min before the meal, 5 min after it and then every 30 min for 3 hours. RESULTS: There were no differences between groups in basal CCK levels. However, the peak of CCK after the meal was significantly higher (P <0.01) in obese patients after VBG (24.9 +/- 18 pmol/l) than before VBG (9.8 +/- 6.7 pmol/l) and when compared with the control group (8.0 +/- 6.3 pmol/l). The time needed to reach the peak was longer in healthy volunteers (105 +/- 24.9 min) than in obese patients before VBG (45 +/- 40 min) and after VBG (7.5+/- 12 min) (P<0.01). CONCLUSIONS: VBG increases the peak of CCK secretion and shortens the time to reach it. These changes could contribute to the satiety effects of gastric restrictive operations.

Plasma leptin levels after vertical banded gastroplasty for morbid obesity: effects of an acidified meal.

BACKGROUND: Leptin is considered one of the anorectic messengers to the central nervous system in lean subjects. Although it is secreted by the gastric mucosa, there are contradictory evidences of its involvement in mediating the acute satiety effect of the meal in obese patients. The effects of restrictive operations on meal-stimulated leptin secretion are unknown. METHODS: The effects of a standard acidified (pH 3) meal on leptin release were investigated in obese patients, before and after vertical banded gastroplasty (VBG). 8 morbidly obese patients (BMI 49.1+/-6.5) had serum leptin determination after an overnight fast. Samples were taken basally and every 30 minutes after the meal for 3 hours. The test was repeated after 20% BMI reduction. 5 lean volunteers (BMI 22.5+/-1.7) served as the control group. RESULTS: In obese patients, basal serum leptin fell from 62+/-20.4 to 23.8+/-15.7 ng/ml after the operation (P <0.01) but still with significant differences vs the control group (5.6+/-3 ng/ml). The meal was associated with a significant decrease of serum leptin (ANOVA test, P <0.01), and significant differences between obese patients after surgery and lean subjects were found. CONCLUSION: Serum leptin was reduced by the meal in obese patients and VBG did not attain satiety through serum leptin changes.