Performance of the CLS Spotorno uncemented stem in the third decade after implantation.

In 2012 we reviewed a consecutive series of 92 uncemented THRs performed between 1986 and 1991 at our institution using the CLS Spotorno stem, in order to assess clinical outcome and radiographic data at a minimum of 21 years. The series comprised 92 patients with a mean age at surgery of 59.6 years (39 to 77) (M:F 43;49). At the time of this review, seven (7.6%) patients had died and two (2.2%) were lost to follow-up. The 23-year Kaplan-Meier survival rates were 91.5% (95% confidence intervals (CI) 85.4% to 97.6%; 55 hips at risk) and 80.3% (95% CI, 71.8% to 88.7%; 48 hips at risk) respectively, with revision of the femoral stem or of any component as endpoints. At the time of this review, 76 patients without stem revision were assessed clinically and radiologically (mean follow-up 24.0 years (21.5 to 26.5)). For the 76 unrevised hips the mean Harris hip score was 87.1 (65 to 97). Femoral osteolysis was detected in five hips (6.6%) only in Gruen zone 7. Undersized stems were at higher risk of revision owing to aseptic loosening (p = 0.0003). Patients implanted with the stem in a varus position were at higher risk of femoral cortical hypertrophy and thigh pain (p = 0.0006 and p = 0.0007, respectively). In our study, survival, clinical outcome and radiographic data remained excellent in the third decade after implantation. Nonetheless, undersized stems were at higher risk of revision owing to aseptic loosening.

Modification of the lipidic and coagulative pattern in postmenopause women: effect of hormone replacement therapy.

AIM: We evaluated the changes of lipidic and coagulative pattern during menopause and the influence of hormone replacement therapy (HRT) on these parameters. METHODS: We considered 158 patients divided into 2 groups: Group I consisted of 127 women in physiological/surgical menopause and Group II of 31 women with childbearing potential. Subsequently, we considered a group III formed of 34 patients from menopausal women (group I) who underwent three months of HRT. We evaluated total-cholesterol (TC), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), triglycerides (TG), lipoprotein (a) (Lpa), fibrinogen, antithrombin III (ATIII), factor VII (FVII) and tissue factor pathway inhibitor (TFPI). RESULTS: We found a worse lipid profile in the post-menopausal group compared to controls (TC 243.8+/-29.7 vs 217.9+/-32.7 mg%, P=0.002; TG 121.5+/-68.4 vs 88.6+/-53.0 mg%, P=0.039; LDL-C 163.0+/-27.9 vs 136.2+/-29.6 mg%, P=0.004; HDL-C 60.9+/-14.9 vs 64.1+/-14.6 mg%, P=ns). With regard to the coagulative pattern, fibrinogen was significantly higher in the post-menopausal group (fibrinogen: 273.3+/-67.4 vs 243.8+/-39.5 mg%, P=0.013; ATIII 112.2+/-11.7 vs 117.5+/-12.7% %, P=0.059; FVII 121.6+/-11.3 vs 117.6+/-10.8 mg%, P=ns; TFPI activity 2.5+/-2.3 vs 2.1+/-1.1 U/mL, P=ns; TFPI antigen 120+/-38 vs 127+/-39 U/mL, P=ns). Comparing the same parameters, before and after three months of HRT, in patients of Group III we observed a significant improvement of TC and TG levels (TC from 232.3+/-42.7 to 215.2+/-37.6 mg%, P=0.0001; TG from 103.7+/-56.8 to 95.0+/-44.3 mg%, P=0.059; HDL-C from 62.3+/-12.9 to 63.6+/-12.6 mg%, P=ns; LDL-C from 149.3+/-38.7 to 132.6+/-34.5 mg%, P=0.0001). The following changes were observed with regard to coagulative parameters: fibrinogen from 270.9+/-69.4 to 253.2+/-56.2 mg%, P=0.07; ATIII from 113.5+/-11.4 to 110.8+/-13.2 mg%, P=0.198; FVII from 108.6+/-18.0 to 104.4+/-17.5 mg%, 0.014. TFPI activity from 2.6+/-2.3 to 2.3+/-1.4 U/ml, P=ns; TFPI antigen from 68+/-13 to 87+/-22 U/mL, P=0.001. CONCLUSION: Our data confirm the presence of an alteration in lipidic and coagulative pattern in post menopausal women and positive changes after HRT.

Insulin resistance and acute coronary syndrome.

BACKGROUND: Insulin resistance (IR), which can be quantified by HOMA index (fasting glucose X fasting insulin/22.5), is considered the "primum movens" for the development of Metabolic Syndrome. Many authors have suggested that insulin resistance could raise both incidence and mortality of coronary heart disease (CHD). IR is also associated with important predictors of cardiovascular disease, as increased concentration of LDL or triglyceride, decreased concentration of HDL, high systolic blood pressure, visceral obesity. There is accumulating evidence that chronic sub-clinical inflammation, as measured by inflammatory markers as C-reactive protein (CRP) and fibrinogen, is related with insulin resistance. AIM OF THE STUDY: To clarify if insulin resistance would predict cardiovascular disease independently of the other risk factors, such as hypertension, visceral obesity or dyslipidemia, by focusing our attention on the relation between Acute Coronary Syndrome (ACS) and high HOMA index. METHODS: We evaluated glucose and insulin levels at baseline and post-prandial phase, in order to estimate HOMA index in both the conditions; we related the data obtained with the incidence of cardiovascular events, also investigating traditional cardiovascular risk factors. The cohort included 118 patients with a clinical diagnosis of ACS and excluded those with type 1 diabetes, acute inflammatory diseases, hepatic or renal failure, disreactive disorders, autoimmunity and cancer. SUBJECTS: Subjects were followed-up for a period of 1 year, being subdivided in three groups: (1) subjects at elevated HOMA (HOMA > or = 6); (2) subjects at intermediate HOMA (HOMA <6 and > or = 2); (3) subjects at low HOMA (HOMA < or = 2). We considered as end points new cardiovascular events, cerebrovascular events (both TIA and stroke), procedures of revascularization with angioplasty or surgery, cardiovascular death, sudden death. RESULTS: Patients with elevated HOMA have a higher incidence of previous cardio- and cerebrovascular events (p=0.03), myocardial infarction without ST elevation (p=0.005), unstable angina (p=0.01), asymptomatic carotid plaques (p=0.05), depressed systolic function (p=0.05); we found, also, a significant statistic correlation between HOMA index and high levels of CRP, fibrinogen, serum creatinine and TnI. Cardiovascular and cerebrovascular events were registered in 61% of patients with elevated HOMA during the follow up, despite of 25% registered in the control group: so we could consider HOMA index as a negative prognostic variable, also in virtue by the statistic correlation with the inflammatory markers, whose power of prediction is already known. CONCLUSIONS: Beyond traditional cardiovascular risk factors, insulin resistance quantified by HOMA index seems to significantly have an important prognostic role, both in primary and secondary prevention in patients with Acute Coronary Syndrome.

Short term prognostic role of NT-proBNP in patients after myocardial infarction.

AIM: The clinical and prognostic role of cardiac natriuretic peptides (CNP) in patients with heart failure is well known; recently, several studies have evaluated the possibility of using CNP to evaluate their potential prognostic role in patients with acute coronary syndromes (ACS). The aim of this study was to evaluate the short term prognostic value of NT-proBNP in 70 patients admitted for ACS. METHODS: The authors studied 70 patients with ACS, evaluating, at admission, clinical-anamnestic, instrumental and laboratory characteristics including NT-proBNP plasma levels. Patients were monitored in a 6-month-follow-up to record adverse fatal events and their possible correlation with baseline characteristics. RESULTS: The incidence of adverse events during the follow-up period was 28% (10 patients). In patients with adverse events, the authors observed lower left ventricle ejection fraction (P=0.01), higher prevalence of ST elevation myocardial infarction (P=0.03) and higher NT-proBNP levels (P=0.03), compared to those without adverse events. Moreover, the logistic regression analysis underlined how ST elevation myocardial infarction (P=0.05) and higher NT-proBNP levels (P=0.05) were the only predictive variables for adverse events during the follow up period. CONCLUSIONS: This study demonstrates the short term prognostic role of NT-pro BNP in patients admitted for ACS.

Motion Index: a new parameter to evaluate the diastole by M-Mode imaging.

AIM: Heart failure with normal left ventricle (LV) ejection fraction is commonly understood as diastolic heart failure because this expression implies the presence of LV diastolic dysfunction diagnosed by specific echocardiographic findings, such as slow LV relaxation and increased LV stiffness. In this work the authors propose a new parameter named Motion Index, which is measurable by M-Mode technique and it is likely linked to diastolic dysfunction. METHODS: A patient population composed by 134 subjects was enrolled. They all were in New York Heart Association (NYHA) functional class II. Echocardiogram carried out in all patients allowed the authors to distinguish 2 patient arms depending on the presence or absence of diastolic dysfunction, evaluated by flow Doppler and tissue Doppler. RESULTS: After carrying out every echocardiographic examination, the authors also measured the new parameter that called Motion Index, and found that it had an average value of 46 in patients with normal diastolic function and 33.5 in patients with diastolic dysfunction. This parameter did not depend on systolic dysfunction. CONCLUSIONS: Data obtained showed a statistically significant correlation between Motion Index and means of diastolic function assessed by both flow and tissue Doppler.

The long QT syndrome in pediatric age: prognosis and risk factor.

AIM: Long QT syndrome is a rare arrhythmic disease with a low incidence in the general population. There are no sure clinical or electrocardiographic parameters that could lead to a correct prognostic stratification in patients affected by this syndrome. The correlation between the incidence of a sudden death or dangerous ventricular arrhythmias and the duration of QTc interval is still a controversial topic. METHODS: Twenty nine children affected by QT long syndrome were admitted to the Division of Pediatric Cardiology of the Casa del Sole Hospital of Palermo (Italy). Their diagnosis was made by electrocardiogram (ECG). The average age of the patients was 7.6 years. The average follow-up was 4 years and three months. A therapy with beta-blocker was administered to all the children. During the follow-up of 4 year and three months, patients were genotyped. Twenty-three out of 29 children had at least one relative affected by the syndrome. Three of them had a familiar dead because of this syndrome and everyone had a duration of maximum QTc higher than the cut off (P=0.0002). All the people who died had not followed the therapy with beta-blocker. Patients with a maximum QTc recorded <500 had not familiar death by this syndrome. RESULTS: Holter and echocardiogram recorded periodically during the observation did not show dangerous arrhythmic events. All children maintained a good health during the follow-up. CONCLUSION: Although conducted on a small study population, the data analysis recorded during this study suggests that in patients affected by QT long syndrome younger than 16 years old undergoing a beta-blocker therapy the prognosis is excellent. The duration of QTc interval appears as a negative prognostic factor, although the beta-blocker therapy has been reduced considerably the incidence of sudden death.

[Treatment of serious hepatic lacerations with Ton That Tung's technique]. / Trattamento delle gravi lacerazioni epatiche secondo la tecnica di Ton That Tung.

BACKGROUND: Serious hepatic lacerations are associated with an elevated mortality which depends on the consequent haemorrhage. The hepatic resection in emergency, according to Ton That Tung, seems to be the more appropriate operation for the rapidity of execution and the low mortality associated (11% out of 1000 operations). METHOD: According to Ton That Tung' technique, 12 operations of hepatic lobe and segment resections were executed after trauma caused by road accidents, firearm lesions, sidearm lesions and bleeding neoplasms. RESULTS: Among 12 patients operated on, 9 healed (75%) and 3 died (25%). CONCLUSIONS: The high mortality in the hepatic resections depends on the technique used. The anatomic resection, according to Bismuth, has an operative time longer than the time described by Ton That Tung, time that in emergency is important because the mortality depends not only from the blood lost, but, also the time in which the blood is lost. Hepatic resection according to Ton That Tung is the gold standard for the treatment of serious lacerations and hepatic bleeding neoplasms.

[Fetal malformations diagnosed using ultrasonography during tri-test. A retrospective study of 1633 fetuses]. / Malformazioni fetali diagnosticate all'esame ultrasuonografico durante l'esecuzione del tri-test. Studio retrospettivo su 1,633 feti.

BACKGROUND: To find out which fetal malformations are diagnosed during the tri-test. METHODS: A total of 1633 pregnant women were enrolled in the study and underwent biochemical screening for Down s syndrome and DTN at the Outpatient Clinic for Prenatal Diagnosis of Santo Bambino Hospital in Catania between January 1997 and December 1998. Scans were performed using a TA route in all cases and mainly during the 16th week. RESULTS: 21 abnormal fetuses were diagnosed, equal to 1 out of 77 fetuses (3 cases of isolated DTN; 1 case of cyst in the posterior cranial fossa associated with complex heart malformation; 6 cases of cyst of the choroid plexus; 2 cases of bone dysplasia; 2 cases of cardiopathy; 4 cases of non-immunological fetal hydrops; 1 case of hygroma). In 8 out of 21 abnormal fetuses the tri-test was positive for DNT and SD or atypical. One case of trisomy 18 and 1 case of mosaicism were diagnosed. CONCLUSIONS: A fetal abnormality was diagnosed in one out of 77 fetuses. This finding, although it underestimates the real frequency of these anomalies (retrospective study, selected sample, non optimal period for the diagnosis of fetal malformations, non-systematic study of 4 chambers), once again underlines the importance of a careful morphological evaluation in eyery scan carried out. In our study some malformations were not diagnosed previously because this was the first scan (1 case of anencephaly), or because the abnormality was presumably not present in earlier tests (bone dysplasia at early stage of pregnancy) or because the earlier test was inadequate (2 DTN tested after the 12th week). In some cases it is also possible to diagnose images, such as transient hygromas which indicate a group of patients with a risk of chromosome pathology. Since they are transient, these lesions are only found if the test is performed at a period of pregnancy before the optimal moment for the tri-test. In personal experience the execution of biochemical screening for Down s syndrome and DTN should always be associated with a scan not only to date the pregnancy, but also because it is not infrequent to diagnose malformations.

[The hemorrhagic complication of peptic ulcer]. / Complicanza emorragica dell'ulcera peptica.

The hemorrhagic complication of peptic ulcer is a pathology which is still responsible for a high mortality. After reviewing the etiopathogenesis and physiopathology of hemorrhagic complications in the light of the recent discoveries regarding H. pylori, the authors report their experience and confirm the important role of surgery in the treatment of this pathology. Resolution is improved by the use of surgical staplers which are regarded as particularly valuable in emergency surgery where the need to cut operating times has undoubted advantages in terms of patient survival.

[Mirizzi syndrome]. / La sindrome di Mirizzi.

Mirizzi's syndrome is a rare, but well described cause of obstructive jaundice which occurs in less than 1% of patients presenting for cholecystectomy. The syndrome is due to a stone impacted in the cystic duct or in the neck of gallbladder, causing compression or obstruction of the common emphatic duct. The clinic, physiopathologic, diagnostic and therapeutic aspects of this disease are described. The patient observed, arrived in emergency with obstructive jaundice and hyperpyrexia. Echography showed a remarkable dilatation of the biliary ducts, whereas endoscopic retrograde cholangiography (ERCP) showed an obstruction of the hepatic common duct of undefinable nature (stone, neoplasia). The surgical operation performed in emergency made clear the diagnostic doubt. Since inflammation impacted biliary duct and gallbladder, an incision of the gallbladder at its fundus was performed. In this way it was possible to extract about 40 stones of dimensions less than 1 cm, and one of 3 x 1 cm, impacted in the cystic duct, compressing the common hepatic duct. A partial cholecystectomy was performed and no connection between gallbladder and common emphatic duct (fistula) was found. The surgical operation led to complete resolution of the symptomatology. Therefore, the conclusions is drawn that Mirizzi's syndrome a rare but non infrequent pathology, finds its definition and complete resolution with surgical operation. Mirizzi's syndrome or obstructive jaundice due to extrinsic compression of principal biliary duct by a stone impacted in the cystic duct, is an uncommon complication of cholecystic lithiasis. Although this syndrome is rare (1%), it causes obstructive jaundice, sometimes dangerous, and serious complications as recurrent cholangitis.