Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations.

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

Anatomy, pathophysiology and classification of posterior tibial tendon dysfunction.

OBJECTIVE: Adult acquired flatfoot deformity is generally associated with a collapsing medial longitudinal arch and a progressive loss of strength of the posterior tibial tendon (PTT). This condition is commonly associated with PTT dysfunction or rupture, which can have an arthritic or a traumatic etiology. Several causes have been proposed to explain the clinical evidence of tendon degeneration observed at the time of surgery including trauma, anatomical, mechanical, inflammatory and ischemic factors. MATERIALS AND METHODS: In this review, we analyzed anatomy, pathophysiology and existing classifications of posterior tibial tendon dysfunction. RESULTS: Anatomical features, and in particular vascularization, expose PTT to major degenerative disorders until rupture. A literature overview showed that a low blood supply of the gliding part of the tendon is linked to a dysfunction and/or a rupture of the PTT in the region located behind the medial malleolus. CONCLUSIONS: PTT low blood supply causes a dysfunction resulting in an abnormal loading of the foot's medial structures. This may be the reason why PTT dysfunction leads to an acquired flatfoot deformity. Conversely, flatfoot deformity may be a predisposing factor for the onset of PTT dysfunction.

The effect of hydroxyapatite coated screw in the lateral fragility fractures of the femur. A prospective randomized clinical study.

Due to a growing numbers of lateral fragility fractures of the femur and their high social costs the need to work out an effective strategy in order to find a better solution for these patients is warranted. From January 2010 to July 2011, we carried out a prospective randomized clinical study comparing the results of patients with femoral lateral fractures treated by nail and cephalic hydroxyapatite coated screws (study group including 27 patients) compared to the patients with the same fractures treated with nail and head standard screws (control group including 27 patients). We defined the two parts of the femoral neck as ROI 1 (under the head screw) and ROI 2 (above the femoral screw) on the AP view. The bone density of the two areas was calculated using DEXA at T0 (1st day post-surgery), at T1 (40th day post-surgery), at T2 (3 months later), at T3 (1 year later). The clinical-radiography evaluations were based on the Harris Hip Score (HHS), ADL test and x-ray views of the hip. As far as the bone mineral density average of ROI 1 and ROI 2 is concerned, we found a significant statistical increase at T1 and T3 in the study group, while it was not significant in the control group. We could account for this data through the higher mechanical stability of hydroxyapatite coated screws than standard screws. In fact, this material was responsible for improved implant osteointegration. Thanks to a 1 year follow-up we were able to demonstrate the implant utility associated with augmentation and the importance of densitometry exams such as easily repeatable and low cost diagnostics to prevent the onset of complications linked to screw loosening.

Louis Appia (1818-98): military surgeon and member of the International Committee of the Red Cross.

From Appia's writings we compose a view on his contribution to international medical relief in warfare, to the establishment of the Red Cross and the Geneva Convention, and to surgical procedures on the battlefield. Much information comes from his work on the Battle of San Martino e Solferino in June 1859 on the subject of which he wrote seven letters. We report also on his role during the Garibaldinian Campaign in 1866 and his work in Europe as a member of the International Committee of the Red Cross (ICRC).

Bone grafts and bone graft substitutes in prosthetic hip surgery replacement.

The need for bone grafting procedures to replace skeletal defects has become more considerable because of increased opportunities to save major bone loss. We report our experience and a critical analysis about the role of bone grafts and bone graft substitutes in prosthetic hip surgery replacement.

Interleukin-18, from neuroinflammation to Alzheimer's disease.

A large body of evidence on brain development and ageing has revealed that inflammatory processes profoundly affect brain functions during life span of mammalians, including humans. Activation of innate immune mechanisms leading to pro-inflammatory cytokine up-regulation is involved in devastating and disabling human brain illnesses, as Alzheimer's disease (AD), a progressive neurodegenerative disease that causes dementia in the elderly. Emerging data indicates that the cytokine Interleukin (IL)-18, one of the key mediator of inflammation and immune response, has relevance in the physiopathological processes of the brain, by ultimately influencing the integrity of neurons and putatively contributing to AD. In this review, the relationship between specific IL-18-mediated processes and AD neurodegeneration is summarized and clinical studies pointing to a role of the cytokine in the pathology are discussed. Altogether, the presented data indicate that a more complete knowledge of the molecular mechanisms underlying IL-18 implication in neuroinflammatory and neurodegenerative pathways could contribute toward the development of new therapeutic strategies for AD.

[The mechanism of operation of the malaria therapy]. / Sul "meccanismo d'azione della malarioterapia".

This article intends to synthetically introduce a meaningful Italian monographic contribution to the debate of the years '30 relatively to the mechanism of operation of the malariatherapy on the "paralytic" subjects to the light of the laboratory investigation own of neuropsychiatric medicine in that age.

Rewriting of the biography of Henry Dunant, the founder of the International Red Cross.

This paper presents quite a different version of the origins of the Red Cross from that officially recognised. On the basis of historical documents and statements of authors who are critical and attentive to the detail of the circumstances and events which gave rise to the Red Cross, it is possible to discern a surprising historical truth.

[On Esquirol's historical and statistical study of the royal establishment at Charenton]. / Sur le "Mémoire historique et statistique de la Maison Royale de Charenton" de M. Esquirol.

The authors present a critical interpretation of an historical and statistical work on the Maison Royal de Charenton by M. Esquirol, three years prior to the publication of his fundamental work: "Des maladies mentales". The three historical periods of life at the Maison Royal de Charenton are described, together with the work carried out under the leadership of Esquirol during the third period. Finally, particular attention is devoted to Esquirol's statistical studies, which are re-examined in the light of present-day statistical methodologies.

Henry Dunant and Norman Bethune: a Canadian surgeon who worked with H. Dunant at the Battle of Solferino.

Following a description of both scenarios involved in the Battle of Solferino (1859), and the consequent horrors which spurred Henry Dunant to set up the International Red Cross organisation, for which he received the first Nobel Peace Prize in 1901, the present paper discusses the meeting between Henry Dunant and the Canadian surgeon Norman Bethune (1822-1892). During the days immediately after the battle, they worked together, and Bethune voluntarily operated on the injured soldiers, probably at the hospital of Brescia. In the final part, we describe the life of Norman Bethune, grandfather of the famous Henry Norman Bethune, hero of Maoist China. Norman Bethune was not only a famous surgeon in Toronto, but also Dean of the Medical School at Trinity College in 1856, a colleague of Dr George Ansel Sterling Ryerson, (recognised as founder of the Canadian Red Cross), and other members of the First Central Council of the same organisation. We suggest that Dr Norman Bethune communicated his Italian and European experience with Henry Dunant the founder of the International Red Cross, to his colleagues.

The organisation of spinal projecting brainstem neurons in an animal model of muscular dystrophy. A retrograde tracing study on mdx mutant mice.

Previous studies we performed on the mdx mouse demonstrated marked central nervous system alterations in this model of human Duchenne muscular dystrophy, such as reduction in number and pathological changes of cortico-spinal neurons. Prompted by these findings we extended the survey of the mdx brain to the major brainstem-descending pathways: the rubro-, vestibulo-, reticulo-, and raphe-spinal projections. Horseradish peroxidase microinjections were performed in the cervical spinal cord of mdx and control mice. The rubro-spinal neurons were found to be significantly reduced in mutants compared to controls. The vestibulo-spinal, reticulo-spinal, and raphe-spinal cell populations, though less numerous in mdx than in control mice, were instead substantially spared. Our data further unveil the selective nature of mdx brain damage indicating a marked and selective involvement of the highest centers for motor control.

[Experimentation with Di Bella polychemotherapy in Tuscany]. / Sperimentazione della multiterapia Di Bella in Toscana.

The study reports the experience of Di Bella Treatment (an unconventional treatment for cancer) for advanced cancer patients in Tuscany. A total of (38 + 140 + 463) patients were treated (38 phase II study, 140 observational study and 463 distributional study) and all the case report forms were collected and analyzed in the Regional Coordinator Center of Pisa. No objective response was observed; as of May 31, 1999 63 patients are in stable disease (1 phase II, 3 observational and 59 distributional study). Percentage of interruptions to treatment due to death, refusal and toxicity were similar between patients O and D, while there are significant differences in terms of progressive disease (O = 52% vs D = 18%) and number of losts to follow up (40% in distributional study). The median duration of treatment was 2.31 months (range: 0-15) in the observational study and 3.2 months (range: 0-13) in the distributional study. The median overall survival time (4.5 months) and the median time to disease progression (2.7 months) were calculated by Kaplan-Meier Method and were based on all treated patients (intention to treat population). Follow-up of the study was stopped at 31.05.1999.

Joseph Daquin, Piedmontese Savoyard physician, a "not well-known chiarugi".

We present a critical review of La philosophie de la folie, second edition, published in 1804. Joseph Daquin's thoughts and clinical activity in the psychiatric field are described. Daquin's ideas about various forms of madness and the different therapeutic, moral, physical treatments, his anatomical studies, successes and failures are presented. Several clinical cases are described. The author's view of the moon's influence on madness is described. Finally it is shown how very important was the human person and the moral treatment of madness for Daquin, in contrast with the current opinion at the end of 1700.

Transcranial Doppler and brain death diagnosis.

OBJECTIVES: a) To examine the clinical utility of transcranial Doppler and continuous-wave Doppler in monitoring nonsurgical patients with severe intracranial disease until intracranial circulatory arrest and brain death; and b) to investigate if hemodynamic phenomena that occur under such conditions are correlated to specific transcranial Doppler and continuous-wave Doppler waveforms. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit (ICU) in a city hospital. PATIENTS: Thirty-seven consecutive patients with Glasgow Coma Scores of < 7. MEASUREMENTS AND MAIN RESULTS: Transcranial Doppler examination was conducted transtemporally on the left- and right-middle cerebral artery four times daily. In all patients, transcranial Doppler waveforms exhibited high resistance profiles with low, zero, and then reversed diastolic flow velocity. Only three waveform patterns, consisting of diastolic reverse flow without diastolic forward flow, brief systolic forward flow, and undetectable flow in the middle cerebral artery were registered in the 22 brain-dead patients, but in none of the other comatose patients. CONCLUSION: Transcranial Doppler offers a noninvasive method to document deterioration of cerebral perfusion pressure and in the future could be included in protocols for brain death diagnosis.

Human prostacyclin platelet receptors in diabetes mellitus.

Conflicting data have been reported about the impaired sensitivity to the inhibitory effect of prostacyclin (PGI2) in platelets from patients with diabetes. In the present paper we investigated binding of and sensitivity to PGI2 of platelets from insulin dependent (IDDM) (n = 9), non insulin dependent (NIDDM) (n = 8) diabetics and two groups of ten healthy subjects of equivalent age in relation to platelet lipidic content. Platelet sensitivity to PGI2 (PGI2 IC50) was found not significantly changed in diabetics as compared to controls; similarly, no significant differences of the number of high affinity receptors for PGI2 in platelets from patients with IDDM and NIDDM were observed. Platelet sensitivity to PGI2 and PGI2 receptors were found to be significantly related to platelet cholesterol content (r = 0.89, p less than 0.001 and r = -0.80, p less than 0.001 respectively). In conclusion platelet PGI2 receptor changes are not detectable in diabetics in good metabolic control, but could take place when platelet lipid composition is altered.

Red blood cell lipid alterations in type II diabetes mellitus.

Alterations in blood rheological properties have been reported in diabetes mellitus. Changes in lipid composition of red blood cell (RBC) membranes resulting in an impairment of RBC deformability may play a role in the altered blood rheological pattern. The aim of this study was to investigate the lipid composition of RBC membrane in a group of patients affected by type II diabetes (age 21-45 years), selected on the basis of the absence of complications and good metabolic control, and in a group of suitable control subjects. Saturated fatty acid amounts in the different phospholipid fractions were significantly higher in diabetics than in controls (p less than 0.05), whereas polyunsaturated fatty acids were decreased (p less than 0.05). Cholesterol/phospholipid molar ratio was not altered. On the contrary, sphingomyelin/phosphatidylcholine ratio was higher in diabetics than in controls (1.10 +/- 0.08 vs 0.96 +/- 0.10, p less than 0.01) due specially to high levels of sphingomyelin. These alterations could account for the impairement of RBC deformability frequently reported in diabetes mellitus, independently of metabolic control and the presence of severe atherosclerotic lesions.

Altered membrane fatty acid composition and increased thromboxane A2 generation in platelets from patients with diabetes.

Lipid composition of platelet membranes and thromboxane A2 (TxA2) generation by platelets were investigated in 42 diabetic patients (14 with macroangiopathic complications, 10 with microangiopathy and 18 without vascular complications) and in 42 clinically healthy subjects of similar age. All subjects were on a similar dietary regimen and the adherence to diet was checked by analysis of red blood cell lipids. Platelets from all groups of diabetic patients produced increased amounts of TxA2 than platelets from controls (at least p less than 0.01) and patients with macroangiopathy (p less than 0.01). Platelet cholesterol and total platelet phospholipids were higher in patients with macroangiopathy, while the relative percentage of the different phospholipid fractions in platelet membrane and their saturated and unsaturated fatty acids were similar in the different groups. Arachidonic acid (AA) content in phosphatidylcholine (PC) was found to be significantly higher in diabetic patients than in controls (at least p less than 0.005). Moreover patients with macroangiopathy had higher AA (p less than 0.001) and lower eicosapentaenoic (EPA) and docosahexaenoic acid (DHA) levels in PC (p less than 0.001) than the other groups of patients and controls.

Platelet synthesis of cyclooxygenase and lipoxygenase products in type I and type II diabetes.

In 24 type I and 22 type II diabetic patients without vascular complications and in 25 controls platelet thromboxane A2 (TxA2) and prostaglandin E2 (PGE2) production (by radioimmunoassay-RIA) and 1-14C arachidonic acid (AA) metabolism (by high pressure liquid chromatography-HPLC) after thrombin stimulation were studied. Platelets both from type I and type II diabetics generated larger amounts of TxB2 (p less than 0.001) and PGE2 (p less than 0.005) than controls, independently of the presence of retinopathy. No significant differences in platelet AA uptake or metabolism via the cyclooxygenase (CO) route, after thrombin stimulation (5 NIH U/ml), were observed in diabetic patients: lipoxygenase metabolites were found to be slightly, but significantly decreased. A positive linear relationship (r = 0.64, p less than 0.001) was found between HbA-1c and TxB2 production, but not with fasting plasma glucose. These results indicate that metabolic alterations can affect platelet function independently of vascular complications. The absence of alterations in intraplatelet 1-14C AA metabolism via CO, in the presence of increased TxB2 and PGE2 production from endogenous AA, suggests that the activation of CO is not the only possible mechanism of platelet activation and that probably an increased availability of platelet AA plays an important role in the enhanced platelet aggregation commonly found in diabetics.