Modified National Early Warning Score as Early Predictor of Outcome in COVID-19 Pandemic.

COVID-19 represented an important challenge to the Italian healthcare system (IHCS). Our main aim was to obtain evidence to support the use of modified national early warning score (m-NEWS) as an interdisciplinary, common, and universal scoring scale to quickly recognize patients with a risk of clinical deterioration before admission and during hospitalization. As a secondary goal, we tried to find a score threshold that can trigger patients' immediate medical review as a part of an optimal triaging protocol for an emergency setting where healthcare resources are overloaded. We performed a retrospective observational study. We included in our study all patients treated for COVID-19 infection in surgical departments between 01 March 2020 and 16 April 2020. Patients with negative test results for SARS-COV-2 were excluded. m-NEWS was obtained twice a day. Patients' m-NEWS were analyzed in order to verify the correlation between m-NEWS (at admission and m-NEWS variation 24 h after admission) and outcome (positive outcome-survival, negative outcome-death, or intensive care unit (ICU) transfer). We included a population-based sample of 225 SARS-COV-2-infected patients. Overall, the average age at hospitalization was 71 (ranging from 40 to 95). 144 (64%) patients were males and 81 (36%) females. m-NEWS values lower or equal to 7 were associated with the majority of the "recovered" population (100/132 75.75%) and at the same time with the minority of the "non-recovered" population (25/93 26.88%). For our sample, age is statistically correlated to the outcome but a triage protocol based solely on this variable is less effective than m-NEWS, which showed to be a reliable and easy-to-use score for first patient evaluation. Our observations pave the way towards further studies aiming at optimizing territorial and community healthcare management protocols.

The "Pandemic" of Disinformation in COVID-19.

In recent years, mass media and social networks have played an important role in disseminating information regarding public health. During the COVID-19 epidemic, misinformation and fake news have represented an important issue generating confusion and insecurity among the population. In our analysis, we investigate the role of mass media as a critical element during the SARS-CoV-2 outbreak that has influenced the public perception of risk.

Revision of ASR hip arthroplasty: analysis of two hundred and ninety six recalled patients at seven years.

PURPOSE: The aim of this study is to present an algorithm for the evaluation of both symptomatic and asymptomatic patients. METHODS: From November 2004 to May 2010, there were performed 296 operations: 245 total hip arthroplasty and 51 resurfacing arthroplasty with the ASR DePuy system. In April 2010, there was the first Medical Device Alert regarding all MoM hip replacements in the UK and in August 2010, DePuy recall started worldwide. In March 2012, we started our recall. All patients were invited to undergo clinical investigation, X-ray evaluations, and blood chrome and cobalt level determination. For a short period of time, there were performed second level exams and subsequently, we carried out MARS MRI hip study to all symptomatic patients and there was evidence of ALVAL lesions. RESULTS: To the patients with ALVAL lesions were proposed surgical hip revision while the others frequent follow-up controls. One hundred patients underwent hip surgical revision. CONCLUSIONS: We recommend constant MoM THA patients monitoring and early revision if necessary.

Blunt rectal trauma Case report and literature review.

Blunt colorectal traumas are rare clinical entities with a challenging diagnostic and operative management. We describe the case of a 40-year-old man, victim of an accidental fall from a height of four meters who was subsequently diagnosed to have a blunt rectal trauma. A first CT scan showed fracture of the skull and an extensive subcutaneous haematoma of the lower back associated with a fracture of the left transverse processes of lumbar vertebrae. No other visceral abdominal lesions were recognized and patient was admitted to our department for observational studies. After 48 hours from admission the patient presented a subcutaneous emphysema suspicious for hollow viscus injuries. A digital rectal examination detected a laceration both of the posterior rectal wall and the superior anal margin. The patient was successfully managed with spur colostomy, transanal evacuation of the retroperitoneal haematoma and primary repair of both the sphincteric muscle and the rectal wall. As soon as the patient achieved full recovery we performed a reversal colostomy. Diagnosis and management of rectal blunt trauma is still a matter of debate and no definitive recommendation treatments are available. The surgical treatment should be tailored on patient medical conditions and clinicians should maintain a high index of suspicious because a delay in diagnosis can result in higher morbidity and mortality rate. KEY WORDS: Colorectal blunt injury, Colostomy, Laparoscopy, Trauma.

Cutaneous metastasis from lung cancer. Case report.

UNLABELLED: Lung cancer is the most common neoplasm diagnosed worldwide. Metastatic presentation of the disease is frequent. Apart from the usual sites of metastatic disease (bone, adrenals, liver, brain), a particular site for metastases is represented by skin. The case we report is about a 66 year-old man with cutaneous metastasis from lung cancer. A 66 year-old man, with a previous history of abdominal aortic aneurism, chronic obstructive pulmonary disease, cardiopathy, diabetes mellitus, was admitted to our institution for left lower lobe lung cancer. After accurate preoperative staging, patient underwent a thoracotomic left lower lobectomy. Histological examination revealed a squamocellular carcinoma: G2-3, pT2bN0. Patient underwent oncological evaluation for the scheduled follow up. After 6 months patient went back to our observation for the appearance of a skin nodule, firm, dischromic, painful and ulcerated, localized in right iliac fossa. Biopsies demonstrated the nodule to be squamocellular carcinoma. Patient underwent a CT scan of the abdomen and thorax, which revealed the absence of infiltration of the deep fascial and muscular planes by the neoplasm. Patient underwent surgical removal of the lesion. Final histological examination confirmed the lesion to be metastasis of squamocellular lung cancer. Metastases from lung cancer occur in about 2,5-7,5% of cases. Median survival for these patients is 2,9 months. The most common type of neoplasm, according to Japanese Authors, is adenocarcinoma followed by squamocellular carcinoma. Some studies demonstrated the adequacy of surgery followed by chemotherapy, in case of single lesion. In case of multiple cutaneous metastases, many Authors suggest only chemotherapy, although the ideal scheme hasn't been discovered yet. Cutaneous metastases from lung cancer are rare; however the appearance of skin lesions, in patients with a positive oncological history, requires much attention. Accurate evaluation of the patient is paramount in choosing the adequate therapeutic algorithm. KEY WORDS: Chemotherapy, Lung Cancer, Skin Metastases.

Rotational alignment of the tibial component in total knee arthroplasty: the anterior tibial cortex is a reliable landmark.

PURPOSE: to compare the anterior tibial surface curvature, the Akagi's line and the medial third of the tibial tubercle in order to assess which is the most reliable landmark for correct tibial component rotational positioning in total knee arthroplasty. METHODS: three independent investigators reviewed 124 knee MRI scans. The most suitable tibial baseplate tracing for the Nexgen Total Knee System (Zimmer, Warsaw, USA) was superimposed on the scan matching the anterior tibial cortex with the anterior aspect of the baseplate. The rotation of the tibial baseplate tracing was calculated with respect to the transepicondylar axis (TEA), the medial third of the tibial tubercle line, Akagi's line and the femoral posterior condylar axis (PCA). Customized software was created and used for analysis of the MRI datasets. The reliability of each measurement was then calculated by using the intraclass correlation coefficient for interobserver agreement. RESULTS: observer agreement on the position of the Akagi's line was within 3° in 64% of the cases and within 5° in 85% of the cases. Agreement on the position of the medial third of the tibial tubercle was within 3° in 29% of the cases and within 5° in 70% of the cases. Agreement on the localization of the anterior tibial surface curvature was within 3° in 89% of the cases and within 5° in 99% of the cases. Component alignment along the anterior cortex guaranteed full matching ± 3° with the epicondylar axis in 75% of the knees. CONCLUSIONS: the anterior tibial surface curvature was found to be a more reliable and more easily identifiable landmark for correct tibial component alignment than either Akagi's line or the medial third of the tibialtubercle. LEVEL OF EVIDENCE: level III, retrospective cohort study.

Continuous femoral nerve block provides superior analgesia compared with continuous intra-articular and wound infusion after anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective, randomized, clinical trial compared pain intensity and analgesic drug consumption after anterior cruciate ligament (ACL) reconstruction with patellar tendon under femoral-sciatic nerve block anesthesia in patients who received either a continuous femoral nerve block (CFNB) or continuous local anesthetic wound and intra-articular infusions. METHODS: Fifty patients were randomized to CFNB (n = 25) or an ON-Q device (I-Flow Corp, Lake Forest, Calif) (n = 25). All patients received sciatic nerve block (25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). The first group received a CFNB (2 mg/mL of ropivacaine at 7 mL/hr), and the second group received a single-shot femoral nerve block (both using 25 mL of ropivacaine 7.5 mg/mL and clonidine 30 microg). At the end of the intervention, an ON-Q device was positioned on the ON-Q patients to continuously infuse the patellar tendon wound and intra-articular cavity with ropivacaine 2 mg/mL at 2 mL/hr for each catheter. Data regarding demographic, hemodynamic, pain scores, adverse effects, and need for supplemental analgesia were registered in a 36-hr follow-up period. RESULTS: The CFNB group reported lower visual analog scale values than the ON-Q group: at rest at 12 hrs (2.4 [SD, 2.2] vs 5.4 [SD, 3.1]; P < 0.001) and on movement at 12 (3.1 [SD, 2.5] vs 6.3 [SD, 2.9]; P < 0.001) and 24 hrs (2.7 [SD, 1.9] vs 4.6 [SD, 2.6]; P = 0.01) after surgery. The number of morphine and ketorolac boluses was lower in the CNFB group (morphine: 3.2 [SD, 2.2] vs 6.2 [SD, 2.5]; P < 0.001; ketorolac: 1.1 [SD, 1.0] vs 2.4 [SD, 0.9]; P < 0.001). CONCLUSION: Continuous femoral nerve block provides better analgesia than the continuous patellar tendon wound and intra-articular infusions after anterior cruciate ligament reconstruction with patellar tendon.

Efficacy of continuous femoral nerve block with stimulating catheters versus nonstimulating catheters for anterior cruciate ligament reconstruction.

BACKGROUND AND OBJECTIVES: This prospective randomized controlled trial investigated the clinical efficacy of stimulating catheters for continuous femoral nerve block in patients who underwent anterior cruciate ligament reconstruction. METHODS: Seventy patients were randomized to either a stimulating catheter (SC, n = 35) or a nonstimulating catheter (NSC, n = 35) for femoral nerve block using 25 mL ropivacaine 7.5 mg/mL and clonidine 50 microg injected through the catheter. A single-injection sciatic block was also given to ensure surgical anesthesia. The time to loss of sensation to cold and pinprick of the femoral nerve was registered as the onset time. Data were registered intra- and postoperatively regarding pain scores, adverse effects, and need for supplemental anesthesia and analgesia other than a continuous postoperative infusion of ropivacaine 2 mg/mL through the continuous femoral nerve catheter set at 7 mL/h. RESULTS: Onset time was faster in the SC group (SC: 6.4 +/- 2.5, NSC: 8.3 +/- 2.9 min, P = .006). Visual analog scale pain scores were similar in both groups. The number of patient-controlled regional analgesia boluses (SC: 14.6 +/- 12.6, NSC: 23.2 +/- 13.6 mg ropivacaine 2 mg/mL, P = .008) as well as intravenous rescue ketorolac (SC: 34.3 +/- 35.7, NSC: 54 +/- 39.7 mg, P = .033) administered were higher in the NSC group. CONCLUSION: Although the use of a stimulating catheter was associated with faster onset time for the femoral nerve block and lower additional analgesics postoperatively, the clinical superiority (analgesia; lateral femoral cutaneous, and obturator nerve block) of stimulating catheters was not evident in this clinical setting.

Patellofemoral evaluation after total knee arthroplasty. Validation of a new weight-bearing axial radiographic view.

BACKGROUND: Radiographic assessment of the patella after total knee arthroplasty is typically performed with use of static, unloaded views that may not reproduce the in vivo patellofemoral kinematics. The purpose of the present study was to evaluate and validate the reliability and reproducibility of a weight-bearing radiographic assessment of the patellofemoral joint in patients who have undergone total knee arthroplasty. METHODS: Radiographs were made for 100 knees in sixty-nine patients who had undergone total knee arthroplasty. Radiographic assessment of the patellofemoral joint was performed with use of both the standard Merchant axial view and a modification of that view. The Merchant axial view was modified by positioning the standing patient in the semi-squatted position with the knees in 45 degrees of flexion. The relationship between the x-ray source, the angle of incidence on the joint, and the cassette position was kept unchanged from the original view. The standing position and consequent muscle involvement were the only differences. RESULTS: Compared with the standard Merchant axial view, the weight-bearing axial view showed a number of patellofemoral tracking changes. Specifically, lateral tilt and subluxation of the patella were significantly reduced; the rate of exposed, uncovered patellar bone contact with the femoral trochlea was significantly increased; and radiographic evidence of maltracking was more closely correlated with clinical symptoms. CONCLUSIONS: An axial weight-bearing radiographic view with the patient in the semi-squatting position was developed to reproduce patellofemoral joint loading. This view demonstrates that the position of the patella, as seen on the standard unloaded Merchant view, changes during squatting. Utilization of this axial weight-bearing view to evaluate total knee arthroplasty may provide additional information over standard radiographic views.

Local anesthesia for stapled prolapsectomy in day surgery: results of a prospective trial.

PURPOSE: This article reports the results of a prospective trial of the feasibility of Longo's procedure under local anesthesia in day surgery. METHODS: From April 2002 to May 2003, 66 patients (42 males and 24 females) were enrolled in the study; the mean age was 47.5 (range, 23-65) years. Thirty-six patients (55 percent) had prolapsed third-degree hemorrhoids, while 30 (45 percent) had fourth-degree hemorrhoids. All patients were operated on under local infiltration of the anorectal region by injecting ropivacaine 7.5 mg/dl using a Quadrijet. During the surgical procedure, blood pressure and heart rate were always monitored and the level of pain was checked using a visual analog scale. Hospital discharge was programmed for 6:00 p.m. Any immediate complications, such as bleeding, urinary retention, or pain, were also recorded. RESULTS: It was possible to perform the procedure under local anesthesia in all patients, and the anesthesiologist did not need to intervene at any time. No vagal reaction was observed; the transient reduction of blood pressure and heart rate, which occurred in four patients (6 percent),was controlled with an analgesic drug. In 96 percent of the cases the mean intraoperative visual analog score was not higher than four. Fifty-six patients were discharged at 6:00 p.m., while only 10 percent required an overnight stay. CONCLUSIONS: The stapled prolapsectomy procedure is feasible and can be performed safely under local anesthesia and as day surgery. This procedure provides good pain control and results in a minimal number of complications.

Morphology of colorectal lymphoid aggregates in cancer, diverticular and inflammatory bowel diseases.

The present study compares the characteristics of colorectal lymphoid aggregates in patients with carcinoma, diverticular disease, Crohn's disease, or ulcerative colitis of the large bowel. A total of 77 patients (41 colorectal cancer, 27 diverticular disease, six ulcerative colitis, three Crohn's disease) undergoing colorectal resection were included. Acetic acid staining, hematoxylin and eosin staining, CD3, CD20, and MIB1 immunostaining were employed in order to assess density, diameter, subepithelial or basal location, cellular profile, and proliferation of lymphoid aggregates in normal-appearing and actively inflamed large bowel. In normal-appearing tissue, mean density of lymphoid aggregates was lower in patients with ulcerative colitis and Crohn's disease than in those with colorectal cancer or diverticular disease. A larger mean diameter of aggregates was observed in patients with Crohn's disease. In inflammatory bowel diseases, a marked increase of the mean density of lymphoid aggregates was observed in actively affected specimens. In Crohn's disease more than in ulcerative colitis, the aggregates had a predominant basal or transmural distribution. In diverticular disease, active inflammation determined a less significant increase of subepithelial aggregates harboring a lower proportion of germinal centers. No significant variations of CD3, CD20, and MIB1 were recorded among the four disease groups. The lymphoid aggregate derangements observed not only in the actively affected mucosa but also in the unaffected colorectal lining of patients with Crohn's disease and ulcerative colitis support a relevant involvement of lymphoid aggregate system in the pathogenesis of inflammatory bowel diseases.

Constipation, anthranoid laxatives, melanosis coli, and colon cancer: a risk assessment using aberrant crypt foci.

The associations between colorectal cancer (CRC) and constipation, anthranoid laxative use, and melanosis coli are controversial. Aberrant crypt foci (ACF) are microscopic lesions of the colonic mucosa suspected of being preneoplastic, and their investigation has been advocated to evaluate the cause-effect relationship between putative risk factors and CRC. To this aim, we investigated the relationship between sigmoid cancer (SC) and constipation, anthranoid laxative use, and melanosis coli using ACF analysis as an additional tool of investigation. Fifty-five surgical patients with SC, 41 surgical patients with diverticular disease (DD), and 96 age- and sex-matched subjects without intestinal disease (controls) were interviewed on their history of constipation and anthranoid laxative use. Melanosis coli and ACF characteristics were investigated on sigmoid mucosa in patients with SC or DD. Constipation and anthranoid laxative use were similar between patients with SC (30.9% and 32.7%, respectively) and those with DD (39% and 26.8%) but higher than among controls (18.8% and 8.3%). Melanosis coli was found in 38.2% of patients with SC and in 39% of those with DD. Mean ACF frequency was higher in patients with SC (0.24/cm(2)) than in those with DD (0.10/cm(2); P < 0.0001), and it did not vary according to constipation, laxative use, or melanosis coli in either group. This study confirms the association of ACF frequency with colon cancer and does not support the hypothesis of a cause-effect relationship of CRC with constipation, anthranoid laxative, use or melanosis coli.