Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus percutaneous surgery. / [Artículo traducido] Utilidad del índice de fragilidad modificado de 5 items para predecir complicaciones y reoperaciones después de la cirugía percutánea de hallux valgus.

INTRODUCTION: The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery. METHODS: 551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: 1) non-frail: patients without any of the 5 comorbidities, 2) pre-frail: patients with one comorbidity and 3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded. RESULTS: In the study period 772 percutaneous surgeries were performed to correct HV deformity, 551 patients were included with a median age of 60 (IQR 48-70). Three hundred eighty-nine patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (P=.11). Frailty patients had worse AOFAS scores at final follow up (P=.011). CONCLUSION: The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Utility of the modified 5-item frail index to predict complications and reoperations after hallux valgus surgery.

INTRODUCTION: The modified 5-item frailty index (mFI-5) has been recently proposed as a useful tool for predicting postoperative complications in orthopedic surgery. We aimed to analyze the utility of this score in predicting complications and reoperations after hallux valgus (HV) deformity surgery. METHODS: 551 patients undergoing percutaneous HV corrective surgery were retrospectively reviewed. The mFI-5 was calculated based and patients were categorized in three groups: (1) non-frail: patients without any of the 5 comorbidities, (2) pre-frail: patients with one comorbidity and (3) frail: patients with two or more comorbidities. Complications and surgical reoperations were recorded. RESULTS: In the study period 772 percutaneous surgeries were performed to correct hallux valgus deformity, 551 patients were included with a median age of 60 (IQR 48-70). 389 patients were non-frail (70.6%), 132 were pre-frail (23.9%) and 30 were frail (5.4%). 75 patients suffered complications (13.6%). Even though the rate of complications was higher in frailty patients (23.3%) compared with pre-frail (13.6%) and non frail (12.8%), no significant differences were observed among groups. 48 patients required reoperation (8.7%) but the rate of reoperations among frailty groups was not significantly different (p=0.11). Frailty patients had worse AOFAS scores at final follow up (p=0.011). CONCLUSION: The mFI-5 was not useful to predict postoperative complications and reoperations after hallux valgus corrective surgery. Therefore, other factors should be considered when analyzing the risk of complications after HV corrective surgery.

Optimization of wide-band linear arrays.

An optimization method is proposed for linear arrays to be used in ultrasound systems under wide-band operation. A fast algorithm, the threshold accepting, has been utilized to determine the element positions and weight coefficients of a linear array that generates a desired beam pattern. To reduce the computational burden in the optimization procedure, an efficient numerical routine for the beam pattern evaluation has been implemented. We address the optimization problem of both dense and sparse wide-band arrays. In the first case, the goal is to minimize the side-lobe energy by varying the element weights; we compare the optimized beam pattern with that obtained with classical shading functions, showing that better results can be achieved with a wide-band optimization. We also consider the optimization of the layout (positions and weights) of a sparse linear array to achieve a desired beam pattern with a fixed or minimum number of array elements. The comparison of the proposed method with a narrow-band optimization algorithm is presented, showing that better performances (about -7 dB further reduction of the side-lobe level) can be achieved with a wide-band sparse array optimization. Further numerical simulations are given, showing that the proposed method yields better results than wide-band sparse random arrays and periodic arrays with the same aperture width.

A novel approach to the aperture windowing in medical imaging.

A new technique is proposed to improve the lateral resolution in the conventional B-mode imaging systems, which enables a simple array aperture windowing in the transmitting mode. Amplitude shaping is performed without modifying the transmitting voltage of the array elements, but only varying the excitation pulse length from one element to another. This method presents some attractive practical advantages, and the reduction of the sidelobe energy is comparable to that attainable with a conventional aperture windowing. Parametric plots are given, which transform an amplitude apodization into a 'time apodization' for any type of transducer array.

A new beamforming technique for ultrasonic imaging systems

We propose a simple, versatile and inexpensive beamforming method that performs the aperture windowing of an ultrasonic transducer array in the transmit mode, without modifying the driver voltage, but simply controlling the length of the electric pulse driving the array elements. A conversion formula has been determined that permits us to compute, for a desired emitted pulse amplitude, the corresponding driving pulse length to be applied. Any shading function can be implemented over any type of transducer array, using very low-cost hardware. Computer simulations and experimental measurements, with a 3.8 MHz convex array, confirm the effectiveness of this approach in enhancing the contrast resolution, since the off-axis intensity in the radiated beam pattern is largely reduced.

Efficient transmit beamforming in pulse-echo ultrasonic imaging.

A high performance ultrasound imaging system requires accurate control of the amplitude of the array elements, as well as of the time delays between them, both in the transmit and receive modes. In transmission, conventional array aperture windowing implies a different driving voltage for each element of the array, an expensive solution for systems with a large number of channels. In this paper, we present a simple, versatile, and inexpensive beamforming method that operates the aperture windowing in the transmit mode, simply controlling the lengths of the electric pulses driving the array elements. Computer simulations and experimental measurements are presented for different types of arrays. They confirm that the proposed beamforming technique improves the contrast resolution of the imaging system, reducing the off-axis intensity of the radiated field pattern. Moreover, the axial resolution is slightly enhanced, because the overall length of the transmitted ultrasonic pulse is reduced.

CT of Nissen's fundoplication.

The aim of this work is to describe the computed tomographic (CT) anatomy in patients who underwent Nissen's fundoplication. Forty patients (mean age = 61 years) with peptic esophagitis (nine cases), refractory gastroesophageal reflux (11 cases), and hiatal hernia (20 cases) were studied. Examinations were performed by third-generation CT equipment, with patients in the prone position after the ingestion of gastrovison and barium paste. In 34 patients, the examination demonstrated anatomical variations related to surgery, that is, the presence of a soft tissue mass at the level of the distal third of the esophagus. In four patients, a functional incompetence of the fundoplication (three cases) and a recurrent hiatal hernia (one case) were demonstrated. Our results suggest a possible application for CT study in postoperative follow up of patients who undergo Nissen's fundoplication, complementary to endoscopy and functional exams.

[Magnetic resonance of the brain: comparative assessment of conventional sequences versus fast sequences]. / Risonanza Magnetica dell'encefalo: valutazione comparativa tra sequenze tradizionali e sequenze veloci.

The conventional Spin-Echo sequences have been the most used acquisition techniques on Magnetic Resonance Imaging (MRI) of the brain, since the beginning of 1990s. Recently, however, technological developments proposed such new fast acquisition techniques, with a dramatic reduction in acquisition time as Gradient Echo, Turbo Spin Echo, Gradient Spin Echo ed Echo Planar sequences. We investigated the comparative adequacy of the new fast sequences, in brain MR studies versus conventional sequences, on medium field strength MR equipment (.5 T). On in vitro exams S/N ratio was evaluated and on in vivo study C/N ratio between white substance grey substance and fluid were evaluated, in 15 healthy volunteers. All the exams were carried out on Philips NT5 Gyroscan MR unit operating at .5 T, with 15 mT/m power gradients. Both conventional and fast sequences Spin-Echo (SE), Inversion Recovery (IR), Gradient-Echo (GE), Turbo Spin-Echo (TSE), Gradient Spin-Echo (GRASE) and Echo Planar (EPI), all optimized to obtain T1, T2 and T1-IR weighted images, were performed. The sequences were evaluated separately comparing different acquisition techniques relative to the same type of contrast (T1, T2, and T1-IR). The results indicate the superiority of the fast acquisition techniques, both in terms of quality and acquisition times, except for T1-weighted images, where the conventional Spin-Echo sequences confirmed to be superior. In conclusion, the present study suggests that fast acquisition techniques can improve the conventional protocol of sequences, in the anatomical representation of the normal brain even with medium field strength equipment only on T2 and T1-IR weighted images. On T1-weighted imaging conventional SE acquisition technique is still the best choice. The time saving obtained with fast sequences can therefore be used for an overall improvement in the quality of images, and to apply accessory acquisition plans on routine exams.

[Magnetic resonance study of patellofemoral cartilage with a fat-suppressed T1-3D gradient-echo sequence: a comparison with other acquisition technics at medium field strength]. / Studio della cartilagine femoro-rotulea con Risonanza Magnetica mediante sequenza Gradient Echo-T1-3D con soppressione del segnale del tessuto adiposo: confronto con le altre tecniche di acquisizione con media intensità del campo.

PURPOSE: We compared GRE T1 3D FS sequence with other acquisition techniques available on medium field strength MR units (.5 T) in patellofemoral cartilage studies. MATERIAL AND METHODS: The imaging protocol scheduled Spin Echo (SE), Inversion Recovery (STIR), Gradient Echo (GRE), Turbo Spin Echo (TSE), Turbo-Inversion Recovery (Turbo-STIR), Gradient Spin Echo (GRASE) and Echo Planar (EPI) sequences, in some cases combined with Fat Suppression (FS) or Magnetization Transfer Contrast (MTC) sequences when suitable. In vitro studies were carried out for signal-to-noise ratio (SNR) evaluation, and in vivo on 10 healthy volunteers for contrast-to-noise ratio (CNR) evaluation between cartilage, bone marrow and fluid. The exams were carried out on MR equipment operating at .5 T, with 15 mT/m power gradients. RESULTS: In both in vitro and in vivo studies, GRE T1 3D FS sequences yielded better results in SNR and CNR than other sequences. The GRE T1 3D FS technique combines the advantages of the increased resolution of 3D images with the increased dynamic range of fat suppressed images, for better CNR between cartilage, fluid and bone marrow. CONCLUSION: GRE T1 3D FS sequences are the MR acquisition technique of choice in the assessment of the hyaline cartilage of the knee, even at medium field strength.

[Computed tomography patterns in patients treated with laparoscopic Nissen fundoplication for gastroesophageal reflux]. / Quadri con tomografia computerizzata nei pazienti sottoposti a intervento di fundoplicatio secondo Nissen per via laparoscopica per reflusso gastroesofageo.

This work was aimed at investigating the CT anatomy in patients submitted to Nissen's fundoplication. Forty patients (mean age: 61 years) with peptic esophagitis (9 patients), refractory gastroesophageal (GE) reflux (11 patients) and hiatal hernia (20 patients) were examined. CT studies were performed with a third generation unit (CT Pace, General Electric, USA) with the patients in the prone position, after Gastrovison (Schering) and barium paste administration. In 34 patients, CT demonstrated surgery-related anatomical changes, such as the presence of a soft tissue mass at the distal third of the esophagus. In 4 patients, functional incompetence of the fundoplication (3 patients) and a recurrent hyatal hernia (1 patient) were demonstrated. In conclusion, CT studies performed with a dedicated technique permitted the accurate assessment of the anatomy of the GE junction after Nissen's fundoplication. In our study, CT demonstrated the presence of postoperative fluid collections and specific signs related to fundoplication incompetence. Our results suggest a possible application of CT to the postoperative follow-up of the patients submitted to Nissen's fundoplication, with a complementary role that of to endoscopy and functional exams.

[Anencephaly: a still unresolved problem]. / Anencefalia: un problema ancora irrisolto.

The anencephaly is a congenital malformation, characterized by the absence of the cerebral structures and of the skull. In this study we have considered 5 cases of anencephaly, occurred in the decade 1985-1994. All the pregnant women have been interviewed and underwent ultrasonographic evaluation. Four out of 5 pregnant women have voluntarily interrupted pregnancy. In only 1 case, having achieved woman the 40th week of pregnancy, the delivery has been spontaneous: the fetus has died after few hours. The results of this study suggest that, being the anencephaly the most commonly indications for the abortion, would be important to help the women bearers of anencephalic fetuses to consent taking the organs, using them for transplantations on children that necessitate them.

[Association of interleukin 2 and interferon alpha in the management of cervical condylomatosis]. / Associazione di interleuchina-2 ed interferone-alpha nel trattamento della condilomatosi della cervice uterina.

At present the therapy of cervical condylomatosis is based on the use of interferon because the HPV types responsable for condyloma inhibit the immunitary system. But many A. studying the effects of IFN have found that at high concentration it has an immunosuppressive action. The aim of the present study was to evaluate if interleukin-2 associated with IFN is useful in avoiding this negative effect by improving the efficacy of cervical condylomatosis therapy. We treated 25 women suffering from cervical condyloma with increasing doses of IL-2 injected intralesionally and associated with natural alpha-IFN injected intramuscularly. The duration of the whole therapy was six weeks. We evaluated the percentage of inflammatory cells in peripheral blood before and after treatment. The per-cent number of lymphocytes, eosinophils and lymphoblasts was increased by 27%, 88% and 40%, respectively. The clinical response to the therapy was total in 14 cases, partial in 9 cases and unsuccessful in 2 cases. These data suggested that combination therapy with interleukin-2 and alpha-IFN for the treatment of patients with cervix condylomatous is successful.

[Vulvo-vaginal HPV infection: immunological aspects]. / Infezione vulvo-vaginale da HPV: aspetti immunologici.

All phases of HPV infection are under the control of the immunitary system which is probably inhibited by the virus itself. We studied 65 patients (range 22-55 year). They presented an HPV vulvovaginal infection not healed after common therapy. The aim of our study was to verify the changes occurring in the immune system during HPV vulvo-vaginal infection. Using the immunohistochemical method we evaluated the number of T4,T8 and NK lymphocytes inside the lesion. Moreover we measured the immunitary cells of the hematic compartment. Inside the lesion we noted a reduction of the immune system in 69.23% of cases, while in the hematic compartment it was reduced only in 6.15% of cases. These data strongly suggested that the evaluation of the immunitary state, before starting therapy, is important in deciding when it would be useful to associate immunostimulating substances at the common treatment of vulvo-vaginal infection.

Chemotherapy and cervical cancer: present trends.

A clinical case of cervical carcinoma Stage Ib is described. We treated a 48-year old woman with grade 2 carcinoma, using cisplatin at a dose of 40 mg/mq on the 1st and 4th days, bleomycin at a dose of 15 mg/mq on the 1st and 8th days, and anti-emetic for two cycles. On the basis of the low ratio T4/T8 we also administered along with chemotherapy, alpha natural interferon at a dose of 3,000,000 i.u. three times a week for four weeks. At the end of the chemotherapeutic treatment the lesion was reduced in size and the biopsy was pathognomically of a microinvasive cancer. In spite of the encouraging biopsy results, the patient was submitted to a simple hysterectomy, with random lymphoadenectomy. Today, two years after her treatment, the patient is free of disease. At present there is discussion as to the efficacy of neoadjuvant chemotherapy in the first stages of the neoplasia in relation to conventional treatment, which reserves chemotherapy to stages IV and IVb and to relapses, in the light of both the lesion and the disposability of the patient to treatment and successive follow-up.

[Identification of pancreatic insulinomas. The role of magnetic resonance]. / Identificazione degli insulinomi pancreatici. Ruolo della Risonanza Magnetica.

Insulinomas are the most common endocrine tumors of the pancreas. Although their clinical and biochemical diagnosis is extremely accurate, these lesions must be correctly located preoperatively to plan the best possible treatment. Many different noninvasive diagnostic techniques have been proposed, with only partially satisfying results. For many years such non-invasive modalities as arteriography have been considered the most reliable and accurate diagnostic tools. Recently, however, MRI has been proposed for best pancreas imaging, especially for tumor detection, and its results have been excellent especially thanks to its optimal contrast resolution. Fat-suppressed and turbo-spin-echo (TSE) sequences now yield even better results. In our study we examined 21 patients, whose symptoms were typical of insulinoma, using two different 0.5T magnets, one of which with 15 mT/m gradients. We used T1-weighted spin-echo (SE) sequences with and without respiratory compensation, SE ad TSE T2-weighted and fat-suppressed T1-weighted SE sequences. In 16 patients the lesions were correctly diagnosed and located, as confirmed at surgery. In the other 5 patients, MRI failed to locate the insulinomas. Three of these 5 patients were submitted to surgery, during which palpation and intraoperative US findings were also negative for a solid mass. The remaining 2 patients underwent clinical follow-up. Our study demonstrated that MRI, especially with fat-suppressed and T2-weighted TSE sequences, is a very accurate modality to detect pancreatic insulinomas and can therefore be proposed as the only preoperative technique.

[Carcinoma of the pancreas. Typical and atypical aspects using midfield-strength magnetic resonance]. / Carcinoma del pancreas. Aspetti tipici e atipici con Risonanza Magnetica con media intensità di campo.

Until few years ago, MR assessment of pancreatic carcinoma was thought to be feasible only with high-strength equipment, but today also low- and midfield units allow pancreatic lesion detection, thanks to parameter optimization. The authors retrospectively analyzed the MR findings of 57 patients examined with a midfield MR unit; all the patients had clinically suspected pancreatic carcinoma, which was confirmed in 54 cases. The lesions were more easily detected using T1-weighted sequences, thanks to their high intrinsic contrast, while T2-weighted sequences often confirmed the glandular changes already depicted by T1-weighted sequences. MRI correctly depicted vascular and lymph node involvement and detected liver metastases with no i.v. contrast agent injection. The only limitations of this technique are the unfeasibility of MR exams of diagnostic value in uncooperative patients (5% of cases) and the very similar MR features of parenchymal scars, due to previous acute pancreatitis, to those of pancreatic carcinoma. In conclusion, CT remains the gold standard in the study of pancreatic cancers, but midfield strength MRI, if correctly performed, can be proposed as a complementary tool to CT, especially in questionable cases and in the patients with known reactions to iodinated contrast agents.

[Incidence of HPV and CIN in HIV positive women]. / Incidenza dell'infezione da HPV e della CIN in donne HIV-positive.

Cervical intraepithelial lesions associated with genital human papilloma virus (HPV) infection occur with increased frequency and severity among women with immunodeficiency. In this study, we considered 24 HIV-seropositive and 12 HIV-seronegative women. Each woman was interviewed and underwent a cytologic and colposcopic evaluation. Then colposcopic and cytologic findings were correlated with histologic and differences between HIV-seropositives and seronegatives were analyzed. Ten (41%) of 24 HIV-seropositive and one (9%) of 12 HIV-seronegative women had human papilloma virus infection. Among seropositives, eight (34%) had cervical intraepithelial (CIN): of those eight, 5 had CIN I, 2 CIN II and 1 CIN III. There (24%) of the 12 HIV-seronegative had CIN: two had CIN I and one CIN II. Six of the HIV-seropositive women were found to have multicentric disease (two or more sites). The objective of this study is to determine the relationship between human immunodeficiency virus (HIV) and human papilloma virus infection, sexual habits, reproducive history, and risk of cervical intraepithelial neoplasia (CIN). The results of this study suggest that cervical intraepithelial neoplasia is a common finding in HIV-infected women. Papanicolaou tests should be effective for detecting cervical disease in this population.

Malignant melanoma of the vagina in pregnancy: description of a clinical case.

Vaginal melanoma in pregnancy is a rare but extremely malignant tumour for which the prognosis is worsened by the fact that pregnancy increases the secretion of Melanocyte-Stimulating Hormone (MSH). The clinical case is described of a malignant vaginal melanoma in a 27 year-old woman in her 38th week of gestation, who was referred for slight vaginal bleeding. Clinical examination revealed a 3 cm pedunculate tumour on the anterior wall of the vagina. Vaginal cytology suggested a melanoma and instrumental examination failed to reveal any lymph node involvement. The vaginal tumour was removed during a caesarean section and subsequent histological examination identified it as a Breslow Stage II malignant melanoma. A 24-month follow-up showed the patient to have been completely cured.

[Magnetic resonance in the study of inflammatory diseases of the pancreas]. / La Risonanza Magnetica nello studio delle malattie infiammatorie del pancreas.

The role of diagnostic imaging modalities in pancreatic inflammatory diseases is to assess gland damage and peripancreatic tissue involvement. The artifacts related to breathing and to peristaltic movements can be partially resolved with the optimization of acquisition parameters, which allows MRI to be suggested for the assessment of pancreatic inflammatory conditions. Sixty-nine patients with pancreatic inflammatory diseases (20 acute and 49 chronic pancreatitis cases) were examined. MRI was performed with a 0.5-T superconductive magnet and T1- and T2-weighted spin-echo (SE) sequences. In 4 of 20 acute pancreatitis patients image quality was poor. MRI in acute pancreatitis demonstrated glandular edema, intraparenchymal necrosis and the extent of peripancreatic fluid collections; in chronic pancreatitis MRI depicted glandular atrophy and Wirsung duct dilatation and detected the presence of pseudocysts. Even though its spatial resolution is lower than that of CT, MRI can provide useful pieces of information in inflammatory diseases of the pancreas, much more so after the introduction of Fast SE sequences and of fat-saturation techniques which are likely to make MR examinations of the pancreas more widely used.

[Assessment of primary renal lymphoma with computerized tomography]. / Valutazione dei linfomi renali primitivi con Tomografia Computerizzata.

Renal involvement during lymphoma can be extrinsic, i.e., renal compression or displacement due to lymph node masses, or intrinsic, i.e., parenchymal involvement secondary to blood or lymphatic spread, or primary, as initial neoplastic site. Primary renal lymphoma is very rare (3% of all renal lymphomas) for the absence of lymphatic tissue in the kidney. The disease might be due to parapyelic lymph nodes or to blood spreading from an unknown site. In our study we reviewed the CT findings of five cases of primary non-Hodgkin's renal lymphoma with surgical or histologic confirmation. Renal alterations due to lymphomatous involvement were classified according to macroscopic pathologic findings: type I (single nodular disease, 2 patients), type II (multinodular disease, 1 patient), and type III (infiltrating disease with retroperitoneal involvement, 2 patients). In the two patients with single nodular involvement (type I), CT showed a solid, hypodense and clear-cut nodule. In the only patient with multinodular disease (type II), renal tissue was replaced by multiple hypodense nodular masses, which were partially confluent. In the two infiltrating forms with retroperitoneal involvement (type III), renal structure was diffusely disorganized, with thickening of soft tissues and perirenal fasciae, peripyelic infiltration and, in one case, urinary tract obstruction. To conclude, CT always allowed the accurate assessment of the presence, site and size of renal lesions and of perirenal and urinary involvement. However, CT findings were completely aspecific, not allowing an unquestionable differential diagnosis with other conditions, e.g., hypernephroma, transitional cell carcinoma, metastatic lesions or chronic inflammations. Therefore, a biopsy specimen is necessary to make an unquestionable diagnosis.