Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment.

INTRODUCTION: Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed),in order to determine the best treatment option. MATERIALS AND METHODS: We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score. A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed). RESULTS: We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%. CONCLUSIONS: After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.

Reliability and reproducibility analysis of the AOSpine Sacral Fractures Classification System by spinal and pelvic surgeons.

STUDY DESIGN: Retrospective Cohort Study OBJECTIVES: The AOSpine Sacral Classification System was proposed as a comprehensive and universally accepted new classification for Sacral Fractures, and was recently internally validated. However, an external, independent and multidisciplinary reports on validation of this classification is lacking. Aim of the present study is to analyze the interobserver reliability and intraobserver reproducibility of the AOSpine Sacral Classification System for Sacral Fractures between orthopedic spinal and pelvic surgeons with different levels of experience. METHODS: Our institutional database was searched to retrieve patients with acute, traumatic sacral injury admitted from June 2017 to June 2020. For each patients, X-Rays and CT scans were collected. Three Orthopedic Pelvic Surgeons (Group A) and three Spine Surgeons (Group B), with different level of experience (Junior, 〈 5 years; Middle, 5-10 years; Expert 〉 10 years) independently classified all the sacral fractures included in the dataset, with two separate evaluation three weeks apart. Both intra and interobserver reliability were calculated with k-coefficient. RESULTS: Overall, 150 patients were included in the final dataset, for a total of 1800 different assessments, with all the subtypes reported. The intraobserver reproducibility for the whole group was substantial (κ=0.72). Overall, the interobserver reliability was moderate, with a κ=0.57. When only fracture type was taken in account, the κ value became substantial (κ=0.62). No significant differences were found comparing group A and group B (0.55 vs κ 0.55, p>0.05). No significant differences according to surgeon's experience were found; however, the κ value was slightly lower among the junior surgeons. CONCLUSIONS: Our findings confirmed the reliability and reproducibility of this classification in clinical practice. In the current study the surgeon's expertise (pelvic and spinal trauma) and the level of experience does not influence the reliability of the classification system.

Pelvic ring and acetabular fracture: Concepts of traumatological forensic interest.

Fractures of the pelvic ring and acetabulum generally result after high energy trauma. Pelvic fractures, especially, are considered complex injuries from a therapeutic point of view, in relation to the frequent coexistence of skeletal and / or parenchymal lesions affecting other areas, and the abundant bleeding invariably associated with the latter. The systematic study of these injuries, starting from the 1950s, has led to a significant prognostic improvement, while generally remaining a non-negligible degree of disability. The knowledge of the characteristics of the lesions and of the classification systems, as well as an accurate assessment of the anatomo-functional repercussions, represent therefore the fundamental prerequisites for the correct assessment of physical damage. Herein, we aim to examine whether the medico-legal assessment parameters of physical damage being used in Italy and Europe are appropriate and consistent with the complexity of similar injuries.

A role for accelerometry in the differential diagnosis of tremor syndromes.

Accelerometry is a reliable tool for gauging the occurrence, amplitude and frequency of tremor. However, there is no consensus on criteria for accelerometric diagnosis of tremor syndromes. We enrolled 20 patients with essential tremor (ET), 20 with dystonic tremor (DT), and 20 with classic parkinsonian tremor (PD-T), all meeting accepted clinical criteria. All the patients underwent dopamine transporter imaging (by means of single-photon emission computed tomography) and triaxial accelerometric tremor analysis. The latter revealed groupwise differences in tremor frequency, peak dispersion, spectral coherence, unilaterality and resting vs action tremor amplitude. From the above, five diagnostic criteria were extrapolated for each condition. Receiver operating characteristic curves, depicting criteriabased scoring of each tremor type, showed negligible declines in specificity for scores ≥4 in patients with ET or DT and scores ≥3 in patients with PD-T, thus providing a simple scoring method (accelerometrically derived) for differential diagnosis of the principal tremor syndromes.

Canopy physiology, vine performance and host-pathogen interaction in a fungi resistant cv. Sangiovese x Bianca accession vs. a susceptible clone.

The present study compares the physiological and cropping response of the new fungi-resistant grapevine Accession 72-096 ('Sangiovese' x 'Bianca' hybrid) against a susceptible 'Sangiovese' clone which was either fully (FS-SG) or partially sprayed (PS-SG). Data logged on Accession 72-096 indicate that while two early season sprays were enough to avoid major downy mildew (DM) and powdery mildew (PM) outbreaks, Accession 72-096 also showed concurrent desirable features such as moderate cropping, loose clusters, fast sugar accumulation coupled with sufficient acidity even at peak total soluble solids (TSS) concentration (around 24 °Brix), good color and higher flavonols prompting co-pigmentation. Conversely, FS-SG showed final lower acidity despite the notably lower sugar concentration (≅18 °Brix), as well as larger clusters and berries that resulted in more compact bunches. From a methodological viewpoint, end of season single-leaf readings appeared to overestimate the limitation of leaf function due to PM and DM infections in SG-PS vines which, when assessed via a whole-canopy approach, did not show significant differences vs. Accession 72-096, a result likely due to counteracting effects linked to a compensation mechanism by healthy tissues. Our data also suggest that a PM infection can lead to a decoupling in sugar-color accumulation patterns.

New olfactometric findings in Parkinson's disease.

OBJECTIVES: To investigate in Parkinson's disease-affected patients a correlation between hyposmia and gastrointestinal dysfunction and their possible identical etiopathogenesis. DESIGN: Retrospective cohort study. SETTING: ENT and neurology departments (Gemelli Hospital, Rome, Italy). PARTICIPANTS: A total of 78 patients with diagnosis of PD according to the UK Brain Bank criteria. INCLUSION CRITERIA: informed consent and olfactory testing executed; exclusion criteria: signs of dementia according to the DSM-IV criteria; Mini Mental State Examination score ≤26; head trauma; central neurological disorders, nasal or systemic diseases potentially affecting olfactory function. Motor condition was assessed by means of Hoehn and Yahr staging and by section III of the Unified PD Rating Scale, performed off and on medications. MAIN OUTCOME MEASURES: The patients underwent olfactory evaluation (TDI score), after rhinomanometry with nasal decongestion. A total of 25 non-motor symptoms were evaluated through an interview. RESULTS: Olfactory dysfunction was objectively found in 91.0% of patients, a percentage higher than the subjective hyposmia reported (55.1%) P = 0.0001. Seven patients (9.0%) were normosmic, 49 (62.8%) hyposmic and 22 (28.2%) anosmic. Subjective hyposmia, constipation, bloating and dyspepsia differed across groups, being higher in anosmic and hyposmic ones than in the normosmic group. P value was ≤0.05 for each symptom. Despite the original results, this study has the limitation of being based on subjective ratings by a relatively limited group of patients. CONCLUSIONS: Hyposmia and gastrointestinal symptoms are correlated, and this would support a possible common origin; the CNS could be reached through two different pathways, both starting in the peripheral nervous system.

Comorbidity in pathological gambling: clinical variables, personality and treatment response.

INTRODUCTION: Pathological gambling shows high comorbidity rates, especially with substance use disorders, although affective, anxiety and other impulse control disorders, as well as personality disorders, are also frequently associated. OBJECTIVES: To explore comorbidity in pathological gambling with other mental disorders in a consecutive sample of patients attending a unit specialized in pathological gambling, and specifically the relationship between substance-related disorders, on the one hand, and personality and clinical variables in pathological gamblers, on the other. METHOD: A total of 498 patients with a DSM-IV-TR diagnosis of Pathological Gambling (11.8% women) were assessed with a semi-structured clinical interview and several clinical and personality scales. RESULTS: Higher comorbidity with affective disorders was found in women (30.5%), while higher comorbidity with substance-related disorders was found in men (11.2%). A positive association was also detected between a history of psychiatric disorders and current comorbidity with substance-use disorders, as well as between alcohol abuse and age. Finally, some personality traits such as low reward dependence (OR=0.964) and high impulsivity (OR=1.02) predicted other substance abuse (not alcohol). High selftranscendence scores predicted both alcohol and other substance abuse (OR=1.06). CONCLUSIONS: Our results suggest a high prevalence of comorbid disorders in pathologic gambling, mainly with affective and substance-related disorders. The results of the present study, conducted in a broad sample of consecutively admitted pathologic gamblers, may contribute to understanding of this complex disorder and treatment improvement.

Analysis of 80 bilateral hip replacement surgeries performed in a single session. Feasibility study.

Patients affected with bilateral coxarthrosis often present with clinical and radiographic findings that are similar on both sides. The experience with 80 patients submitted to bilateral hip replacement in a single session demonstrated the usefulness and the reduction in costs in relation to hospitalization and rehabilitation. Indications and contraindications must be taken seriously.

[Cancer risk in breast lesions: diagnostic and therapeutic strategy]. / Lesioni a rischio della mammella: protocollo diagnostico-terapeutico.

BACKGROUND: The classification, diagnostic recognition and surgical treatment of breast lesions at risk of neoplastic transformation represent some of the most important objectives in breast research. Attention has been focused on lesions at risk of neoplastic transformation in breast pathology, such as: atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), multiple intraductal papilloma and sclerosing adenosis. METHODS: Our experience regards activity carried out from 1996 to 2001; the diagnostic approach included routine performance of echotomographic examination, mammography screening indicated in women >40 and, in selected cases, in women <40; FNAB was carried out in all lesions containing suspicious cells. In the case of non-palpable lesions we carried out a CT-guided FNAB using the stereotaxic technique. In cases of secreting breast, galactography proved useful. As regard clinically suspect nipple secretions, cytology was useful in the diagnosis of intraductal papillomatous lesions. Surgery was indicated for: mammographically negative nodular lesions with cytological finding of suspect lesions. Continuous, spontaneous mono-orificial, serous, sero-hematic or hematic secretion of the nipple also in the presence of negative and/or inconclusive galactographic and cytological findings. From a nosological viewpoint we have distinguished 3 groups: A) 49 women (average age 47.3 years) with suspect lesions subjected to biopsy. On the basis of the cytological response we carried out: 37 quadrantectomies with extemporary examination, 4 excisional biopsies, 5 radical ductectomies and 3 microductectomies. B) 26 patients (36.7 years) subjected to mammary biopsy for non-suspect lesions; in 24 cases excisional biopsy of the lesion and in 2 cases radical ductectomy. C) Control group consisting of 141 women (average age 44.5 years) suffering from benign pathology not suspected of lesions at risk and not subjected to surgery. RESULTS: The final histological examination evidenced: Group A: 7 cases of T1aN0M0 carcinoma (14.3%); 20 lesions at risk (40.8%); 22 lesions not at risk; Group B: 25 (96.1%) lesions not considered at risk, in 1 case (3.9%) area of sclerosing adenosis with ductal proliferation and slight atypias; Group C: in 4 cases (3.1%) the onset at follow-up of lesions at risk made it necessary to remove the lesion. Histology did not confirm the presence of cancer in any case. CONCLUSIONS: The diagnostic and therapeutic protocol proposed enables us to identify and radically treat high risk patients (Group A) and follow them up closely. On the contrary, Group B evidenced a very low incidence of lesions at risk which escaped preoperative diagnosis and in confirmation of this in Group C, during follow-up, the onset of only 4 lesions at risk was identified in which histological examination however excluded the presence of cancer.

Prevalence of autism in a United States population: the Brick Township, New Jersey, investigation.

OBJECTIVE: This study determined the prevalence of autism for a defined community, Brick Township, New Jersey, using current diagnostic and epidemiologic methods. METHODS: The target population was children who were 3 to 10 years of age in 1998, who were residents of Brick Township at any point during that year, and who had an autism spectrum disorder. Autism spectrum disorder was defined as autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger disorder. The study used 4 sources for active case finding: special education records, records from local clinicians providing diagnosis or treatment for developmental or behavioral disabilities, lists of children from community parent groups, and families who volunteered for participation in the study in response to media attention. The autism diagnosis was verified (or ruled out) for 71% of the children through clinical assessment. The assessment included medical and developmental history, physical and neurologic evaluation, assessment of intellectual and behavioral functioning, and administration of the Autism Diagnostic Observation Schedule-Generic. RESULTS: The prevalence of all autism spectrum disorders combined was 6.7 cases per 1000 children. The prevalence for children whose condition met full diagnostic criteria for autistic disorder was 4.0 cases per 1000 children, and the prevalence for PDD-NOS and Asperger disorder was 2.7 cases per 1000 children. Characteristics of children with autism in this study were similar to those in previous studies of autism. CONCLUSIONS: The prevalence of autism in Brick Township seems to be higher than that in other studies, particularly studies conducted in the United States, but within the range of a few recent studies in smaller populations that used more thorough case-finding methods.

[Measures for biomechanically correct positioning of knee joint endoprostheses]. / Massnahmen zur biomechanisch korrekten Positionierung von Kniegelenkendoprothesen.

Normal post-operative function, permanent stable fixation and long life for the implant material are determined mainly by the correct biomechanical positioning of the knee joint prosthesis. We have identified six measures within the surgical procedure that are of vital importance for achieving biomechanically correct positioning. Because of their great importance, we call these measures "The Golden Six", and describe their application using the ESKA Resurfacing Knee System (RKS). This system, which is so designed that it enables a maximal bone saving resection technique, makes use of a diagonal screw-fixation of the endoprosthetic elements, resulting in increased primary stability. For the safe and reliable implementation of our measures, we have developed a special set of instruments. Anatomical, kinematic and surgical studies have shown that with the aid of the above-mentioned six measures biomechanically correct positioning of all the implanted elements can be achieved, thus ensuring trouble-free post-operative function of the knee joint and the least possible mechanical stressing of the implanted materials.

Birth weight reduction associated with residence near a hazardous waste landfill.

We examined the relationship between birth weight and mother's residence near a hazardous waste landfill. Twenty-five years of birth certificates (1961-1985) were collected for four towns. Births were grouped into five 5-year periods corresponding to hypothesized exposure periods (1971-1975 having the greatest potential for exposure). From 1971 to 1975, term births (37-44 weeks gestation) to parents living closest to the landfill (Area 1A) had a statistically significant lower average birth weight (192 g) and a statistically significant higher proportion of low birth weight [odds ratio (OR) = 5.1; 95% confidence interval (CI), 2.1-12.3] than the control population. Average term birth weights in Area 1A rebounded by about 332 g after 1975. Parallel results were found for all births (gestational age > 27 weeks) in Area 1A during 1971-1975. Area 1A infants had twice the risk of prematurity (OR = 2.1; 95 CI, 1.0-4.4) during 1971-1975 compared to the control group. The results indicate a significant impact to infants born to residents living near the landfill during the period postulated as having the greatest potential for exposure. The magnitude of the effect is in the range of birth weight reduction due to cigarette smoking during pregnancy.

Assessment of reproductive disorders and birth defects in communities near hazardous chemical sites. I. Birth defects and developmental disorders.

Members of the workgroup on birth defects and developmental disorders discussed methods to assess structural anomalies, genetic changes and mutations, fetal and infant mortality, functional deficits, and impaired fetal and neonatal growth. Tier 1 assessments for all five adverse reproductive outcomes consist of questionnaires and reviews of medical records rather than laboratory testing of biologic specimens. The work-group members noted a role for neurodevelopmental testing and for limited genetic studies, such as karyotyping in Tier 2 assessments. Emerging methodologies to identify chromosomal aberrations, DNA adducts, and repair inhibition were reserved for Tier 3.

[Total hip replacement in presence of acetabular dysplasia type II according to the AAOS classification.]. / Zur Alloarthroplastik der Hüftgelenkpfanne bei Dysplasie-Typ II der AAOS-Klassifikation.

GOAL OF SURGERY: Incorporation of the acetabular cup in ideal position in patients with a primary dysplastic acetabulum. Two thirds of the surface of the cup must be covered by bone. INDICATIONS: Joint replacement in patients with acetabular dysplasia type II according to the AAOS classification. CONTRAINDICATIONS: Presence of acetabular dysplasia types I and III according to the AAOS classification. PREOPERATIVE WORK UP: Radiographic measurement of the acetabular depth and width using templates. POSITIONING AND ANAESTHESIA: Supine, affected side of pelvis slightly elevated. General or spinal anaesthesia. Special set of instruments mandatory. SURGICAL TECHNIQUE: Insertion of an acetabular cup through a lateral approach. Reaming of the acetabulum and filling of the defect under compression with a mixture of autogenous, morcellized bone from the resected femoral head and fibrin glue. Coverage of the transplanted bone with a pedicled capsular flap. POSTOPERATIVE MANAGEMENT: Phlebitis prophylaxis. Walking with 2 forearm crutches on the first postoperative day. Removal of stitches after 10 days. Thereafter gradual increase of weight bearing (10 kg every second day, use a bathroom scale to check loading). Once full weight bearing and full muscle control have been reached, use of 1 crutch is allowed. Radiographic control after 6 weeks, 3,6 and 12 months and yearly thereafter. POSSIBLE COMPLICATIONS: Perforation of the bony acetabulum. Fracture of the anterior or posterior acetabular rim. Thrombophlebitis, lung embolism, infection and/or periarticular ossification. RESULTS: Between 1986 and 1994 the technique has been used in 140 hips with congenital dysplasia (type II according to the AAOS classification) and secondary osteoarthritis. 132 hips were regularly assessed and the mean of follow-up was 6.2 years (1 to 9 years). The mean age of the mostly female patients was 48 years (28 to 62 years). Only porous surfaced metallic cups without cement were used. The following complications were observed: thrombophlebitis 1, superficial infection 1, transient paresis of the fibular nerve 1 and transient irritation of the femoral nerve 3 (see Table 2). Additional complications such as thigh pain, periarticular ossification and resorption of the bone graft are listed in Table 3. Complete bony incorporation of the bone grafts was seen in 122 hips. Resorption up to 8 mm occurred in the remaining 10 hips.

A case-control study to determine risk factors for elevated blood lead levels in children, Idaho.

OBJECTIVE: A pair-matched, case-control study was conducted to identify if risk factors or behaviors suspected to affect childhood blood lead levels, were more prevalent among children with elevated blood lead levels living in the vicinity of a defunct mining and smelting facility. METHODS: Study individuals were recruited from the 1992 Silver Valley blood lead screening participants. The cases were children with a blood lead level > 10 micrograms per deciliter (microgram/dL). The controls were children with a blood lead level < 10 micrograms/dL, who were matched to cases by age and sex. Data on risk factors were obtained through personal interviews. RESULTS: Of the variables examined, yard soil remediation showed the strongest association with changes in blood lead levels. This variable was found to be a protective factor for elevated blood lead levels in children (odds ratio, 0.28; confidence interval, 0.08-0.92). CONCLUSION: The results suggest that removal of lead contaminated soil from residential yards was effective in reducing blood lead levels in children.

Prolactin response to thyrotropin-releasing hormone as a guideline for cyclical mastalgia treatment.

METHODS: We studied a group of 36 fertile women affected with moderate-to-severe cyclical mastalgia (mean age: 26.0 years) showing a normal menstrual history and normal basal levels of circulating hormones, including prolactin (PRL), luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol (E2), progesterone (P), testosterone (T), dehydroepiandrosterone sulphate (delta HEAs), androstenedione (A). Using serial measurements of PRL plasma levels after an intravenous injection of thyrotropin-releasing hormone (TRH), (TRH test), patients were divided in two groups: 19 patients with abnormal PRL response to TRH and the remaining 17 with normal response. RESULTS: Bromocriptine treatment, 2.5 mg b.i.d. for 3-6 months, was effective in 73.6% of patients with abnormal TRH test and in 23.5% of patients with normal TRH test: the difference was statistically significant. On the other hand, 76.9% of patients with either normal TRH test or resistant to bromocriptine therapy had a favourable response to percutaneous progesterone and systemic non-steroidal antiinflammatory drugs (NSAIDs). CONCLUSIONS: These results seem to confirm the hypothesis that PRL response to TRH could be used to identify patients affected with cyclical mastalgia that are likely to benefit by bromocriptine treatment.

Cardiovascular problems and diving

In the US the Diving Alert Network has a list of physicians for medical consultation. I am one of the cardiologists on the list and I get about a call a day about some cardiac question that raises issues of safety or fitness for diving. I will discuss the commoner categories such as coronary artery disease, congenital heart disease, valvular disorders, arrhythmias, conduction disorders, pacemakers, some of the common cardiac drugs used in the treatment of hypertension and some other relatively benign medical conditions that raise questions about the use of the drugs rather than the condition itself.