Preoperative infection risk assessment in hip arthroplasty a matched-pair study of the reliability of 3 validated risk scales.

Peri-prosthetic infection (PJI) represents one of the most devastating complications of total hip arthroplasty (THA). The aim of this study is to assess the reliability of different PJI risk assessment scales between two matched pairs of THA groups. This study included 37 patients with PJI following THA performed between 2012 and 2020 (Group A). Each patient in this group was matched, based on sex, age, and follow-up duration, with a control patient who underwent the same surgical procedure without any septic complications (Group B) during the same period. Each patient's assessment included the American Society of Anesthesiologists (ASA) score and a retrospective evaluation using three different preoperative, specific PJI risk assessment scales: the International Consensus Meeting (ICM) Preoperative Risk Calculator for PJI, the Mayo PJI Risk Score, and the KLIC-score. The two groups were statistically compared using descriptive analyses, both for binomial data and numerical variables. Statistically significant higher values were observed in the preoperative ASA score and surgical time in Group A. Statistically different higher scores were determined only with the ICM risk calculator score in Group A. No significant differences were found using the KLIC score and Mayo score between the two groups. We emphasize the reliability of the ASA score as a nonspecific preoperative assessment scale for PJI. The ICM risk calculator was confirmed as a reliable, specific preoperative assessment scale for PJI, suggesting its routine adoption in THA clinical practice.

Exploring patient safety culture in preventive medicine settings: an experience from Northern Italy.

INTRODUCTION: Patient safety and quality in healthcare are inseparable. Examining patient safety culture in staff members contributes to further develop quality in healthcare. In Italy there has been some experience in assessing patient safety culture in staff working in hospital. In this pilot study we explored patient safety culture in public health staff working in Italian Local Health Authorities. METHODS: We carried out a descriptive cross sectional study in four Italian territorial Prevention facilities in Northern Italy. We administrated an adapted Italian version of the US Hospital Survey of Patient Safety Culture to all the staff within these facilities. The survey consisted of 10 dimensions based on 33 items, according to the results of a previous psychometric validation. RESULTS: Seventy per cent of the staff responded to the survey (N = 479). Overall, six out of the 10 dimensions exhibited composite scores of positive response frequency for patient safety culture below 50%. While "communication openness" (65%) was the most developed factor, "teamwork across Units" (37%) was the least developed. The work areas with the highest composite scores were Management and the Public Health Laboratory, while in terms of professional categories, Physicians had the highest scores. Patient safety culture in the staff participating in this study was lower than in hospital staff. DISCUSSION: Our descriptive cross sectional study is the first to be carried out in Preventive medicine settings in Italy. It has clearly indicated the need of improvement. Consequently, several interventions with this aim have been implemented.

Enhanced preovulatory progesterone levels in clomiphene citrate-induced cycles.

We measured basal body temperature, cervical mucus, follicular diameter, and serum LH, FSH, 17 beta-estradiol, and progesterone daily in 40 spontaneous ovulatory cycles in 27 infertile women and in 40 clomiphene citrate-induced ovulatory cycles in 31 women. The cervical score was significantly lower and the serum FSH, LH, and 17 beta-estradiol levels were significantly higher during the follicular phase in induced compared with spontaneous cycles. Serum progesterone was significantly higher on the 3 days preceding ovulation and the day of ovulation in the induced cycles. These increased preovulatory serum progesterone levels could contribute to the lower cervical mucus score in the induced compared with spontaneous cycle, whereas their effect on the endometrium is still unclear.

Ultrasound in the diagnosis of subclasses of unicornuate uterus.

Fourteen infertile women with hysterographic diagnoses of unicornuate uterus underwent pelvic ultrasonography and, subsequently, laparoscopy to evaluate the ability of ultrasound to diagnose the subclasses of this malformation. Seven women underwent laparotomy to remove a rudimentary horn. Ultrasound demonstrated a sensitivity of 85.7% and a specificity of 100% in diagnosing the presence of a rudimentary horn, and a sensitivity of 80% and a specificity of 100% in diagnosing the presence of a cavity in the rudimentary horn. Urography confirmed the supplementary information on the urinary tract provided by ultrasound. Ultrasound appears to have a role in the clinical management of women with unicornuate uterus.

Magnetic resonance evaluation of double uteri.

A total of 18 infertile patients with hysterosalpingographic diagnosis of bifid uterus underwent magnetic resonance imaging (MRI) and subsequent laparoscopy or laparotomy to evaluate the capability of MRI to differentiate among the various classes of the malformation. Magnetic resonance imaging identified both bicornuate uteri correctly, both didelphic uteri, nine of the 12 partial septate uteri, and both complete septate uteri. The method demonstrated a sensitivity of 100% and a specificity of 78.6% in demonstrating cervical prolongation of the spur. Compared with laparoscopy, MRI is less expensive and less invasive, and can also be performed in patients with extensive adhesions. However, it has the disadvantage of not providing information on tubal conditions or on the presence of minimal and mild endometriosis.

Magnetic resonance imaging in Mayer-Rokitansky-Küster-Hauser syndrome.

Six girls with suspected Rokitansky syndrome underwent magnetic resonance imaging (MRI) and then sonography and laparoscopy to confirm the clinical diagnosis and define the precise characteristics of the malformation. The uterus was missing in all; four had müllerian rudiments in place of the uterus, which were cavitary in two as shown by sonography and in one by MRI. Both ovaries were present in all cases, normally located in four and extrapelvic in two; they were correctly identified by MRI in all cases and by sonography in four. Partially canalized vaginal rudiments were recognized by MRI in two girls and by sonography in one. One patient had unilateral renal agenesis, demonstrated by both MRI and sonography. Magnetic resonance imaging was more precise than laparoscopy and sonography in defining the anatomical characteristics of Rokitansky syndrome, and is less invasive and expensive than laparoscopy.

Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas.

Seventy-one women with symptomatic uterine myomas, hospitalized for hysterectomy, underwent preoperative transvaginal ultrasonography and hysteroscopy to compare their reliability in the diagnosis of submucous myomas. After the operation, the surgical specimen was studied carefully and the results were compared with the preoperative diagnostic findings. Transvaginal ultrasonography had a sensitivity of 100% and specificity of 94%; the predictive value of an abnormal ultrasound scan was 81% and that of a normal one was 100%. The sensitivity of hysteroscopy was 100% and the specificity 96%; the predictive value of an abnormal hysteroscopic finding was 87% and that of a normal result was 100%. Mapping of uterine myomas is more precise with transvaginal ultrasonography than with hysteroscopy, but the former method cannot distinguish between a myoma and an endometrial polyp.

Superovulation with human menopausal gonadotropins in the treatment of infertility associated with minimal or mild endometriosis: a controlled randomized study.

OBJECTIVE: To determine the efficacy of superovulation with buserelin acetate, human menopausal gonadotropins (hMG), and human chorionic gonadotropin (hCG) in the treatment of infertility associated with minimal or mild endometriosis. DESIGN: Prospective, randomized, controlled study. SUBJECTS: Forty-nine infertile women with a laparoscopic diagnosis of endometriosis stage I (n = 29) or II (n = 20) according to the revised American Fertility Society classification, randomly assigned to three superovulation cycles (n = 24) or 6 months' expectant management (n = 25). MAIN OUTCOME MEASURES: Cycle fecundity rates and cumulative pregnancy rates (CPR) in the two groups. RESULTS: Nine pregnancies were obtained in the superovulation-treated patients and six in the nontreated ones. The cycle fecundity rates and CPR were 0.15% and 37.4% after three superovulation cycles and 0.045% and 24% after 6 months of expectant management (P less than 0.05 and P = not significant, respectively). The women who did not achieve a pregnancy after three cycles of superovulation were followed for a total of 50 months during which no therapy was given. One pregnancy started in this period (cycle fecundity rate = 0.020). One spontaneous abortion occurred in each group. Three treated patients had multiple pregnancies, and four had ovarian hyperstimulation syndrome. CONCLUSION: Superovulation seems to be associated with a better cycle fecundity rate but not a better CPR than expectant management in infertile women with endometriosis stages I and II. The efficacy and side effects of this therapeutic approach should be evaluated in larger series.

Prediction and self-prediction of ovulation in clomiphene citrate-treated patients.

We studied 15 infertile patients for a total of 25 cycles in order to compare the predictive value of the following parameters in timing ovulation: basal body temperature (BBT), cervical mucus, serum E2 and LH, follicular growth as shown by ultrasonography, and urinary LH. The patients themselves tested urinary LH at home using Clearplan kits. BBT had low value as a predictive test for the time of ovulation, whereas ultrasonography had a predictive value of 9%, serum E2 50%, cervical mucus 59%, serum LH 63.6% and Clearplan kits 63.6%. The best predictive reliability in timing ovulation was obtained by considering both serum LH and E2 measurements. The Clearplan kits were as reliable as serum LH measurements and have greater practical advantages.

Re-examination of the anatomic indications for hysteroscopic metroplasty.

Until now the indication for hysteroscopic metroplasty has been based on laparoscopic findings and thus depended on the operator's experience. Using ultrasound and magnetic resonance images of double uteri it should be possible to find more objective indications for this operation. When three points are identified on longitudinal scans of the uterine fundus, the two tubal ostia and the mid-point of the fundal perimetrium, hysteroscopic metroplasty is indicated only in uteri in which the third point is at least 5 mm above a straight line drawn between the tubal ostia. This classification criterion includes more cases than laparoscopic criteria in this study; we performed hysteroscopic metroplasty in 23 double uteri and had we followed the laparoscopic criteria the operation would have been performed only in 19.

Endometrial patterns during danazol and cyproterone acetate treatment for endometriosis: structural and ultrastructural study.

We studied the endometrial structure and ultrastructure in serial biopsies from 16 patients with endometriosis treated with danazol (n = 9) or the combination cyproterone acetate plus ethinyl estradiol (n = 7) for 6 months. Biopsies were performed before and at 3 and 6 months of treatment. The material obtained was studied by light (LM), scanning (SEM) and transmission electron microscopy (TEM). A morphometric analysis was performed evaluating three morphometric and three stereologic indices. The results indicate that danazol had a progestational effect on endometrial glands and stroma, associated with a marked hypotrophy of the mucosa. The cyproterone acetate/ethinyl estradiol combination induced progressive atrophy of the endometrium with an increase in the stromal component and a reduction of glandular tissue.

Timing of ovulation in spontaneous and induced cycles.

We studied 30 spontaneous cycles, 30 cycles induced with clomiphene citrate, and 30 cycles induced with human menopausal gonadotropin-human chorionic gonadotropin to evaluate the pattern of the following parameters and their predictive value in timing ovulation: basal body temperature; cervical mucus; mean follicular diameter; serum LH and 17-beta-estradiol; and urinary LH. Compared with the spontaneous cycles, in the cycles induced with clomiphene citrate the cervical score was significantly lower on the 4 days preceding ovulation, serum LH was higher in the early follicular phase, and serum 17-beta-estradiol was significantly higher in the pharmacologically treated cycles. The highest predictive values in all groups of cycles were obtained by considering the following combinations of parameters: serum 17-beta-estradiol and LH concentrations; mean follicular diameter as shown by ultrasonography and urinary LH as determined by a rapid method.

Enhanced pre-ovulatory progesterone levels in fertile cycles during clomiphene citrate treatment.

We compared ovulatory changes in fertile and preceding infertile cycles in 21 patients with unexplained infertility conceiving after clomiphene citrate treatment. No significant differences were observed in follicular growth, cervical score and follicle stimulating hormone (FSH) levels. Progesterone was higher (P less than 0.05) in the 2 days preceding ovulation in fertile cycles, luteinizing hormone (LH) higher (P less than 0.05) the day before, and 17-beta-estradiol lower (P less than 0.05) 4 days before. Stimulating progesterone secretion by systematic LH administration before ovulation could improve secretory endometrial transformation and thus reproductive prognosis.

Alveolar soft part sarcoma of the vagina.

We describe a case of primary alveolar soft part sarcoma presenting as a vaginal mass in a 27 year old woman and also review the literature on this type of tumor arising in the lower female genital tract. Histologically, most of the tumor exhibited poorly developed alveolar architecture, but anaplasia was absent. Although the mass was well circumscribed, a few tumor cells were seen focally within the peritumoral tissue. Treatment consisted of wide local excision followed by external radiation therapy. The patient is alive without evidence of disease 17 years after operation.

Argon laser versus microscissors for hysteroscopic incision of uterine septa.

We performed hysteroscopic metroplasty in 21 women with repeated abortion and subseptate uterus. The patients were randomly allocated to septal incision with the argon laser (group I, 10 subjects) or microscissors (group II, 11 subjects) to compare these instruments in terms of surgical feasibility and anatomic results. The mean operating time was 57% longer in group I than in group II (p = 0.001), the intra- and postoperative morbidity of the whole series was negligible, and the anatomic results at abdominal ultrasonography and hysteroscopy performed 2 months postoperatively were similar in the two groups. This study confirms that microscissors are the simplest, fastest, most effective, and least expensive instrument to correct a septate uterus. The complete agreement of the findings at follow-up hysteroscopy and ultrasonography suggest the use of the latter as the method of choice to check the surgical results.

Changes in blood flow velocity waveforms following fetal blood sampling.

The umbilical artery, aorta, and middle cerebral artery pulsatility indices were investigated by pulsed Doppler ultrasound in 73 fetuses at 18-37 weeks of gestation, before and after fetal blood sampling performed either at the placental cord insertion (n = 46) or at the intrahepatic vein (n = 27). At the end of the procedure, after randomization, 35 fetuses were infused amounts of normal saline equal to the blood volume withdrawn, and 38 fetuses served as controls. Following blood sampling, the umbilical artery pulsatility indices decreased both in controls (p = 0.004) and in the saline group (p = 0.006). The middle cerebral artery velocity waveforms exhibited similar changes only in controls (p = 0.01), and no changes in fetal heart rate and aortic pulsatility indices were recorded in either group. The changes in blood flow velocity waveforms did not correlate with gestational age and the blood volume sampled, and were similar whether the site of sampling was the placental cord insertion or the intrahepatic vein. In 10 acidemic and/or hypoxemic fetuses, pulsatility indices in the umbilical and middle cerebral arteries were not modified by the blood sampling procedure. The release of vasoactive substances is most likely the cause of diminished vascular resistances following fetal blood sampling. Hypoxemic/acidemic fetuses may fail to mount a normal vasodilative response to needle puncture.

[Intervention for integrated dento-periodontal prevention]. / Intervento di prevenzione integrata dento-parodontale.

An epidemiological survey has been achieved on elementary and secondary schoolchildren of five different areas in the territory of Ussl no 16 in Lecco. The study, performed on a randomly sample of 458 children aged 6, 10, 12 years, used the epidemiological indexes DMFT/dmft and CPITN to monitor dental and periodontal status. The treatment needs of the subjects was monitored too and the amount of Streptococco mutans in 6 years old schoolchildren, using spittle drawning, was investigated. The results seem to show that the DMFT/dmft values are on a moderate level as regards the European goals, while the amount of dental and periodontal treatment performed is very low. The gingivitis prevalence is high, as well as scaling is required in many children. The analysis of the spittle samples drawned in 6 years old schoolchildren points out high levels of Streptococcus mutans as regard those collected in other similar studies achieved by our Department. According to the results analysis, two sorts of preventive intervention were planned to have the maximum preventive efficacy according to the disease level located in the different areas.

Treatment with GnRH agonists before myomectomy and the risk of short-term myoma recurrence.

Twenty-four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200 micrograms/day intranasally, for 3 months followed by myomectomy (n = 8) or to immediate myomectomy (n = 16). Pre-operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml (P less than 0.01) but intra-operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of less than 1.5 cm in five women (63%) treated pre-operatively with the analogue and in two women (13%) who underwent immediate surgery (P less than 0.05). Induction of a period of hypo-oestrogenism before myomectomy seems to favour short-term recurrence of uterine myomas, limiting the efficacy of surgery.