Search

(Background) The diagnosis and the antimicrobial treatment of orthopedic infection are challenging, especially in cases with culture-negative results. New molecular methods, such as next-generation sequencing (NGS), promise to overcome some limitations of the standard culture, such as the detection of difficult-to-grow bacteria. However, data are scarce regarding the impact of molecular techniques in real-life scenarios. (Methods) We included cases of suspected orthopedic infection treated with surgery from May 2021 to September 2023. We combined traditional cultures with NGS. For NGS, we performed a metagenomic analysis of ribosomal 16s, and we queried dedicated taxonomic libraries to identify the species. To avoid false positive results, we set a cut-off of 1000 counts of the percentage of frequency of reads. (Results) We included 49 patients in our study. Our results show the presence of bacteria in 36/49 (73%) and 29/49 (59%) cases studied with NGS and traditional cultures, respectively. The concordance rate was 61%. Among the 19/49 discordant cases, in 11/19 cases, cultures were negative and NGS positive; in 4/19, cultures were positive and NGS negative; and in the remaining 4/19, different species were detected by traditional cultures and NGS. (Conclusions) Difficult-to-grow microorganisms, such as slow-growing anaerobic bacteria, were better detected by NGS compared to traditional culture in our study. However, more data to distinguish between true pathogens and contaminants are needed. NGS can be an additional tool to be used for the diagnosis of orthopedic infections and the choice of appropriate antimicrobial therapy.

Humeral non-union is a rare complication in shaft fractures, as well as humeral head necrosis is a possible complication in fracture involving the proximal third especially in four-part fractures. The presence of head osteonecrosis and diaphyseal non-union in the same arm represents a formidable challenge for an orthopaedic surgeon. We could not find any similar report in the literature dealing with this issue thus far. We present a case of a 65 years old woman referred to our hospital being affected by an atrophic humeral diaphyseal non-union with a massive bone loss (>10cm) associated to a humeral head osteonecrosis following a previous surgical procedures with a clear loosening of the hardware. At our institution,she was treated with hardware removal and insertion of a diaphyseal antibiotic spacer with Gentamycin for 2 months suspecting an active septic process at the union site despite negative cultural exams. Finally, she was treated with a cemented modular humeral megaprosthesis. At 20 months follow up, the patient, despite a reduced shoulder range of motion, referred to a pain-free recovery to an almost normal lifestyle, including car driving with no major disturbances. This case suggests that, in extreme selected cases following several failed treatments, megaprosthesis can represent a viable solution, especially in huge bone loss associated to joint degeneration, to ensure an acceptable return to a normal lifestyle.

Objective: The Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture (HSOPS) was designed to assess staff views on patient safety culture in hospital. This study examines psychometrics of the Italian translation of the HSOPS for use in territorial prevention facilities., Design: After minimal adjustments and pre-test of the Italian version, a qualitative cross-sectional study was carried out., Setting: Departments of Prevention (DPs) of four Local Health Authorities in Northern Italy., Participants: Census of medical and non-medical staff (n. 479)., Intervention: Web-based self-administered questionnaire., Main Outcome Measures: Descriptive statistics, internal reliability, Confirmatory Factor Analysis (CFA) and intercorrelations among survey composites., Results: Initial CFA of the 12 patient safety culture composites and 42 items included in the original version of the questionnaire revealed that two dimensions (Staffing and Overall Perception of Patient Safety) and nine individual items did not perform well among Italian territorial Prevention staff. After dropping those composites and items, psychometric properties were acceptable (comparative fit index = 0.94; root mean square error of approximation = 0.04; standardized root mean square residual = 0.04). Internal consistency for each remaining composite met or exceeded the criterion 0.70. Intercorrelations were all statistically significant., Conclusions: Psychometric analyses provided overall support for 10 of the 12 initial patient safety culture composites and 33 of the 42 initial composite items. Although the original instrument was intended for US Hospitals, the Italian translation of the HSOPS adapted for use in territorial prevention facilities performed adequately in Italian DPs., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Purpose: The aim of this systematic review was to assess the efficacy of heparin flushing in the lock of central venous catheters., Methods: We searched MEDLINE and CINAHL databases. Eligible studies were randomized controlled trials evaluating the use of heparin versus normal saline or other solution in the flushing of central catheter among adult patients. No language restrictions were applied. Two reviewers independently screened titles and abstracts in order to identify relevant publications. The same two reviewers retrieved and evaluated full texts. Parameter estimates regarding catheter occlusion were pooled using network meta-analysis with Bayesian hierarchical modeling., Results: We identified 462 references. Eight studies were included. There was no evidence that heparin was more effective than normal saline in reducing occlusions. It was unclear whether urokinase and lepirudin were more effective than heparin in reducing occlusions. Vitamin C solution does not appear to prolong catheter patency., Conclusions: There is no evidence of a different effectiveness between heparin flushing and normal saline or other solutions in reducing catheter occlusions. Due to the little and inconclusive evidence available in this field, further studies might be necessary.

The existence of a diverse serine proteinase gene family in lepidopteran insects suggests they play a significant role in the insect adaptation to plant proteinase inhibitors. These proteinases have been shown to be involved in the process of proteolytic digestion in insect larvae. We carried out a selective transcriptome study of midguts from Spodoptera frugiperda larvae fed on a diet supplemented with soybean proteinase inhibitor (SPI). Using subtracted cDNA libraries made of gut-expressed transcripts, a total of 2100 partial sequences were obtained, of those 38% were related to digestive process. Two large and diverse groups of chymotrypsins and trypsins were obtained, and some of these proteinase-encoding genes were further characterized by quantitative RT-PCR. The transcription analyses revealed two groups: one group of genes constitutively expressed in the control larvae that is up regulated by introducing SPI to the diet, and a second group that is absent in the control but is induced by the SPI-rich diet. This observation suggests that adaptation of S. frugiperda to SPI involves de novo synthesis and also up regulation of existing enzymes. Proteases from intestines of larvae reared on a diet with SPI showed insensitivity to the inhibitor. The proteases were also insensitive to a broad-spectrum potato proteinase inhibitor preparation. We propose that adaptation of S. frugiperda to SPI follows a "shotgun" approach, based on a general up regulation of a large set of endoproteinases.

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.

Objective: We evaluated the reliability of transvaginal ultrasonography in the differential diagnosis of adenomyoma versus leiomyoma., Study Design: Preoperative transvaginal ultrasonographic results were compared with postoperative pathologic findings in 405 women who underwent surgery for symptomatic uterine nodularity., Results: For adenomyoma diagnosis, transvaginal ultrasonography demonstrated a sensitivity of 87%, a specificity of 98%, a positive predictive value of 74.1%, and a negative predictive value of 98.6%, compared with a sensitivity of 96.1%, a specificity of 83.3%, a positive predictive value of 98.4%, and negative predictive value of 35.7% for leiomyoma diagnosis., Conclusion: Transvaginal ultrasonography is an effective, noninvasive, and relatively inexpensive procedure for the preoperative differential diagnosis of adenomyoma versus leiomyoma.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Five patients with a hysterosalpingographic diagnosis of unicornuate uterus underwent magnetic resonance imaging (MRI) and subsequently laparoscopy/laparotomy to evaluate the ability of MRI to identify the various subclasses of this malformation. The method was demonstrated to be valid, since in all 5 cases (one subclass A1b, two subclass A2, two subclass B) were correctly diagnosed. Compared with laparoscopy, MRI is less expensive, less invasive, and can be performed in women in whom laparoscopic examination is risky. However, unlike laparoscopy, MRI can not detect the presence of minimal and mild endometriosis and does not allow assessment of the tubal conditions.

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.

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.

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.

Sonography was used to study the site of uterine implantation of 12 pregnancies in eight patients with complete septation of the uterus. The purpose was to determine the incidence of septal implantation in these patients and its relation to the outcome of the pregnancies. The live-birth rate in the 12 pregnancies was 33%. Three pregnancies (25%) went to term and ended in live neonates. One (8%) resulted in a premature delivery and the neonate survived. Eight (67%) ended in abortion. Sonograms showed that in all four pregnancies that were not aborted, implantation was in the lateral wall of the uterus. In comparison, in the eight pregnancies that terminated in abortion, implantation was septal in six, mixed in one, and undetermined in one. Our experience with this small group of patients suggests that pregnancies in septate uteri have a poor prognosis and that abortion is related to septal implantation.

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.