Search

Purpose: Planovalgus foot deformity (PVFD) is common in children with neuromuscular conditions and severe deformity may require surgical correction. This study aims to assess clinical and radiological outcomes of PVFD secondary to neuromuscular disease managed by subtalar arthroeresis (SuAE), midfoot soft tissue release and talo-navicular arthrodesis (TNA)., Methods: A retrospective analysis of children with neuromuscular disease and nonreducible PVFD who underwent SuAE, midfoot soft tissue release, and TNA and with a minimum follow-up of 5 years was performed. A total of 60 patients with neuromuscular disease (108 feet) including cerebral palsy were reviewed. Mean age at surgery was 12.7 ± 4.6 years (6-17). Mean follow-up was 7 ± 2.9 years (5-10). Clinical outcomes and radiologic correction at final follow-up were compared with preoperative values. Statistical analysis was performed and significance was set at P < 0.01., Results: Statistically significant radiological improvements between pre- and postoperative values were found for all angle values. At final follow-up, there was a significant improvement in VAS score (4.8 vs. 2; P < 0.01). There was also a positive trend in the improvement of walking ability. No cases of pseudoarthrosis were reported at final follow-up. Screw removal was required in 5 out of 108 feet (4.6%) and 2 feet (3.3%) had delayed medial wound healing., Conclusions: SuAE combined with TNA and midfoot soft tissue is a safe and feasible procedure that can provide good clinical and radiologic results in patients with neuromuscular disease and nonreducible PVFD; the procedure can improve foot stability, and has a limited number of complications., Level of Evidence: IV., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background and Aim: The World Health Organization (WHO) goal of Hepatitis C Virus (HCV) elimination by 2030 rose awareness about the need of screening plans, worldwide. In Italy, graduated screening starting from people born in 1969-1989 might be the most-effective strategy. We performed an opportunistic HCV screening study in the general population attending health facilities in Lombardy region, Northern Italy., Methods: This is a prospective, multicenter, territory-wide, opportunistic study supported by the Regional Government of Lombardy, Italy. Between June 2022 and December 2022, all subjects born in 1969-1989, hospitalized or accessing blood collection centres were offered anti-HCV and HCV-RNA tests. Patients with known anti-HCV positivity and/or previous anti-HCV treatment were excluded. Demographic features were uploaded into a regional web-based platform., Results: In total, 120 193 individuals were screened in 75 centres. Mean age was 44 (±6) years, 65.2% were females, 83.7% were tested at blood collection centres. Anti-HCV tested positive in 604 (0.50%) subjects: mean age 47 (±5), 51.1% females. HCV seroprevalence was higher in males (p < 0.00001), elderly (p < 0.00001) and in- vs. outpatients (p = 0.0009). HCV-RNA was detectable in 125 out of 441 (28.3%) anti-HCV positive subjects. Actively infected patients were 46 (±6) years old, mainly males (56.8%). The overall prevalence of active HCV infection was 0.10%, higher in elderly (p = 0.0003) and in in-patients (p = 0.0007). Among 93 HCV-RNA positive patients, the median age was 48 years, 58% males, 62% Italian born, median HCV-RNA levels were 6,1 log IU/mL, liver stiffness measurement (LSM) values 5.5 (3.1-29.9) kPa and ALT levels 48 U/L., Conclusions: The prevalence of active HCV infection in the 1969-1989 population attending health facilities in Lombardy was low. Most viremic patients were Italian-born, with mild liver disease but high-HCV-RNA levels. Due to the higher prevalence in the elderly, the extension of such opportunistic screening programs to lower birth cohorts would be warranted., (© 2023 The Authors. Liver International published by John Wiley & Sons Ltd.)

Avascular necrosis (AVN) of the first metatarsal (MTT) head is an uncommon condition and it occurs most often as a complication after capital osteotomy in correction of hallux valgus deformity. Idiopathic osteonecrosis of the first MTT head in adolescent are rare and treatment is challenging (1,2). Many conditions have been proposed as predisposing factors of AVN, including trauma, hemoglobinopathies such as sickle-cell disease, steroid therapy, Cushing's disease, alcoholism, Gaucher's disease, Caisson's disease, and irradiation (3,4). However, etiology remains elusive. We described a case of an idiopathic AVN of the 1st MTT in adolescent treated by dorsal closing-wedge osteotomy, which to the authors' knowledge has not been described before.

The proximal tibia physis' anterior growth arrest is the cause of the uncommon condition known as acquired genu recurvatum, which can also be congenital, idiopathic, or secondary to trauma, infections, cerebrovascular accidents, or neuromuscular diseases. In order to avoid the reported drawbacks that could complicate osteotomies-incomplete correction, patella infera, knee pain or stiffness, and the requirement to remove plate metalwork-physeal distraction and callotasis with external fixation has been suggested. We present the case of a 14-year-old boy who had a 5 cm difference in limb length, with the right leg being shorter, and a right knee that was 30° recurved with flexion restriction beyond 40°. The correction was made in 50 days, and the external fixator was removed in 92 days after we performed a physeal distraction with an axial EF (ST.A.R., Citieffe) through an anterior physeal osteotomy just proximal to the tuberosity in conjunction with simultaneous asymmetrical tibial and femoral contralateral epiphysiodesys. The patient returned to playing football within 8 months despite the persistence of a 3 cm leg length discrepancy and had a symmetric full range of motion of the knee without any complications or persistent pain. The correction of genu recurvatum in adolescents may be achieved safely and effectively through physeal distraction with an axial external fixator.

For diagnosing SARS-CoV-2 infection and for monitoring its spread, the implementation of external quality assessment (EQA) schemes is mandatory to assess and ensure a standard quality according to national and international guidelines. Here, we present the results of the 2020, 2021, 2022 EQA schemes in Lombardy region for assessing the quality of the diagnostic laboratories involved in SARS-CoV-2 diagnosis. In the framework of the Quality Assurance Programs (QAPs), the routinely EQA schemes are managed by the regional reference centre for diagnostic laboratories quality (RRC-EQA) of the Lombardy region and are carried out by all the diagnostic laboratories. Three EQA programs were organized: (1) EQA of SARS-CoV-2 nucleic acid detection; (2) EQA of anti-SARS-CoV-2-antibody testing; (3) EQA of SARS-CoV-2 direct antigens detection. The percentage of concordance of 1938 molecular tests carried out within the SARS-CoV-2 nucleic acid detection EQA was 97.7%. The overall concordance of 1875 tests carried out within the anti-SARS-CoV-2 antibody EQA was 93.9% (79.6% for IgM). The overall concordance of 1495 tests carried out within the SARS-CoV-2 direct antigens detection EQA was 85% and it was negatively impacted by the results obtained by the analysis of weak positive samples. In conclusion, the EQA schemes for assessing the accuracy of SARS-CoV-2 diagnosis in the Lombardy region highlighted a suitable reproducibility and reliability of diagnostic assays, despite the heterogeneous landscape of SARS-CoV-2 tests and methods. Laboratory testing based on the detection of viral RNA in respiratory samples can be considered the gold standard for SARS-CoV-2 diagnosis.

Objective: To evaluate the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) anti-spike (S) IgG antibody production after vaccination with BNT162b2 and the protection from symptomatic breakthrough infections in health care workers., Methods: This prospective observational study (RENAISSANCE) had as a primary end point the evaluation of serologic response to BNT162b2 14 days after a second dose. SARS-CoV-2 anti-S IgG antibodies were evaluated with LIAISON SARS-CoV-2 TrimericS IgG assay (DiaSorin S.p.A.), which is able to detect the presence of both binding and neutralizing antibodies for trimeric spike glycoprotein. Participants were recruited from February 1, 2021, to February 22, 2021. Occurrence of vaccine breakthrough infections was assessed by reverse transcription-polymerase chain reaction on symptomatic and contact cases up to June 6, 2021., Results: Of 2569 staff evaluated, only 4 were nonresponders (0.16%; 95% CI, 0.04% to 0.41%). All 4 nonresponders were severely immunosuppressed and receiving treatment with mycophenolate mofetil or mycophenolic acid. At 14 days after the second dose, 67.5% (1733) of staff had anti-S IgG titers of 2000 BAU/mL or higher; 19.2% (494), between 1500 and 2000 BAU/mL; 9.8% (251), between 1000 and 1500 BAU/mL; and 3.4% (87), 1000 BAU/mL or lower. Women had a higher probability of having higher titers than men (64.5% [1044/1618] vs 58.3% [410/703]; P=.005). This was confirmed after adjustment for age group (odds ratio, 1.275; 95% CI, 1.062 to 1.531; P=.009). Four months after the end of the vaccination program, only 13 participants (0.26%) had experienced a breakthrough SARS-CoV-2 infection, including 1 nonresponder. This was the only participant requiring hospitalization for severe COVID-19., Conclusion: The vaccination campaign among health care workers at the ASST GOM Niguarda has resulted in a marked serologic response and reduction of incident COVID-19 cases. Yet, the lack of protection should not be overlooked in immunocompromised individuals., (Copyright © 2021 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic has placed a huge strain on the health care system globally. The metropolitan area of Milan, Italy, was one of the regions most impacted by the COVID-19 pandemic worldwide. Risk prediction models developed by combining administrative databases and basic clinical data are needed to stratify individual patient risk for public health purposes., Objective: This study aims to develop a stratification tool aimed at improving COVID-19 patient management and health care organization., Methods: A predictive algorithm was developed and applied to 36,834 patients with COVID-19 in Italy between March 8 and the October 9, 2020, in order to foresee their risk of hospitalization. Exposures considered were age, sex, comorbidities, and symptoms associated with COVID-19 (eg, vomiting, cough, fever, diarrhea, myalgia, asthenia, headache, anosmia, ageusia, and dyspnea). The outcome was hospitalizations and emergency department admissions for COVID-19. Discrimination and calibration of the model were also assessed., Results: The predictive model showed a good fit for predicting COVID-19 hospitalization (C-index 0.79) and a good overall prediction accuracy (Brier score 0.14). The model was well calibrated (intercept -0.0028, slope 0.9970). Based on these results, 118,804 patients diagnosed with COVID-19 from October 25 to December 11, 2020, were stratified into low, medium, and high risk for COVID-19 severity. Among the overall study population, 67,030 (56.42%) were classified as low-risk patients; 43,886 (36.94%), as medium-risk patients; and 7888 (6.64%), as high-risk patients. In all, 89.37% (106,179/118,804) of the overall study population was being assisted at home, 9% (10,695/118,804) was hospitalized, and 1.62% (1930/118,804) died. Among those assisted at home, most people (63,983/106,179, 60.26%) were classified as low risk, whereas only 3.63% (3858/106,179) were classified at high risk. According to ordinal logistic regression, the odds ratio (OR) of being hospitalized or dead was 5.0 (95% CI 4.6-5.4) among high-risk patients and 2.7 (95% CI 2.6-2.9) among medium-risk patients, as compared to low-risk patients., Conclusions: A simple monitoring system, based on primary care data sets linked to COVID-19 testing results, hospital admissions data, and death records may assist in the proper planning and allocation of patients and resources during the ongoing COVID-19 pandemic., (©Rossella Murtas, Nuccia Morici, Chiara Cogliati, Massimo Puoti, Barbara Omazzi, Walter Bergamaschi, Antonio Voza, Patrizia Rovere Querini, Giulio Stefanini, Maria Grazia Manfredi, Maria Teresa Zocchi, Andrea Mangiagalli, Carla Vittoria Brambilla, Marco Bosio, Matteo Corradin, Francesca Cortellaro, Marco Trivelli, Stefano Savonitto, Antonio Giampiero Russo. Originally published in JMIR Public Health and Surveillance (https://publichealth.jmir.org), 15.11.2021.)

SARS-CoV2 infection is a systemic disease that may involve multiple organs, including the central nervous system (CNS). Aims of our study are to describe prevalence and clinical features of neurological manifestations, mortality and hospital discharge in subjects hospitalized with COVID-19. All individuals admitted for to our hospital COVID-19 were retrospectively included. Patients were classified according to the symptoms at hospital entry in (1) isolated respiratory, (2) combined respiratory and neurologic, (3) isolated neurologic and (4) stroke manifestations. Descriptive statistics and nonparametric tests to compare the groups were calculated. Kaplan Meier probability curves and multivariable Cox regression models for survival and hospital discharge were applied. The analysis included 901 patients: 42.6% showed a severe or critical disease with an overall mortality of 21.2%. At least one neurological symptom or disease was observed in 30.2% of subjects ranging from dysgeusia/anosmia (9.1%) to postinfective diseases (0.8%). Patients with respiratory symptoms experienced a more severe disease and a higher in-hospital mortality compared to those who showed only neurologic symptoms. Kaplan Meier estimates displayed a statistically significant different survival among groups (p = 0.003): subjects with stroke had the worst. After adjusting for risk factors such as age, sex and comorbidity, individuals with isolated neurologic manifestations exhibited a better survival (aHR 0.398, 95% CI [0.206, 0.769], p = 0.006). Neurologic manifestations in COVID-19 are common but heterogeneous and mortality in subjects with isolated neurologic manifestations seems lower than in those with respiratory symptoms., (© 2021 Federation of European Neuroscience Societies and John Wiley & Sons Ltd.)

Background: Reverse Transcription-Polymerase Chain Reaction (RT-PCR) for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2) diagnosis currently requires quite a long time span. A quicker and more efficient diagnostic tool in emergency departments could improve management during this global crisis. Our main goal was assessing the accuracy of artificial intelligence in predicting the results of RT-PCR for SARS-COV-2, using basic information at hand in all emergency departments., Methods: This is a retrospective study carried out between February 22, 2020 and March 16, 2020 in one of the main hospitals in Milan, Italy. We screened for eligibility all patients admitted with influenza-like symptoms tested for SARS-COV-2. Patients under 12 years old and patients in whom the leukocyte formula was not performed in the ED were excluded. Input data through artificial intelligence were made up of a combination of clinical, radiological and routine laboratory data upon hospital admission. Different Machine Learning algorithms available on WEKA data mining software and on Semeion Research Centre depository were trained using both the Training and Testing and the K-fold cross-validation protocol., Results: Among 199 patients subject to study (median [interquartile range] age 65 [46-78] years; 127 [63.8%] men), 124 [62.3%] resulted positive to SARS-COV-2. The best Machine Learning System reached an accuracy of 91.4% with 94.1% sensitivity and 88.7% specificity., Conclusion: Our study suggests that properly trained artificial intelligence algorithms may be able to predict correct results in RT-PCR for SARS-COV-2, using basic clinical data. If confirmed, on a larger-scale study, this approach could have important clinical and organizational implications.

Background: As the novel SARS-CoV-2 pandemic occurred, no specific treatment was yet available. Inflammatory response secondary to viral infection might be the driver of severe diseases. We report the safety and efficacy (in terms of overall survival and hospital discharge) of the anti-IL6 tocilizumab (TCZ) in subjects with COVID-19., Methods: This retrospective, single-center analysis included all the patients consecutively admitted to our Hospital with severe or critical COVID-19 who started TCZ treatment from March 13th to April 03rd, 2020. A 1:2 matching to patients not treated with TCZ was performed according to age, sex, severity of disease, P/F, Charlson Comorbidity Index and length of time between symptoms onset and hospital admittance. Descriptive statistics and non-parametric tests to compare the groups were applied. Kaplan Meier probability curves and Cox regression models for survival, hospital discharge and orotracheal intubation were used., Results: Seventy-four patients treated with TCZ were matched with 148 matched controls. They were mainly males (81.5%), Caucasian (82.0%) and with a median age of 59 years. The majority (69.8%) showed critical stage COVID-19 disease. TCZ use was associated with a better overall survival (HR 0.499 [95% CI 0.262-0.952], p = 0.035) compared to controls but with a longer hospital stay (HR 1.658 [95% CI 1.088-2.524], p = 0.019) mainly due to biochemical, respiratory and infectious adverse events., Discussion: TCZ use resulted potentially effective on COVID-19 in terms of overall survival. Caution is warranted given the potential occurrence of adverse events., Financial Support: Some of the tocilizumab doses used in the subjects included in this analysis were provided by the "Multicenter study on the efficacy and tolerability of tocilizumab in the treatment of patients with COVID-19 pneumonia" (EudraCT Number: 2020-001110-38) supported by the Italian National Agency for Drugs (AIFA). No specific funding support was planned for study design, data collection and analysis and manuscript writing of this paper., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020. Published by Elsevier Ltd.)

Lombardy is the Region in Italy the most heavily affected by coronavirus disease (COVID-19) contagion. The Regional Health Authority mandates that mental health services should be guaranteed, identifying mental health as a priority for their citizens. Recommendations for occupational and health safety have been provided to patients and hospital staff, including support for telemedicine activities and remote psychosocial interventions. Services of the Mental Health Departments of Milano "Niguarda" and Brescia "Spedali Civili" Hospitals are providing continued care at a community, residential and hospital level, and to positive COVID-19 psychiatric patients in need of hospitalization., Competing Interests: Declaration of Competing Interest The Authors declare that they have no competing interests., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: The thoracic spine, the chondral and osseous ribs, and the sternum together make up the thoracic cage. These elements are strictly correlated, although their growth is not synchronous. The purpose of this study is to provide a comprehensive data set of thoracic dimensions and non-invasive volumetric assessment in a large cohort of males and females from early childhood to young adult age., Methods: In all, 622 healthy individuals (406 girls, 216 boys) aged 6-18 years were consecutively enrolled between 2006 and 2016. All had to be healthy with no history of spinal deformity, or any lung, cardiovascular, systemic or neuromuscular disease. The optical ORTEN system for trunk surface data acquisition was used to calculate thoracic cage volume (V) and perimeter (Pe), anterior-posterior depth (AP) and transverse diameter (TD), AP/TD ratio, sternal length (St), and T1-T12 distance (Tle) in all patients., Results: The overall average age was 11.1 ± 2.5 years (4-18) for girls and 11.0 ± 3.1 years (4-18) for boys. Average growth parameters were: standing height 146.2 ± 14.6 cm (103-172) for girls and 146.4 ± 20.0 cm (94-192) for boys, sitting height 75.4 ± 8.6 cm (61-91) for girls and 75.5 ± 10.3 cm (60-99) for boys, weight 37.6 ± 10.4 kg (16-65) for girls and 38.3 ± 14.3 kg (13.7-104) for boys, BMI 16.7 ± 3.7 (18.5-26) for girls and 17.0 ± 3.3 (18.7-34.3) for boys. At age 6-8 years: V was 52.5% of its final size in girls and 44.9% in boys; Pe was 80.2% its final length in girls and 76.8% in boys; St reached 68% of its final size in girls and 66.9% in boys; Tle reached 73.3% of its final length in girls and 71.2% in boys. At skeletal maturity, thoracic cage volume in boys was 19.4% greater than in girls (p < 0.05). AP/TD ratio remained < 1 in all age groups and did not differ between genders (p > 0.05)., Conclusion: Growth of the thoracic cage is shown to be a gradual process that is more linear than previously reported. Only small increases in annual growth rates were observed during the pubertal growth spurt. The most important events characterizing thoracic cage development occurred during the first few years of postnatal growth. The circular cross-section of the very young child's thorax reached adult-like proportions together with its ovoid shape before age 6 years.

Background/aim: In the last few decades, treatment strategies for acute lymphoblastic leukemia (ALL) have been associated not only with improvement of prognosis, but also with an increasing rate of late complication as osteonecrosis (ON). Herein, the cumulative incidence, risk factors, new conservative therapeutic strategies as hyperbaric oxygen therapy (HBO), and outcome of symptomatic ON were studied in pediatric patients with ALL., Patients and Methods: Between 2000 and 2017, 495 children and young adolescents with a diagnosis of ALL were evaluated. All the symptomatic patients underwent magnetic resonance imaging (MRI) to detect bone vascularization and structure., Results: Twenty-three out of 495 patients presented ON (4.6%). ON was associated with an older age (p<0.0001) and a higher steroid dose (p=0.0013). All the patients underwent standard therapies and HBO was performed in 8 of 23 patients. During the follow-up, 15 patients were stable: 6 were totally asymptomatic, 5 complained of pain during activity, and 4 presented mild function limitation., Conclusion: Our data highlight the importance of early diagnosis of ON by screening MRI in asymptomatic patients, in order to start conservative treatment strategies. Moreover, HBO could have beneficial effects on ON patients., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Femoral fractures are a major healthcare problem worldwide. One of the most difficult issues is their preoperative care, which is still managed by either skeletal or skin traction in some countries, including Italy. These issues are discussed and compared with the contemporary literature., Objective: This study aims to analyse the distribution of these treatment options within the orthopaedic community and the reasons for their use, as well as to identify how this may impact nursing care in terms of pain management, hygiene care, venous thromboembolism (VTE)prophylaxis and prevention of pressure ulcers., Design: For this cross-sectional study, a 12-item survey was administered to the nursing staff, consultants and residents of the Orthopaedic Units in three different hospitals in NorthEastern Italy. The questionnaire investigated the routine use of skeletal or skin traction for the preoperative management of hip fractures in those settings., Findings: 136 surveys were completed, providing a response rate of 87.74%. Preoperative traction for hip fractures was still in use in the three hospitals, mainly applied by experienced surgeons for subtrochanteric fractures. Pain management, VTE and pressure ulcer prevention were perceived as worse only with skeletal traction, while hygiene was described as more difficult with both skeletal and skin traction., Conclusions and Recommendations: Based on the data and the literature revision, skin or skeletal traction for patients with proximal femoral fractures should be discouraged as standard practice. This is supported widely in the international literature, and consideration of knowledge translation strategies should be made to refine current practice in these settings., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The purpose of this prospective study was first to evaluate the safety and effectiveness of Minimally Invasive Distal Metatarsal Metaphyseal Osteotomy (DMMO) in treating central metatarsalgia, identifying possible contraindications. The second objective was to verify the potential of DMMO to restore a harmonious forefoot morphotype according to Maestro criteria., Methods: A consecutive series of patients with metatarsalgia was consecutively enrolled and treated by DMMO. According to Maestro criteria, preoperative planning was carried out by both clinical and radiological assessment. Patient demographic data, AOFAS scores, 17-FFI, MOXFQ, SF-36, VAS, and complications were recorded. Maestro parameters, relative morphotypes, and bone callus formation were assessed. Statistical analysis was carried out ( p < 0.05)., Results: Ninety-three patients (93 feet) with a mean age of 62.4 (31-87) years were evaluated. At mean follow-up of 58.7 (36-96) months, all of the clinical scores improved significantly ( p < 0.0001). Most of the osteotomies (76.3%) had healed by 3-month follow-up, while ideal harmonious morphotype was restored only in a few feet (3.2%). Clinical and radiological outcomes were not different based on principal demographic parameters. Long-term complications were recorded in 12 cases (12.9%)., Conclusion: DMMO is a safe and effective method for the treatment of metatarsalgia. Although Maestro criteria were useful to calculate the metatarsal bones to be shortened and a significant clinical improvement of all scores was achieved, the ideal harmonious morphotype was restored only in a few feet. Hence, our data show that Maestro criteria did not have a predictive value in clinical outcomes of DMMO.

Purpose: Hemiplegic cerebral palsy patient may present a shorten leg on the hemiplegic side that afflicts negatively the kinematic of the uninvolved limb. Thus, the aim of this study was to investigate the modification of gait kinematic after epiphysiodesis for limb equalization and secondary to verify the prediction of correction., Methods: Skeletally immature hemiplegic patients with a minimum limb leg discrepancy (LLD) of 2.5 cm were treated with epiphysiodesis of the unaffected knee and clinically evaluated with Edinburgh visual gait score (EVGS). Green-Anderson curve was used to predict time decision for correction., Results: Ten LLD patients were evaluated with the Edinburgh visual gait score (EVGS) before and after surgery. Mean age was 12.7 years, mean follow-up was 6.7 years, and mean LLD was 3.4 cm before surgery and 1.2 cm at final follow-up. After lower limb equalization surgery, improvement in gait kinematics was observed on both the uninvolved and hemiplegic limb of hemiplegic cerebral palsy patients (p < 0.001). Final correction did not reach expected correction (2.3 vs. 2.8 cm). However, the difference was not statistically significant (p = 0.058)., Conclusion: This is the first study to report improvement on both the uninvolved and hemiplegic limb gait kinematics after limb equalization surgery. Due to the impaired dorsiflexion of the hemiplegic foot, LLD target at the end of growth should range between 0.5 and 1.5 cm.

Background: The aim of the study is to review the outcome of using the VAC system in children and adolescents who have developed postoperative spinal infection after posterior instrumented spinal fusion, and to evaluate whether this technique is also feasible in patients treated with posterior instrumented fusion with polyester sublaminar bands., Methods: A total of 11 out of 118 consecutive children and adolescents (5 males) with deep postoperative spinal infection were identified; infections were categorised as early (acute), delayed (subacute) or late (chronic) according to time of onset. Irrespective of the etiology and the onset, all the deep infections were managed with the reported technique. All the patients had regular clinical and radiological follow-up., Results: Eight out of 11 patients developed an early (72.7%), 2 a delayed (18.2%) and 1 a late deep postoperative infection (9.1%); 7 out of 11 (63.6%) showed severe mental compromise. No statistically significant differences were observed for mean number of VAC dressing changes (p = 0.81) and mean length of hospitalisation comparing patients with early infection versus patients with delayed or late infections (p = 0.32). Mean number of VAC dressing changes (p = 0.02) and mean number of hospitalisation days (p = 0.05) were higher in patients with underlying neurological disorders than in those without, while mean length of hospitalisation was longer in neuromuscular patients., Conclusions: The application of the VAC system, as an adjunct to surgical debridement and adequate antibiotic therapy, is a reliable method for the treatment of postoperative infection in children and adolescents undergoing spinal instrumentation and fusion. It can reduce the need for further complex soft-tissue procedure, removal of hardware with consequent loss of correction, and pseudoarthrosis. Finally, the use of VAC therapy is not contraindicated in patients treated with hybrid constructs with sublaminar bands., Level of Evidence: III.

Background: The purpose of this non-randomized retrospective study was to investigate outcomes of minimally displaced, proximal 5MTB fractures, treated by a below-knee walking cast or a functional elasticated bandage with a support of a flat hard-soled shoe., Methods: A consecutive patient series was divided into two groups: the cast group (CG) and the functional group (FG). The subjects were radiologically and clinically evaluated according to Mehlhorn and Lawrence-Botte classification, and AOFAS Midfoot score, respectively., Results: 154 patients were followed up for a median of 15 months (range 12-24). There was no significant difference (p > 0.05) among the outcomes of each fracture pattern regarding the treatment choice. However, an earlier return to sports was noted in the FG, while Type-3 fractures achieved the worst results., Conclusion: Type-1 and 2 minimally displaced 5MTB proximal fractures can be successfully treated conservatively without weight-bearing restriction and without benefit of a cast with respect to a functional elasticated bandage., Level of Clinical Evidence: level III retrospective comparative study., Competing Interests: Conflict of interest statement The Authors declare that they have no conflict of interest related to the publication of this manuscript, and they have not received benefits or financial funds in support of this study.

Background: The aims of this prospective study were first to evaluate the safety and effectiveness of minimally invasive distal metatarsal diaphyseal osteotomies (DMDOs) for treating a consecutive series of diabetic patients with chronic plantar diabetic foot ulcers (CPDFUs) and second to assess their clinical-functional and radiographic outcomes., Methods: A consecutive series of patients affected by diabetes mellitus with CPDFUs, not responsive to previous nonoperative management, underwent DMDO. The CPDFUs were evaluated using the University of Texas Diabetic Wound Classification System (UTDWC). Demographic parameters, Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores, healing times, and complications were recorded. Maestro et al criteria and bone callus formation were analyzed radiologically. Statistical analysis was carried out ( P < .05). Thirty consecutive enrolled patients with a mean age of 66.7 (range, 53-75) years presented 35 CPDFUs with a mean diameter of 16.3 mm and a mean duration of 10.3 months. The most frequent grade of the UTDWC was IIIB (42.9%)., Results: All ulcers recovered with a mean healing time of 7.9 ± 4.0 (range, 4-17) weeks. AOFAS scores improved significantly from 55.3 to 81.4 points ( P < .001). At a mean follow-up of 25.3 months (range, 18-71), no cases of ulcer recurrence were recorded, while a major complication or a wound infection required longer healing time., Conclusion: Minimally invasive DMDO was a safe and effective method in promoting CPDFU healing, regardless of the grade of severity, by the reduction of the high plantar pressure under the metatarsal heads. This technique improved functional and radiographic outcomes with few complications., Level of Evidence: IV, case series.

Purpose: Thoraco-lumbo-sacral orthosis (TLSO) is an effective treatment in adolescent idiopathic scoliosis (AIS) patients, but cervical sagittal alignment (CSA) variations after bracing have never been evaluated. The purpose of this study was to assess changes in CSA before, during and after TLSO treatment, and to determine whether patients developed cervical pain., Methods: This was a retrospective study in 38 AIS patients (33 females; mean age 10.8 years) treated by TLSO. Patients were Risser 0 (n = 34) or 1 (n = 4). Major curve deformity (MC) in the coronal plane and cervical (CSA), thoracic (TSA) and lumbar (LSA) sagittal alignment were evaluated radiographically at start of treatment (t 0 ), after 1 month of brace treatment (t 1 ), and 1 year after end of treatment (t 2 ). Cervical pain was evaluated at t 2 using a visual analogue scale (VAS)., Results: The TLSO was worn for an average of 4.6 years. Mean CSA, TSA and LSA were significantly lower at t 2 than at t 0 : 0 ± 2.5° vs. 9.4 ± 2.3°, 24.1 ± 2.6° vs. 29.3 ± 2.4° and 5 ± 1.9° vs. 44.2 ± 2.5°, respectively (p < 0.05). CSA and TSA showed moderate-good correlation (r = 0.57). CSA was normolordotic in 1/38 patients at t 2 compared to 18/38 at t 0 (p < 0.05). MC did not progress during treatment (p > 0.8). VAS score was 0 in all patients., Conclusions: The TLSO can control progression of the deformity in the frontal plane, but it influences CSA, TSA and LSA. In particular, it decreases cervical spine lordosis, with reduction maintained 1 year after the end of treatment. Numerical differences, although statistically significant, were not clinically relevant.

Purpose: Chronic osteomyelitis and infected nonunion are relatively rare conditions in pediatric patients and are more frequently seen in developing countries. Although relatively rare, they are medically and surgically challenging. Here we report a novel surgical technique used to manage five patients with chronic osteomyelitis of long bones., Methods: Five skeletally immature patients with chronic osteomyelitis and infected nonunion of the long bones were treated surgically between 2010 and 2014 by a combination of resection of necrotic infected bone, debridement of surrounding soft tissue, and application of antibiotic-laden cement spacer inducing periosteal membrane before final bone reconstruction. Once inflammatory markers normalized, all the patients were re-operated for cement removal, bone graft substitution, and concomitant osteosynthesis of the affected bone, if needed. All patients underwent MRI, CT scan, and laboratory evaluation prior to surgery. The antibiotic regimen was started empirically and then adjusted according to culture and sensitivity results., Results: Mean patient age at the time of diagnosis was 11 years (range 4-14), and all patients had at least 2-year follow-up (range 2-5). At last follow-up, clinical and laboratory evaluation had normalized, the bone had healed, and all patients had resumed daily living and sports activities., Conclusion: Surgical debridement is the standard approach to chronic osteomyelitis. Use of antibiotic-laden cement is recommended to penetrate local infection, with antibiotic therapy playing an adjunctive role. The cement also induces membrane formation that aids bone reconstruction., Level of Evidence: IV.

Purpose: Renal osteodystrophy (ROD) may cause severe lower limb deformities in children. The purpose of this study is to evaluate the efficacy of the temporary hemiepiphysiodesis for the correction of lower limb deformities in children with ROD., Methods: Guided growth correction by hemiepiphysiodesis has been performed in skeletally immature patients with deformities of the lower limbs caused by ROD. The correction of the mechanical axes of the lower limbs and its correction speed have been evaluated., Results: A total of seven patients with ROD, five males and two females, were treated with the above technique. The average age of the patients at their first surgery was 7.8 years (2.9 to 13.6). The average follow-up time 5.2 years (2.3 to 8). There were 13 valgus deformities and one varus deformity of the knee. The measure of the lower limb angular deformity was in the range of 10° to 47°. Restoration of normal mechanical axis was achieved in all patients at the final follow-up. Three patients relapsed and required further hemiepiphysiodesis. The average time for correction was 20 months (7 to 30). The average speed of correction was 0.49° per month for a tibia and 1.73° per month for a femur. There were two minor complications: a screw mobilisation and a screw breakage occurred during removal., Conclusion: Guided growth technique by hemiepiphysiodesis is a mini-invasive surgical procedure that has been found to be effective for the correction of misalignment due to ROD in skeletally immature patients. The method has allowed progressive correction of the deformities at any age in childhood. These patients are predisposed to relapse to their deformities, thus a strict follow-up is required.

Background: Minimally invasive surgery (MIS) represents one of the most innovative surgical treatments of hallux valgus (HV). However, long-term outcomes still remain a matter of discussion within the orthopaedic community. The purpose of this longitudinal prospective study was to evaluate radiographic and functional outcomes in patients with mild-to-severe HV who underwent Reverdin-Isham and Akin percutaneous osteotomy, following exostosectomy and lateral release., Methods: Eighty patients with mild-to-severe symptomatic HV were treated by MIS. Clinical evaluation was assessed preoperatively, as well as at 3 and 12 months after surgery and at final follow-up of 48 months, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Patient satisfaction and complications were recorded. Computer-assisted measurement of antero-posterior radiographs was taken preoperatively, as well as at 3 and 12 months after surgery and at 48-month follow-up, analysing the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA) and the tibial sesamoid position. Also, the bridging bone/callus formation was evaluated at the different radiographic follow-ups, while the articular surface congruency and the metatarsal index were calculated only preoperatively and at the last follow-up. Patient satisfaction was assessed using the visual analogue score (VAS). Statistical analysis was carried out using the paired t test. Statistical significance was set at p < 0.05., Results: The mean AOFAS score was 87.15 points at the final follow-up of 48 months, and the VAS score was 8.35/10. The post-operative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections of each angular value at the last follow-up were as follows: IMA 3.90°, HVA 12.50°, DMAA 4.72° and a tibial sesamoid position of 1.10. The articular surface was congruent in 77 (96.25%) cases and incongruent only in 3 (3.75%). The complete healing of the osteotomies was achieved in all series at 3-month follow-up. However, the results obtained in the correction of the severe HV deformities were less encouraging., Conclusions: Minimally invasive surgery with Reverdin-Isham and Akin percutaneous osteotomy, in combination with previous exostosectomy and subsequent lateral soft-tissue release, is a safe, effective and reliable procedure for correction of mild-to-moderate HV. However, it requires a long learning curve because of the inherent difficulty of the mixed different surgical procedures., Trial Registration: ClinicalTrials.gov PRS Protocol Registration and Results System: NCT02886221.

Purpose: The olecranon fracture is an uncommon injury reported to incur many possible complications in children. The aim of this study was to compare the outcome of two different surgical techniques in isolated olecranon fracture., Methods: We retrospectively evaluated 22 children with isolated olecranon fracture treated by open reduction and tension band wiring fixation versus closed reduction and percutaneous screw fixation. We compared the dislocation before and after surgery by radiography. The patients were evaluated clinically with Quick DASH(®)., Results: Both techniques showed good radiological and clinical outcome (Quick DASH(®) 1.82 vs. 3.42) with no statistically significance difference (p > 0.05). In two cases (16.6 %) of the group treated with cannulated screw, it was necessary to convert into open reduction to obtain optimal reduction of the fracture. All the children returned to previous activity. In four cases, the extension of the elbow was slightly reduced (15°-20°), with no statistically significant difference in the two groups., Conclusion: It is not contraindicated to operate skeletally immature patients with displaced olecranon fracture. However, results were essentially the same, and so either method is a satisfactory choice for pediatric displaced olecranon fractures, with equally acceptable radiological results and similar rate of complications and clinical outcome at final follow-up., Level of Evidence: III.

Background: Hypermobility of the first ray, a probable primary cause of hallux valgus, has traditionally been evaluated in the dorsal direction only although the first tarso-metatarsal joint allows movement in a dorso-medial direction., Materials and Methods: 600 feet, divided according to the presence or absence of hallux valgus, were evaluated for both dorsal and dorso-medial displacement using a Klaue device., Results: In the control group, the mean first ray displacement was 7.2mm (4.2-11.3) in the dorsal direction (sagittal plane) and 8.3mm (4.0-12.6) in the 45° dorso-medial direction. In the hallux valgus group, the mean first ray mobility was 9.8mm (5.2-14.1) in the dorsal direction compared to a mean of 11.0mm (5.9-16.2) in the 45° dorso-medial direction., Conclusion: It is a paradox that hypermobility of the first ray is measured in only a dorsal (vertical) direction whereas a hallux valgus angle and an intermetatarsal angle are only measured in a transverse plane. Furthermore, the weightbearing foot pronates during gait and the first metatarsal is displaced in a dorsomedial direction rather than a pure dorsal direction. It is suggested that measurement hypermobility of the first ray at a 45° dorso-medial direction is more appropriate., (Copyright © 2015 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: Hallux valgus (HV) is a complex deformity of the forefoot altering the kinematics of walking. Many different treatment alternatives exist for the correction of hallux valgus, but to date, none has been shown to be more effective than any other. The rate of complications following hallux valgus surgery is variable and has been reported as ranging from 1 to 55 % in the scientific literature. The purpose of this preliminary prospective study was to evaluate the result of the Endolog device, an innovative titanium endomedullary nail, for the treatment of HV., Methods: Thirty patients with mild-to-severe HV were treated with the Endolog device. Clinical evaluation was assessed preoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery with a final follow-up at 4 years, using the American Orthopaedic Foot and Ankle Society (AOFAS) hallux grading system. Computer-assisted measurement of weight-bearing antero-posterior radiographs was taken preoperatively and postoperatively, as well as at 3, 6, 12, 24, and 48 months after surgery. Non-weight-bearing radiographs were taken before the patients were discharged. The radiological parameters measured included the intermetatarsal angle (IMA), the hallux valgus angle (HVA), the distal metatarsal articular angle (DMAA), and the tibial sesamoid position. Statistical analysis was carried out using the paired t test (p < 0.05)., Results: The mean AOFAS score was 93.98 points at the 48-month follow-up. The postoperative radiographic assessments showed a statistically significant improvement compared with preoperative values. The mean corrections for each angular value at the last follow-up were as follows: IMA 5.95°; HVA 16.81°; DMAA 10.70°; and tibial sesamoid 1.36°., Conclusion: The Endolog is a safe and effective technique for the correction of HV deformity, to relieve pain and to preserve joint movement.

Aim: Aim of the present study was to assess the prevalence of sexting, defined as "the sharing of images or videos of sexually explicit content", identifying the age groups involved and assessing the possible cultural ties. The study also aimed at providing a clear picture of the phenomenon to educators and parents, an essential starting point for planning any effective educational program., Methods: We performed a literature search on Medline (PubMed) database. In addition, the 2011 and 2012 surveys released by Eurispes and Telefono Azzurro were also consulted. "Google Trends" application provided additional details., Results: In Italy teenagers from 12 to 18 years who received sexually oriented material increased from 10.2% in 2011 to 25.9% in 2012. In the USA 69.4% declared having received sexually oriented material, while 66.7% reported having sent it. In Italy, 1 out of 10 teenagers (age range 16-18) found himself in danger for having posted his nude photos online., Conclusion: The practice of sexting involves a wide age range with different legal implications. Teenagers practice sexting to attract attention and prove to be involved in a relationship. Sexting usually does not have any consequence but in rare cases, about 4%, malicious behavior such as sexting for money, to tease or take someone under threat has been reported. Moreover, during the past decade the cases of online harassment increased, especially involving young women. Only by closely monitoring the phenomenon and studying its deeper motivations it could be possible to plan effective educational programs, integrating sexting and the correct use of new media into a structured sexual education project.

Markers of skin wound vitality and the research methodology used for their determination are still matters of debate in forensic pathology. Cathepsin-D, a lysosomal enzyme, is the most expressed cathepsin in human skin, and although it seems to have the necessary requirements to be utilized as a vitality marker, past research has provided no definitive and clear response on its potential usefulness. Immunohistochemistry with monoclonal antibodies and image analysis has been employed to detect and quantify the expression of Cathepsin-D in human skin wounds. We analyzed skin fragments obtained from 20 living individuals (group A) and 20 persons deceased from natural causes (group B). For each case, five skin fragments were withdrawn at 0', 5', 10', 30', and 90' after abdominal incision. Once the samples were formalin-fixed and paraffin-embedded, we analyzed the expression of Cathepsin-D through the quantification of the immunohistochemistry signal by image analysis. Immunoreactivity was displayed in Pixels of positive area measured by image analysis and converted in micrometer squares. The average levels of Cathepsin-D were higher in group B than in group A, except in three cases which showed a lower expression, with a statistically significant difference of Cathepsin-D expression between the two groups (p < 0.0001). Group B showed unvaried levels among the progressive samples and group A revealed an increasing predominant trend at 30'. Due to the high levels of expression of Cathepsin-D found in the post-mortem injuries, our study definitively excludes any usefulness of immunohistochemistry quantification of this enzyme in the differentiation between vital and post-mortem injuries.

Although the plantar fascia (PF) has been studied quite well from a biomechanical viewpoint, its microscopic properties have been overlooked: nothing is known about its content of elastic fibers, the features of the extracellular matrix or the extent of innervation. From a functional and clinical standpoint, the PF is often correlated with the triceps surae muscle, but the anatomical grounds for this link are not clear. The aim of this work was to focus on the PF macroscopic and microscopic properties and study how Achilles tendon diseases might affect it. Twelve feet from unembalmed human cadavers were dissected to isolate the PF. Specimens from each PF were tested with various histological and immunohistochemical stains. In a second stage, 52 magnetic resonance images (MRI) obtained from patients complaining of aspecific ankle or foot pain were analyzed, dividing the cases into two groups based on the presence or absence of signs of degeneration and/or inflammation of the Achilles tendon. The thickness of PF and paratenon was assessed in the two groups and statistical analyses were conducted. The PF is a tissue firmly joined to plantar muscles and skin. Analyzing its possible connections to the sural structures showed that this fascia is more closely connected to the paratenon of Achilles tendon than to the Achilles tendon, through the periosteum of the heel. The PF extended medially and laterally, continuing into the deep fasciae enveloping the abductor hallucis and abductor digiti minimi muscles, respectively. The PF was rich in hyaluronan, probably produced by fibroblastic-like cells described as 'fasciacytes'. Nerve endings and Pacini and Ruffini corpuscles were present, particularly in the medial and lateral portions, and on the surface of the muscles, suggesting a role for the PF in the proprioception of foot. In the radiological study, 27 of the 52 MRI showed signs of Achilles tendon inflammation and/or degeneration, and the PF was 3.43 ± 0.48 mm thick (99%CI and SD = 0.95), as opposed to 2.09 ± 0.24 mm (99%CI, SD = 0.47) in the patients in which the MRI revealed no Achilles tendon diseases; this difference in thickness of 1.29 ± 0.57 mm (99%CI) was statistically significant (P < 0.001). In the group of 27/52 patients with tendinopathies, the PF was more than 4.5 mm thick in 5, i.e. they exceeded the threshold for a diagnosis of plantar fasciitis. None of the other 25/52 paitents had a PF more than 4 mm thick. There was a statistically significant correlation between the thicknesses of the PF and the paratenon. These findings suggest that the plantar fascia has a role not only in supporting the longitudinal arch of the foot, but also in its proprioception and peripheral motor coordination. Its relationship with the paratenon of the Achilles tendon is consistent with the idea of triceps surae structures being involved in the PF pathology, so their rehabilitation can be considered appropriate. Finally, the high concentration of hyaluronan in the PF points to the feasibility of using hyaluronan injections in the fascia to treat plantar fasciitis., (© 2013 Anatomical Society.)

Objective: To prospectively investigate the role of trans-thoracic fine needle aspiration cytology (FNA) and the value of rapid on-site evaluation (ROSE) in the clinical management of patients with pulmonary nodules/masses. Computed tomography (CT)-guided FNA is commonly employed for the diagnosis of lung lesions although its position in the diagnostic work-up is still a matter of debate., Methods: We reviewed 311 patients (211 males and 100 females, mean age 69.5 years) admitted to the University of Padova from 2004 to 2008, correlating the results of cytology with the available histological findings obtained from biopsies, surgery or autopsy., Results: Smears were adequate in 305 cases (98%) and inadequate in six (2%); a diagnosis of malignancy was achieved in 263 cases (86.2%); 39 cases (12.8%) were classified as non-malignant; and three cases (1%) were classified as suspect for malignancy. When correlated with histology, FNA with ROSE discriminated malignant versus non-malignant lesions (Cohen's kappa 0.78), with three false negatives (sensitivity 96.3%, specificity 100%). Moreover, a satisfactory overall agreement of 71.4% was achieved in differentiating the cancer histological types. Pneumothorax occurred in 13 cases, haemoptysis in four, and chest pain in three. A single aspiration was sufficient in 79.6% of patients; two aspirations were needed in 17.4% and three in 3%. The low complication rate was related to the limited number of aspirations needed due to ROSE., Conclusions: FNA with ROSE is a safe and useful tool in the diagnostic work-up of lung cancer patients, with no contraindications to its use as the first diagnostic procedure for all patients with peripheral lung lesions. FNA with ROSE should be reconsidered in the guidelines for diagnosing and managing lung cancer., (© 2010 Blackwell Publishing Ltd.)

Background: EGFR and KRAS are the target genes for tumour response to epidermal growth factor receptor (EGFR) inhibitors., Aims: To investigate EGFR and KRAS mutational status with high resolution melting (HRM) analysis applied to cytological material obtained from trans-thoracic needle aspiration (TTNA) in order to better select patients for targeted therapy., Methods: DNA was extracted from fixed material of 108 TTNAs under CT guidance, from 108 consecutive patients. In 77 TTNAs (71.3.%) that were positive for non-small cell lung cancer, the variant in exon 21 (the missense mutation at codon 858, L858R) and the deletion in exon 19 (in frame deletion at codons 747-749) of the EGFR gene, and the point mutation in exon 2 of KRAS were investigated with HRM assay using sequencing as the reference "gold standard"., Results: Nine (11.7%) samples were positive for KRAS exon 2 mutations, and two (2.6%) samples were positive for the EGFR exon 21 missense mutation by HRM assay. No deletion at exon 19 for EGFR was detected by HRM analysis. All HRM results were confirmed by direct DNA sequencing., Conclusions: HRM analysis of cytological material was accurate for the detection of two major EGFR mutations and KRAS mutations in exon 2. HRM analysis was fast, easy to apply, cheap, highly reproducible, and could be used with small amounts of material, such as is obtainable with needle lavage. Therefore, it may be useful as an adjunct to the cytological report that yields valuable molecular information.

For pathologists, pneumologists, and occupational and environmental physicians it is relevant to know silica levels in lung tissue to better define limits of exposure. Environmental Scanning Electron Microscopy (ESEM) has been employed to detect silica particles and to compare silica levels in subjects with and without Lung Cancer (LC). We investigated 25 paraffin-embedded tissue samples of patients with LC adenocarcinoma, and 20 fresh samples of subjects without LC deceased for extra-pulmonary diseases. Silica levels were quantified considering the Number of Spots of silica particles (NS), and the Number of Positive Zones (NPZ) in which there was at least one spot. Levels of NS and NPZ were assessed with Poisson-type regression models, and in two samples of silica-exposed workers with LC the performance of models were evaluated. LC patients displayed higher silica levels, as compared to controls; smoking, age and gender had no significant effects on this relationship. Values of NS and NPZ for the exposed workers were in agreement with model estimates. The fitted model between NS and NPZ might be useful in evaluating new observations and in the development of threshold limit values of silica in biological tissues. ESEM is a rapid, simple and valid tool for the determination of silica levels in lung tissues.

The increasing number of Malignant Mesothelioma (MM) cases that arrive for expert examinations to court for compensation reasons in subjects exposed to asbestos, in many instances rely exclusively on cytological smears of pleural effusion. We evaluated the accuracy and reproducibility of cytological pleural effusions, based on morphological criteria alone. Nine pathologists and eight residents from seven institutions in north-east Italy blindly examined 45 smears of MM (17), metastases (14) and benign effusions (14), in two rounds. Diagnoses had been confirmed by immunohistochemical and clinical follow-up, and eventually at autopsy. Diagnostic accuracy, interobserver and intraobserver agreement in the distinction of benign vs malignant cases, and in the differentiation of primary from metastatic malignancies, were evaluated. The distinction of benign from malignant smears resulted rather satisfactory (k=0.514), but markedly decreased in differentiation of MM from metastases (overall agreement: k=0.343), as well as when readings from residents were analyzed (k=0.132). Cytology is a useful and reliable tool in the identification of malignancies, but when the distinction of primary from metastatic tumors is addressed morphological criteria alone are not sufficient for a definite diagnosis of MM and the use of cell blocks, immunohistochemistry (IHC) and molecular ancillary techniques are recommended.

Stimulation of the auricle is considered to be an effective analgesic technique. The aim of the present study is to establish whether there is a correspondence between somatic inflammation and the appearance of lower resistance points, and moreover, whether the stimulation of such points has an analgesic effect. The study has been conducted on 57 male Sprague-Dawley rats weighing between 120-140 g; 7 of them have been used to determine whether inflammation in the paw leads to the formation of lower resistance points on the auricle. The 50 remaining animals have been divided into 5 groups: Group 1 [12 animals], control were subjected to all manipulations with the exception of the auricle stimulation; Group 2 [12] was stimulated with manual acupuncture in the area corresponding to that observed in the above-mentioned first group of 7 animals; Group 3 [12] was stimulated with 5 Hz and 5 mA; electroacupuncture (EAP) Group 4 [8] and group 5 [6] were treated with acupuncture and with EAP respectively on points believed to be inactive in areas diametrically opposite to the ones observed in the first group. After acupuncture, 100 microg capsaicin in 50 microL of physiological solution were injected subcutis in the dorsal surface of the paw. Edema response was monitored for two hours, with measurement taken every 5 minutes. The results show a reduction in the edema response, only in the group treated with EAP on the appropriate points compared to the control group; no variation was observed in the sham groups. To conclude, the hypothesis of a somatotopic division would seem to be probable, and it would seem that the stimulation of the appropriate areas and the use of an appropriate intensity constitute the two main variables influencing the result.