A novel retrograde technique for ankle osteochodral lesions: the sub-endo-chondral regenerative treatment (secret)

PURPOSE

To describe a new surgical technique for osteochondral lesions of the ankle, using bone marrow concentrate on a scaffold and homologous bone graft positioned through a retrograde approach. Many surgical options for ankle osteochondral lesions have been described, and the ideal treatment is still debated. Bone marrow stimulating techniques are recommended for cystic lesions, with some concerns regarding the healing potential of the subchondral bone. In case of wide osteochondral defects, regenerative solutions are preferred but a massive chondral debridement is usually required. To overcome these problems, a novel technique is proposed.

METHODS

The proposed technique was performed on patients affected by osteochondral lesions of the talus, either cysts with intact cartilage or wide osteochondral defects. A preoperative magnetic resonance imaging was obtained to localize the lesion. A 6-mm tarsal tunnel was retrogradely created toward the lesion, to allow a complete sub-endo-chondral debridement preserving the healthy cartilage. A hyaluronan scaffold soaked with a previously prepared bone marrow concentrate was retrogradely positioned under the cartilage surface and the tunnel was filled with homologous bone graft. Preoperative clinical scores and postoperative x-rays were registered.

RESULTS

Four patients were treated using this technique. No intraoperative and postoperative complications occurred. Good bone remodeling was observed at 12-week postoperative x-rays.

CONCLUSIONS

This technique combines the mini-invasiveness of retrograde drilling with the regenerative properties of biological scaffold soaked with bone marrow concentrate. Despite further research being needed, it seems a new viable solution to treat both subchondral cysts and large osteochondral defects of the ankle, whose management is still controversial.

Post-operative management after total ankle arthroplasty: A systematic review of the literature

BACKGROUND

Currently, there is no consensus on the most appropriate post-operative management for patients undergoing total ankle arthroplasty. The aim of this study is therefore to offer a systematic review of the pertaining literature to identify current post-operative protocols and describe possible differences.

METHODS

A systematic review to identify recent studies concerning the post-operative management after total ankle arthroplasty was conducted. Five topics were analyzed: length of hospital stay, type and duration of immobilization, weight-bearing management, post-operative pharmacological therapies, adopted rehabilitation scheme.

RESULTS

Eighty-four studies met the inclusion criteria and were included in the review process. Most of the papers appear to have conflicting opinions with no consensus and homogeneous protocols.

CONCLUSION

Due to various methodological limitations, it is not possible to provide sufficiently supported evidence-based recommendations, and it is therefore difficult to determine the superiority of one post-operative protocol over the others after total ankle arthroplasty.

Keller's arthroplasty for hallux rigidus: A systematic review

BACKGROUND

Several surgical procedures have been described to treat hallux rigidus. Keller arthroplasty is a joint-sacrificing procedure proposed in 1904. Considering the current trends to mini-invasiveness and the debate about the technique's suitability, this review intends to state Keller arthroplasty results and the conditions where it could be still adopted in the treatment of hallux rigidus.

METHODS

Selected articles were reviewed to extract: population data, surgical indications, different surgical techniques, clinical and radiological outcomes, and complications.

RESULTS

Seventeen retrospective studies were selected, counting 508 patients. Mean age at surgery was 55 years. Patients were affected by moderate-severe hallux rigidus. Three modified Keller arthroplasty were identified. Good clinical and radiological outcomes were reported. Metatarsalgia was the most frequent complication (12%).

CONCLUSION

Despite for many authors KA seems a viable surgical treatment for middle aged and elderly patients affected by moderate-severe hallux rigidus, the available literature provides little evidence on the real efficacy and safety of the technique. A non-negligible percentage of complications may occur, and therefore is essential to set correct indications through an accurate patients' selection.

Vascular Dysfunction of COVID-19 Is Partially Reverted in the Long-Term

Background:

COVID-19 is characterized by severe inflammation during the acute phase and increased aortic stiffness in the early postacute phase. In other models, aortic stiffness is improved after the reduction of inflammation. We aimed to evaluate the mid- and long-term effects of COVID-19 on vascular and cardiac autonomic function. The primary outcome was aortic pulse wave velocity (aPWV).

Methods:

The cross-sectional Study-1 included 90 individuals with a history of COVID-19 and 180 matched controls. The longitudinal Study-2 included 41 patients with COVID-19 randomly selected from Study-1 who were followed-up for 27 weeks.

Results:

Study-1: Compared with controls, patients with COVID-19 had higher aPWV and brachial PWV 12 to 24 (but not 25–48) weeks after COVID-19 onset, and they had higher carotid Young’s elastic modulus and lower distensibility 12 to 48 weeks after COVID-19 onset. In partial least squares structural equation modeling, the higher the hs-CRP (high-sensitivity C-reactive protein) at hospitalization was, the higher the aPWV 12 to 48 weeks from COVID-19 onset (path coefficient: 0.184; P =0.04). Moreover, aPWV (path coefficient: −0.186; P =0.003) decreased with time. Study-2: mean blood pressure and carotid intima-media thickness were comparable at the end of follow-up, whereas aPWV (−9%; P =0.01), incremental Young’s elastic modulus (−17%; P =0.03), baroreflex sensitivity (+28%; P =0.049), heart rate variability triangular index (+15%; P =0.01), and subendocardial viability ratio (+12%; P =0.01×10 −4 ) were significantly improved. There was a trend toward improvement in brachial PWV (−6%; P =0.14) and carotid distensibility (+18%; P =0.05). Finally, at the end of follow-up (48 weeks after the onset of COVID-19) aPWV (+6%; P =0.04) remained significantly higher in patients with COVID-19 than in control subjects.

Conclusions:

COVID-19-related arterial stiffening involves several arterial tree portions and is partially resolved in the long-term.

Biomarkers Predict In-Hospital Major Adverse Cardiac Events in COVID-19 Patients: A Multicenter International Study

BACKGROUND

The COVID-19 pandemic carries a high burden of morbidity and mortality worldwide. We aimed to identify possible predictors of in-hospital major cardiovascular (CV) events in COVID-19.

METHODS

We retrospectively included patients hospitalized for COVID-19 from 10 centers. Clinical, biochemical, electrocardiographic, and imaging data at admission and medications were collected. Primary endpoint was a composite of in-hospital CV death, acute heart failure (AHF), acute myocarditis, arrhythmias, acute coronary syndromes (ACS), cardiocirculatory arrest, and pulmonary embolism (PE).

RESULTS

Of the 748 patients included, 141(19%) reached the set endpoint: 49 (7%) CV death, 15 (2%) acute myocarditis, 32 (4%) sustained-supraventricular or ventricular arrhythmias, 14 (2%) cardiocirculatory arrest, 8 (1%) ACS, 41 (5%) AHF, and 39 (5%) PE. Patients with CV events had higher age, body temperature, creatinine, high-sensitivity troponin, white blood cells, and platelet counts at admission and were more likely to have systemic hypertension, renal failure (creatinine ≥ 1.25 mg/dL), chronic obstructive pulmonary disease, atrial fibrillation, and cardiomyopathy. On univariate and multivariate analysis, troponin and renal failure were associated with the composite endpoint. Kaplan-Meier analysis showed a clear divergence of in-hospital composite event-free survival stratified according to median troponin value and the presence of renal failure (Log rank p < 0.001).

CONCLUSIONS

Our findings, derived from a multicenter data collection study, suggest the routine use of biomarkers, such as cardiac troponin and serum creatinine, for in-hospital prediction of CV events in patients with COVID-19.

Spontaneous rupture of umbilical hernia in end stage liver disease patient: injection of fibrin glue as a temporary solution

BACKGROUND

Umbilical hernia is a common disease, which occurs in 20% of cirrhotic patients in the presence of persistent ascites. A rare but dangerous complication of this disease in end stage liver patient is a spontaneous rupture of umbilical hernia with ascitic fluid leaking. Up to date there is no general consensus on its most appropriate treatment.

CASE REPORT

A 60 years-old male patient, with Child Pugh C and Meld score of 18 end stage liver disease, came to our observation for a spontaneous minimal rupture of his long lasting 5 cm umbilical hernia with ascitic fluid leaking. A medical therapy was undertaken aiming to manage the ascites and a temporary conservative therapy, with fibrin glue injection, was performed to solve the hernia ulceration, delaying the surgical repair after 20 days, when he underwent to a surgical repair with the positioning of a on lay mesh. At 12 month follow up we did not observe any recurrence.

CONCLUSIONS

Spontaneous rupture of umbilical hernia is a rare but life threatening complication of umbilical hernia in cirrhotic patient with refractory ascites. Even if a general consensus on its management is lacking, a conservative therapy with glue injection, appears feasible and effective, with low risk and representing a bridge therapy to surgery, to treat the ascitic leak and allow the clinical optimization of the patient.

Pre-operative interventional radiology: could it have a role before complex laparoscopic surgery?

Abstract

Bleedings occurring during a surgical intervention can be caused by haemostatic defects, but they are generally due to ineffective local haemostasis. Current coagulation systems may not be sufficient to achieve a good haemostasis, causing, at the same time, tissue dama-ge. Furthermore, the availability of such devices does not eliminate difficulties linked to the isolation of vessels, a crucial step of surgical procedures that require the removal of an organ or part of it, in case of inflammation or neoplasm. This difficulty is even more evident, and weighs more on operative times, when the surgeon engages with video-assisted surgery, where anatomical structures are difficult to detect and the manoeuvres of dissection and separation become more complex. The use of pre-operative radio-guided embolization of organ main arterial vessels with different embolic agents, could represent a great advantage, especially for mini-invasive procedures, such as laparoscopy in patients with high bleeding risk.

Resistive index of ophthalmic artery as an imaging biomarker of hypertension-related vascular and kidney damage

Aim: Resistive index of ophthalmic artery (RI-OA) is associated with atherosclerotic diseases. The aim of this study was to evaluate the association of RI-OA and hypertension-related vascular and kidney damage. Materials and methods: Two-hundred and eighty hypertensive patients underwent evaluation of RI-OA, carotid atherosclerosis and level of 24 h albuminuria. Results: Albuminuria and carotid atherosclerosis were positively associated with RI-OA independently of other cardiovascular risk factors. Receiver-operating characteristic curve analysis allowed us to calculate a cut-off value of RI-OA >0.625, which would be suspicious about the existence of atherosclerotic disease. Conclusion: The ophthalmic vascular circulation allows to study connections between macro- and microcirculation in vivo. RI-OA could be a useful marker for a better stratification of the risk of developing kidney and cardiovascular disease.

Scar endometriosis: not a rare cause for a painful scar

Conclusion

High suspicion of scar endometriosis are painful no-dule in the abdominal scar. Wide surgical excision is the treatment of choice.

Introduction

Endometriosis has been described as the presence of endometrial tissue outside uterine cavity. Scar endometriosis (SE) is a rare disease reported in 0.03-1.08% of women following gynaecologic surgery. In our retrospective observational cohort study we studied anamnesis, symptoms, surgical procedures and outcomes linked to scar endometriosis in our medical experience from 2004 to 2018.

Methods

We reviewed the medical records of 46 patients with a histopathological diagnosis of SE. All patients had a history of at least one previous caesarean section (n=46, 100%). Forty-two patients (91,3%) complained gradually growing nodular abdominal mass near or adjacent to caesarean incision scar, while only 4 patients (8,6%) complained aspecific abdominal pain. Ultrasound scan was performed in all patients (n=46, 100%) and mean size of the nodules at US was 26,8 ± 13,8 mm.

Results

All patients underwent surgery. Seven patients (15,2%) needed mesh implantation, while 39 patients (84,8%) underwent local resection with reconstruction of muscle fascia. Mean follow-up was 31,6 ± 14 months and no patients reported local recurrence of disease.

Lumevis ™: a new medical device to prepare patients for esophagogastroduodenoscopy. Experimental clinical study

BACKGROUND

Esophagogastroduodenoscopy (EGDS) is the gold standard exam for upper gastrointestinal diseases. EGDS is very important in Early Gastric Cancer diagnosis and treatment but it is an operator-dependent exam and there are lots of factors that reduce its visibility (mucus, bubbles and foam).

AIM

The aim of our study is to evaluate if the use of Lumevis™ improves mucosa visualization during EGDS without increasing the examination time and complications' rate and comparing the differences in patients prepared with water or no intervention.

MATERIALS AND METHODS

we recruited 50 patients from 01/08/2020 to 31/08/2020 who came to our observation for epigastric pain, dyspepsia and gastroesophageal reflux (GERD). For each patient we evaluate the satisfaction of the procedure, vision quality, EGDS duration and the presence of bubbles following the administration of: nothing (group 1); 50 ml of water alone (W) (group 2); W + simethicone (S) 150 mg+N-acetylcysteine (NAC) 250 mg+10% acetic acid 2.5 ml (group 3); W+S 100 mg + NAC 300 mg + 10% acetic acid 2 ml (group 4); W + S 100 mg + NAC 200 mg + 10% acetic acid 1.5 ml (group 5).

RESULTS

Our results suggest that the lesion detection rate improves with the use of simethicone, acetylcysteine and acetic acid prior to EGDS, although this needs to be studied prospectively.

CONCLUSIONS

Lumevis™ is proposed as a new product in the routine preparation of all patients who have to undergo an EGDS, raising the level in the quality of the exam.

Relationship of choroidal thickness with pulsatile hemodynamics in essential hypertensive patients

Controversy exists about the association of choroidal thickness (CTh) with blood pressure (BP) values. There is some evidence suggesting that central hemodynamics changes are associated with microvascular disease. Our study was aimed to assess the relationships between CTh and clinic and 24‐h BP and between CTh and estimated 24‐h aortic pulse pressure (aPP), 24‐h aortic systolic BP (aSBP), and 24‐h aortic augmentation index (aAIx) in a group of hypertensive patients. We enrolled 158 hypertensive subjects (mean age 48 ± 13 years) all of which underwent evaluation of the choroidal district by Swept‐Source optical coherence tomography (SS‐OCT) and 24‐h BP monitoring, in order to measure peripheral BP and to estimate central hemodynamic parameters. Inverse significant correlations of clinic PP, 24‐h aPP, 24‐h aSBP, and 24‐h aAIx with thicknesses of central ring, inner ring, and outer ring of the choroid and its overall average were found. The strongest of these correlations was that relating 24‐h aPP with overall average choroidal thickness (r = −.531; P < .001). When we divided the study population in subjects with 24‐h aPP above and below the median value (35 mm Hg), CTh were thinner in subjects with higher values of 24‐aPP as compared to those with lower ones, even after adjustment for age, and other potential confounders. The relationships of CTh with 24‐h aPP remained significant also taking into account the effects of various covariates in linear multiple regression analyses. Our findings support the concept of a cross‐talk between macro‐ and microcirculation.

Left ventricular hypertrophy in chronic kidney disease: A diagnostic criteria comparison

BACKGROUND AND AIMS

CKD patients have a high prevalence of LVH and this leads to an increase of cardiovascular risk. The aim of this study was to assess the prevalence of left ventricular hypertrophy (LVH) and left ventricular geometry in a group of 293 hypertensive patients with stage 2-5 chronic kidney disease (CKD), compared with 289 essential hypertensive patients with normal renal function.

METHODS AND RESULTS

All patients underwent echocardiographic examination. Patients on stage 1 CKD, dialysis treatment, or with cardiovascular diseases were excluded. LVH was observed in 62.8% of patients with CKD and in 51.9% of essential hypertensive patients (P < 0.0001). We found increasingly higher left ventricular diameters, thicknesses, and mass from stage 2-5 CKD. Distribution of concentric and eccentric LVH was not very different between the two groups. However, after introducing mixed hypertrophy, the difference between the two groups group was disclosed (P = 0.027). Multiple regression analysis confirmed that the association between renal function and left ventricular mass (β -0.287; P < 0.0001) was independent by potential confounders. Diastolic function was significantly worse in patients with CKD, especially in more advanced stages.

CONCLUSION

Our study confirms that LVH is highly prevalent in patients with CKD, especially by using the most recent cut off; in this population, LVH is often characterized by the simultaneous increase of wall thicknesses and diameters with negative effects on diastolic function.

Severe paraneoplastic hypoglycemia due to a non-islet cell tumor in a patient with an advanced gastrointestinal stromal tumor

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract, mainly localized in the stomach. Most GIST derive from mutations in tyrosine kinase receptors (KIT) or platelet-derived growth factor receptor-α (PDGFRA). GISTs are rarely associated with paraneoplastic hypoglycemia caused by non-β-cells tumor. This syndrome, defined non-islet cell tumor hypoglycemia (NICTH), arises from excess tumor production of insulin-like growth factor. We describe a 67-year-old female with severe NICTH secondary to an advanced and metastatic GIST.

Inflammatory activation and endothelial dysfunction markers in patients with permanent atrial fibrillation: a cross-sectional study

In recent years a growing body of evidence supported the role of inflammation in the initiation, maintenance and outcome of atrial fibrillation (AF). Nevertheless, despite a large amount of information, whether AF or the underlying structural heart disease (SHD) is the cause of the inflammatory process is still under debate. We, therefore, sought to determine if the inflammatory process reflect an underlying disease or the arrhythmia ‘per se’. We evaluated plasma levels of soluble Interleukin 2 Receptor Alpha (sIL-2Rα), TNF-α and IL-18 in 100 consecutive patients with permanent AF, (43 with a SHD and 57 without a SHD) compared to 121 age and sex-matched controls which had normal sinus rhythm. We also evaluated the endothelial function in both groups of patients using reactive hyperemia index (RHI) values measured by Endo-PAT2000. Compared to controls, AF patients showed higher circulating levels of inflammatory markers and a lower mean value of RHI. At multiple logistic regression analysis, the inflammatory markers and RHI were significantly associated with AF presence, whereas ROC curve analysis had good sensitivity and specificity in inflammatory variables and RHI for AF presence. No significant association was observed in the group of permanent AF patients, between inflammatory markers and the presence of an underlying SHD. These findings could help to clarify the role of inflammation in subjects with AF and suggest that the markers of systemic inflammation are not associated with the underlying cardiovascular disease, rather with the atrial fibrillation ‘per se’.

Inflammation and Aortic Pulse Wave Velocity: A Multicenter Longitudinal Study in Patients With Inflammatory Bowel Disease

Background

Inflammatory bowel disease (IBD) is characterized by a low prevalence of traditional risk factors, an increased aortic pulse‐wave velocity (aPWV), and an excess of cardiovascular events. We have previously hypothesized that the cardiovascular risk excess reported in these patients could be explained by chronic inflammation. Here, we tested the hypothesis that chronic inflammation is responsible for the increased aPWV previously reported in IBD patients and that anti‐TNFa (anti‐tumor necrosis factor‐alpha) therapy reduce aPWV in these patients.

Methods and Results

This was a multicenter longitudinal study. We enrolled 334 patients: 82 patients with ulcerative colitis, 85 patients with Crohn disease, and 167 healthy control subjects matched for age, sex, and mean blood pressure, from 3 centers in Europe, and followed them for 4 years (range, 2.5–5.7 years). At baseline, IBD patients had higher aPWV than controls. IBD patients in remission and those treated with anti–TNFa during follow‐up experienced an aortic destiffening, whereas aPWV increased in those with active disease and those treated with salicylates (P=0.01). Disease duration (P=0.02) was associated with aortic stiffening as was, in patients with ulcerative colitis, high‐sensitivity C‐reactive protein during follow‐up (P=0.02). All these results were confirmed after adjustment for major confounders. Finally, the duration of anti–TNFa therapy was not associated with the magnitude of the reduction in aPWV at the end of follow‐up (P=0.85).

Conclusions

Long‐term anti–TNFa therapy reduces aPWV, an established surrogate measure of cardiovascular risk, in patients with IBD. This suggests that effective control of inflammation may reduce cardiovascular risk in these patients.

Choroidal thickness is associated with renal hemodynamics in essential hypertension

The choroid is the most vascularized structure of the eye and plays a central role in the development of the retinal vascular changes that occur in arterial hypertension. Changes of choroidal thickness (ChT) assessed by optical coherence tomography (OCT) technology could reflect the vascular complications of hypertension. Also, intrarenal hemodynamic damage, associated with endothelial dysfunction, demonstrated to be a good indicator of systemic morphofunctional arterial impairment. The aim of this study is to assess the relationship between ChT and renal hemodynamics in subjects with essential hypertension. Routine laboratory tests, clinical history, and physical examination, including blood pressure assessment, were performed in 90 subjects with essential hypertension. All patients underwent Doppler ultrasonographic evaluation of intra-renal hemodynamics and OCT imaging to assess ChT. When subjects were divided in two groups based on renal resistive index (RRI), group I (RRI ≥ 75% percentile) showed significantly lower values of ChT than group II (RRI < 75% percentile) (P < .001). When divided in two groups based on the ChT median values, patients with lower ChT had significantly higher RRI values than those with ChT above the median values (P < .05). In multivariate model including age, eGFR, and other variables as confounding factors, RRI ≥ 75% was independently associated with ChT. ChT was significantly correlated with renal resistive index in subjects with essential hypertension, confirmed in multivariate analyses. This result could be referred to changes in vascular elastic properties that occur in retinal and intrarenal vascular system probably due to oxidative stress and endothelial dysfunction commonly found in early complications of hypertension.

A rare clinical entity: stump appendicitis. Case report and complete review of literature

BACKGROUND

Stump appendicitis is a rare delayed complication post-appendectomy and it represents a diagnostic problem as clinicians are often not very familiar with this pathology.

MATERIALS AND METHODS

One case of stump appendicitis has been reported in a 54 year old woman, whose acute phase was conservatively treated in our Department. A review of Medline literature was also carried out, from 1945 to 2015, showing 111 cases of stump appendicitis.

RESULTS

Stump appendicitis has been reported after either open or laparoscopic appendectomy, in a range between days to several years from the first procedure. Nowadays, it is not considered yet as a possible differential diagnosis in patients with pain in the right iliac fossa previously undergone appendectomy. For this reason, the diagnosis can be delayed and complications such as acute abdomen, perforation, sepsis can occur. Completion appendectomy is the treatment of choice for stump appendicitis.

CONCLUSIONS

The aim of this article is to underline the importance of stump appendicitis. Clinicians should be aware of the possibility of SA and they should confirm any clinical suspicion throughout radiologic images, in order to promptly recognize this entity and to avoid the related complications.

Rectal Diclofenac administration for prevention of post-Endoscopic Retrograde Cholangio-Pancreatography (ERCP) acute pancreatitis. Randomized prospective study

INTRODUCTION

Post-Endoscopic Retrograde Cholangio-Pancreatography pancreatitis (PEP) is a relevant (1-4%) complication of biliopancreatic operative endoscopy. Rectal nonsteroidal anti-inflammatory drugs (specifically, 100 mg of diclofenac) have shown promising prophylactic activity in PEP. The aim of our prospective study is to report whether prophylactic oral versus rectal suppository versus intramuscular diclofenac versus placebo are able to reduce the incidence and the severity of ERCP-induced pancreatitis.

MATERIALS AND METHODS

In this randomized, double-blinded, prospective study, 100 patients (49 male, 51 female), similar with regard to indication for ERCP, were enrolled between January 2016 and November 2017 to undergo ERCP in the Section of General and Thoracic Surgery of University Hospital of Palermo. They were randomized into five groups, respectively 20 patients with placebo by mouth; 20 patients with 50 mg diclofenac sodium enteric-coated capsules by mouth; 20 with 100 mg rectal suppository diclofenac, 20 with 75 mg/3 ml intramuscular diclofenac sodium, 20 with 75 mg/3 ml intramuscular diclofenac sodium and 20 with 75 mg/3 ml intravenous diclofenac. All drugs were administered 30 to 90 minutes before ERCP. All clinical data were collected one day before and 2, 12 and 24 hour after ERCP.

RESULT

Data were prospectively collected and to demonstrate the preventive effect of rectal diclofenac on PEP, a two-by-two table and chi-square test with Yates correction were used: the incidence of PEP was significantly lower (p < 0.001) in the rectal diclofenac group respect to other groups and, in the same way, the incidence of post-ERCP pain was significantly lower in the rectal diclofenac group than in the other groups (p = 0.001) and patients discharge was consequently earlier (p < 0.01).

CONCLUSION

100 mg dose rectal diclofenac administered 30-60 minutes before ERCP can effectively prevent PEP.

Is echocardiography mandatory for patients with chronic kidney disease?

This study aims at evaluating the prevalence of left ventricular diastolic dysfunction in a group of 319 hypertensive patients with stage 3b-4-5 chronic kidney disease (according to Kidney Disease Improving Global Outcomes classification), compared with 216 patients with essential hypertension and normal renal function. All patients underwent echocardiographic examination. Patients on stage 1-2-3a chronic kidney disease, dialysis treatment, or with previous manifestations of heart failure or other cardiovascular diseases were excluded. Patients with renal disease had significantly worse diastolic function (both considering trans-mitral flow and tissue Doppler imaging parameters). Diastolic dysfunction is found in 70.5% of the CKD group and in 41.6% of hypertensive patients (p < 0.0001). Multiple regression analysis shows an association between renal function and diastolic function (β 0.223; p < 0.0001), independent of potential confounders. Our study shows that diastolic dysfunction is highly prevalent in patients with advanced chronic kidney disease; we posit that in this population, the risk of diastolic heart failure is very high. We think that patients with a marked decrease of glomerular filtration rate (GFR) must be considered at high risk for diastolic heart failure and should have an echocardiographic examination performed, even if asymptomatic and in the absence of evident cardiovascular disease.

Relationship of a Body Shape Index and Body Roundness Index with carotid atherosclerosis in arterial hypertension

BACKGROUND AND AIMS

A Body Shape Index (ABSI) and Body Roundness Index (BRI) are two new anthropometric adiposity indices that have shown to be associated better than BMI with adipose abdominal tissue, with the onset of diabetes and the risk of premature death. Little is known about the influence of ABSI and BRI on subclinical vascular damage. The study was aimed to assess the relationship between ABSI and BRI with carotid atherosclerosis damage in subjects with arterial hypertension.

METHODS AND RESULTS

A total of 468 patients with arterial hypertension (30-80 years old) were enrolled; adiposity indices were calculated (BMI, WC, ABSI, BRI) and carotid ultrasonographic examination was performed to detect atherosclerotic damage (IMT or atherosclerotic plaque). BRI, but not ABSI, was higher in subjects with IMT> 0.90 mm in comparison to those with a lower IMT (p < 0.001), whereas patients with carotid plaques showed higher values of ABSI (p = 0.001), as well as of BRI (p = 0.003). Linear regression analysis disclosed significant correlation of IMT with ABSI, BRI and BMI (all p < 0.001). In the multivariate analysis, BRI was independently correlated with cIMT (p = 0.015). On the contrary, ABSI did not show any independent association with cIMT. However, ABSI was strongly associated with carotid plaques in multiple logistic regression analysis after adjustment for potential confounding factors. When BRI or BMI replaced ABSI into the multivariate models, they did not show any independent correlation with carotid plaques.

CONCLUSIONS

ABSI may be proposed as a better correlate of carotid atherosclerosis than the traditional measures of adiposity.

Trends in surgical management of the infected total ankle arthroplasty

OBJECTIVE

We performed a systematic review of surgical treatment of the infected total ankle arthroplasty. The purpose of this investigation was to describe the current trends and to perform a critical analysis of the evidence reported in the existing literature.

MATERIALS AND METHODS

A comprehensive search for all relevant articles published in English was conducted. Scientific databases were accessed to identify papers dealing with the management of the infected total ankle arthroplasty. We identified and collected every patient that underwent a surgical management of infected ankle arthroplasty. Data extracted were summarized and reported. A descriptive analysis was performed; when possible, a statistical analysis was accomplished.

RESULTS

Thirty-two papers (152 infected ankle arthroplasty) published in the last 20 years were identified. Twenty-seven patients (17.76%) were treated with irrigation and debridement, revision total ankle arthroplasty was performed in 72 cases (47.37%), arthrodesis was performed as a primary treatment in 30 patients (19.74%), 12 patients (7.89%) underwent a spacer arthroplasty while amputation was performed as a primary treatment in 9 patients (5.92%).

CONCLUSIONS

Our study reveals the improvement of the surgical management of the infected total ankle arthroplasty through the last 20 years. Irrigation and debridement and two-stage revision represent the most viable treatment in acute postoperative and late chronic infections respectively. We noted a trend towards maintaining articularity through a two-stage revision. The quality of evidence is weak with biases both in reporting and selection process. High quality randomized controlled trials are required to compare different treatments in order to introduce an evidence-based treatment protocol.

Renal haemodynamics and coronary atherosclerotic burden are associated in patients with hypertension and mild coronary artery disease

Intrarenal hemodynamic alterations are independent predictors of cardiovascular events in different populations. It has been hypothesized that there is an association between renal hemodynamics and coronary atherosclerotic burden in patients with hypertension. Therefore, the present study examined the associations between renal hemodynamics, coronary atherosclerotic burden and carotid atherosclerotic disease. A total of 130 patients with hypertension aged between 30-80 years who had been referred for an elective coronary angiography were enrolled in the present study. A duplex ultrasound of the intrarenal vasculature was performed to evaluate the resistive index (RI), pulsatility index (PI) and acceleration time (AT). The carotid intima-media thickness was additionally assessed. A coronary angiography was performed to detect the atherosclerotic burden using the Gensini Score (GS). Based on the GS values, subjects were divided into quintiles (I: ≤9; II: 9-17; III: 17-30; IV: 30-44; and V: GS >44) as well as in subjects with mild (GS ≤30) or severe coronary disease (GS >30). A weak significant difference in PI was identified among quintiles (P=0.041), whereas, RI and AT did not differ significantly. PI was associated with GS in the group with low coronary atherosclerotic burden (GS ≤30; P=0.047), whereas, no association was detected in subjects with GS >30. This association remained following adjustment for age and left ventricular ejection fraction (P=0.025). In conclusion, renal vascular alterations were associated with coronary atherosclerotic burden in patients with hypertension with mild coronary disease.

Ultrasound-guided port-a-cath positioning with the new one-shoot technique: thoracic complications

OBJECTIVES

Port-a-cath catheterization is often required for those patients who need long-term therapies (malnutrition, neoplasm, renal failure, other severe diseases). The use of ports for a wide range of indications is not exempt from complications. Ultrasound-guided central venous catheterization (CVC) is a safe and fast technique for the introduction of the catheter inside a central vein. This retrospective study reports our experience with US-guided CVC in patient eligible for port-a-cath implantation.

MATERIALS AND METHODS

From January 2007 to March 2017, 108 CVC (out of 770 procedures), were positioned using an ultrasound guide, with the new "one-shoot technique" (group 1) and the classic Seldinger technique (group 2).

RESULTS

One-shoot techniques showed a reduced operative time, in comparison to Seldinger technique, with a negligible minor complication rate. No major complication were evidenced.

CONCLUSIONS

CVC is a safe procedure, although not free from complications. Ultrasonography enhances safety of the procedure by decreasing puncture attempts and complications; it is helpful in patients with vascular anatomical variations, with no visualized or palpable landmarks or for patients with coagulation disorders.

Para-perirenal distribution of body fat is associated with reduced glomerular filtration rate regardless of other indices of adiposity in hypertensive patients

Obesity is a well-known risk factor for the development and progression of chronic kidney disease. Recently, para-perirenal ultrasonographic fat thickness (PUFT) has shown to correlate with both total and visceral fat better than body mass index (BMI), waist circumference (WC), and other indices of obesity. Moreover, a local paracrine and mechanical action of the PUFT on kidney has been described in recent studies. Aim of our study was to assess the relationship between glomerular filtration rate (GFR) and PUFT in comparison with other anthropometric and ultrasonographic indices of adiposity. Two hundred and ninety-six hypertensive patients were enrolled. PUFT, cutis-rectis thickness and rectis-aorta thickness were obtained by ultrasonography. Anthropometric measures of adiposity were also measured. Estimated GFR was calculated using the CKD-EPI equation. Higher PUFT values were observed in patients with impaired renal function (P < 0.001), whereas no differences in BMI and WC were shown between groups divided by GFR. PUFT significantly correlated with GFR in all patients (r = -0.284; P < 0.001), with no differences in groups divided by sex, diabetes, or BMI. This association held in multivariate analyses also after correction for confounding factors, including other adiposity indices (P < 0.001). When receiver operating characteristic curves were built to detect a eGFR < 60 mL/minutes per 1.73 m² , a PUFT value ≤3.725 cm showed a negative predictive value of 94.0%, with the largest area under the curve (AUC: 0.700) among the variables considered. In conclusion, the relationship between PUFT and GFR seems to be more accurate and less influenced by the bias affecting traditional indices of adiposity.

Videolaparoscopic cholecystectomy in patients with previous abdominal surgery. Personal experience and literature review

OBJECTIVES

Laparoscopic cholecystectomy (LC) is today the "gold standard" treatment of gallbladder stones. Role of LC is still debated in the presence of abdominal scars due to the frequent post-operative adhesions which make access to the peritoneal cavity difficult. This study aim to assess role and outcomes of LC on a previous abdominal surgery on the scarred abdomen.

MATERIALS AND METHODS

We have carried out a retrospective study on 499 consecutive patients who had undergone LC from 2009 to 2015; 21 of these (4.2%) undergone previous abdominal surgery. In all 21 cases the pneumoperitoneum was established with Veress needle at the Palmer's point and the procedure was carried out after adhesiolysis in 62% of cases.

RESULTS

The mean operative time was 79±12 minutes; none of the patients with previous abdominal surgery required conversion to open cholecystectomy and there were no postoperative complications related to Veress introduction or to the adhesiolysis. The difficult dissection and adhesiolysis were more frequent in the patients with upper abdomen scar (62%) respect to lower abdomen scar (38%).

CONCLUSIONS

Patients with scarred abdomen for previous abdominal surgery had obviously more adhesions in the abdomen than patients without preceding surgery, but today previous abdominal surgery should not constitutes absolute contraindications to LC. Moreover, patients with previous lower abdominal incisions had fewer adhesions in the upper abdomen than did patients with upper incision and, probably, in these cases adhesiolysis is unnecessary, if the surgical field is well exposed whereas adhesiolysis is mandatory when the adhesions are thick and widespread, to the anterior and posterior abdominal wall.

Direct anterior approach versus posterolateral approach in total hip arthroplasty: effects on early post-operative rehabilitation period

Main surgical approaches to the hip have been modified during last decades, in an effort to reduce invasiveness of the surgical procedure and allow a faster rehabilitation. Direct anterior approach is the only approach, which does not require muscle detachment, thus theoretically leading to reduced post-operative pain and allows earlier recovery. The aim of this study was to report a comparison between patients operated with direct anterior approach and postero-lateral approach in terms of immediate post-operative and in-hospital records. Pain, operative time, intra- and post-operative complications, blood loss, hospitalization, motor component of the Functional Independence Measure (M-FIM), timed up and go (TUG) test were measured between the two groups and compared. Direct anterior approach showed better results in M-FIM, TUG, hospitalization and blood loss, without any significant difference for intra- and post-operative complications between the 2 groups. This study shows that early post-operative recovery is influenced by the chosen approach. Direct anterior approach showed better outcomes when compared to postero-lateral approach, limited to hospitalization, blood loss, and functional scores. Further comparisons are needed to evaluate direct anterior approach to maintain advantages over postero-lateral approach on longer follow-up period.

[Risk factors' analysis of transient and permanent hypoparathyroidism after thyroidectomy]

AIMS

This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism.

DISCUSSION

The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes.

CONCLUSIONS

Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.

Serum uric acid is not independently associated with plasma renin activity and plasma aldosterone in hypertensive adults

BACKGROUND AND AIMS

In experimental investigations conducted in rats, raising serum uric acid (SUA) levels resulted in the stimulation of intrarenal renin expression. Studies in humans exploring the association of SUA with plasma renin activity (PRA) yielded conflicting results. Moreover, little is known about the relationship of SUA with plasma aldosterone concentration (PAC). The study aimed to assess the relationship between SUA levels, PRA, and PAC and the influence of age, gender, body mass index (BMI), and hyperuricemia on these relationships in subjects with essential hypertension (EH).

METHODS AND RESULTS

We enrolled 372 hypertensive patients (mean age 45 ± 12 years, men 67%) with uncomplicated EH that was not pharmacologically treated. The study population was divided in tertiles according to SUA levels. While PRA did not differ significantly across the three tertiles, PAC was higher in subjects belonging to the uppermost tertile of SUA than those in the lower ones (p = 0.0429); however, this difference lost statistical significance after adjustment for age, sex, BMI, and serum creatinine. Univariate correlation analyses showed significant associations of SUA with PRA (r = 0.137; p = 0.008) and PAC (r = 0.179; p < 0.001). However, these relationships were not significant after correcting for confounding factors in multiple linear regression analyses. We did not observe statistically significant effect modification by gender, age, BMI, and hyperuricemia.

CONCLUSION

SUA levels are weakly associated with PRA and PAC in adults with untreated EH. These relationships were lost after adjustment for age, sex, BMI, and serum creatinine.

Renal function and carotid atherosclerosis in adults with no known kidney disease

BACKGROUND AND AIMS

A high prevalence of atherosclerotic lesions characterizes patients with chronic kidney disease, though there is little data on the relationship between kidney function and atherosclerotic changes in the healthy population or in people with no known renal impairment. The aim of our study was to analyze, in a comprehensive general population with no known kidney disease, the relationship between renal function and subclinical carotid atherosclerotic damage.

METHODS AND RESULTS

A general real-life population of 611 participants (233 males and 378 females; age ≥18 years) with no known kidney failure was selected for the study. The glomerular filtration rate (GFR) was estimated according to the CKD-EPI equation. Carotid intima-media thickness (c-IMT) and plaques were assessed by duplex Doppler ultrasonography of the carotid vessels. The main laboratory and metabolic parameters were evaluated in all participants. When we divided the overall study population into tertiles according to GFR values (I tertile <85; II tertile: 85-99; III tertile >99 ml/min/1.73 m²), the c-IMT mean values and the prevalence of carotid plaques decreased with the increasing tertile of GFR. On univariate analysis, c-IMT was significantly correlated with eGFR (r = -0.33; p < 0.001), serum creatinine (r = 0.17; p < 0.001), and other variables such as age, systolic blood pressure, waist circumference, fasting or random glycemia, and glycated hemoglobin (HbA₁c). On multiple regression analysis, serum creatinine was associated with c-IMT (β = 0.069; p = 0.017), independent of other covariates.

CONCLUSION

Our study seems to suggest the importance of early identification of people with near normal or mildly decreased renal function due to its association with carotid atherosclerosis.

Inverse association between type 2 diabetes and aortic root dimension in hypertensive patients

BACKGROUND

Some data support the concept that aortic root diameter (ARD) in hypertension may be regarded as a marker of subclinical organ damage. The impact of type 2 diabetes mellitus (DM) on cardiac structure and function is known, although the relationship between DM and ARD is not clear. The aim of our study was to evaluate the influence of DM on ARD in hypertensive patients.

METHODS

We enrolled 1693 hypertensive patients (aged 63.7±9.6years). The population was divided into two groups: the first one with DM (n=747) and the second one without DM (n=946). ARD was measured by echocardiography at level of Valsalva's sinuses using echocardiography M-mode tracings. It was considered as absolute measure and normalized to height (ARD/H) and body surface area (ARD/BSA). Left ventricular mass index (LVMI) and some parameters of systolic and diastolic function have been valued by means of echocardiography and tissue Doppler imaging.

RESULTS

The DM group was characterized by more elevated values of LVMI and a worst systolic and diastolic function. ARD value was significantly lower in DM group in comparison to patients without DM only when indexed for BSA (ARD/BSA=18.7±2.3mm/m² vs 18.3±2.0mm/m², p=0.01). This difference remained statistically significant, even after correction by age, sex and BMI (p=0.01). A multivariate linear regression analysis demonstrated an inverse relationship between DM and ARD/BSA after correction for potential confounders (β=0.10, p<0.001).

CONCLUSIONS

Our results confirm the hypothesis of a protective role of DM on aortic root dilatation.

Relationship Between Carotid Atherosclerosis and Pulse Pressure with Renal Hemodynamics in Hypertensive Patients

BACKGROUND

Structural atherosclerotic damage, arterial stiffness, pulse pressure (PP), and renal hemodynamics may interact and influence each other. Renal resistance index (RRI) appears as a good indicator of systemic vascular changes. The aim of our study was to assess the independent relationships of carotid intima-media thickness (cIMT), aortic pulse wave velocity (aPWV), and peripheral PP with RRI in hypertensives with various degrees of renal function.

METHODS

We enrolled 463 hypertensive patients (30-70 years) with normal renal function (group 0; n = 280) and with chronic kidney disease (groups I-V; n = 183). All subjects underwent ultrasonographic examination of intrarenal and carotid vasculature, as well as a 24-h ambulatory blood pressure monitoring.

RESULTS

A statistically significant difference in RRI, cIMT, aPWV, and clinic PP was observed in the different 6 groups (all P < 0.001), even after adjustment for age. RRI correlated with cIMT (r = 0.460, P < 0.001), aPWV (r = 0.386, P < 0.001), clinic PP (r = 0.279, P < 0.001), and 24-h PP (r = 0.229, P < 0.001) in the entire study population. These correlations were similar in subjects with and without renal dysfunction. In the overall study population, the association between RRI, cIMT, and clinic PP remained statistically significant even after adjustment for various confounding factors, whereas the relationship between RRI and aPWV was lost in multivariate analysis.

CONCLUSIONS

cIMT and clinic PP rather than directly aPWV are associated with intrarenal hemodynamics. Our results confirm that in hypertensives RRI not only detects derangement of intrarenal circulation but may also be considered as a sensor of systemic vascular changes, independently of level of renal function.

Association Between Uric Acid and Renal Hemodynamics: Pathophysiological Implications for Renal Damage in Hypertensive Patients

The role of vascular renal changes in mediating the association between serum uric acid (SUA) and renal damage is unclear. The purposes of this study were to investigate the relationship between SUA and renal resistive index (RRI), assessed by duplex Doppler ultrasonography, and to assess whether hemodynamic renal changes may explain the association between SUA and renal damage in hypertensive patients. A total of 530 hypertensive patients with and without chronic kidney disease were enrolled and divided into SUA tertiles based on sex-specific cutoff values. RRI and albuminuria were greater and glomerular filtration rate (GFR) was lower in the uppermost SUA tertile patients when compared with those in the lowest tertiles (all P<.001). Moreover, SUA strongly correlated with RRI (P<.001) in all patients. However, RRI did not seem to explain the relationship between SUA and renal damage, and GFR significantly related with SUA in the overall population (P<.001) even after adjustment for RRI.

The Relationship Between Aortic Root Size and Hypertension: An Unsolved Conundrum

Thoracic aortic aneurysms rupture and dissection are among the most devastating vascular diseases, being characterized by elevated mortality, despite improvements in diagnostic imaging and surgical techniques.An increased aortic root diameter (ARD) represents the main risk factor for thoracic aortic dissection and rupture and for aortic valve regurgitation.Even though arterial hypertension is commonly regarded as a predisposing condition for the development of thoracic aorta aneurysms, the role of blood pressure (BP) as determinant of aortic root enlargement is still controversial. The use of different methods for indexation of ARD may have in part contributed to the heterogeneous findings obtained in the investigations exploring the relationships between ARD and BP. Indeed, the best methods for ARD indexation, as well as the normal values of aortic root size, are still a matter of debate.Several non-hemodynamic factors influence ARD, including age, gender, and anthropometric variables, such as height, weight and their derivatives body surface area (BSA) and body mass index. Of these factors, anthropometric variables have the greatest impact.Several studies documented an association between ARD enlargement, assessed by echocardiography, and some indices of hypertensive target organ damage such as left ventricular hypertrophy, diastolic dysfunction, and carotid intima-media thickening. Recently, we found that ARD, expressed either as absolute values or normalized for BSA (ARD/BSA) or height (ARD/H), was significantly greater in hypertensive subjects with chronic kidney disease (CKD) when compared to their counterparts with normal renal function. Moreover, at univariate analyses estimated glomerular filtration rate (eGFR) showed significant inverse correlations with ARD not indexed and with ARD/BSA and ARD/H. Taking into account the effect of age, sex, duration of hypertension and other potentially confounding factors, in multiple regression analyses, only the association of GFR with ARD/H and that between GFR and ARD/BSA remained statistically significant. The receiver-operating characteristic curve analysis revealed that an estimated GFR of about 50 ml/min/1.73 m² represents the better threshold to distinguish hypertensive patients with dilated aortic root from those with a normal one.Some population-based studies showed that an enlarged ARD might predict an adverse prognosis, even in absence of aneurysmatic alterations.In the Cardiovascular Health Study, a dilated aortic root was independently associated with an increased risk for stroke, cardiovascular and total mortality in both sexes and with incident congestive heart failure only in men. The relationship between ARD and heart failure has been observed also in the Framingham Heart Study. More recently, the PAMELA (Pressioni Arteriose Monitorate E Loro Associazioni) study demonstrated an independent relationship of ARD/H with incident cardiovascular morbidity and mortality.Although the relationship between BP and aortic root size is still a matter of debate, increasing evidence seems to support the notion that aortic root dilatation, even in absence of aneurysmatic alterations, may be regarded as an hypertensive organ damage paralleling other preclinical markers whose unfavourable prognostic significance is firmly established. Future studies are needed to assess whether or not antihypertensive therapy is able to reduce aortic root dimension and the increased risk associated with its enlargement.