Functional evaluation of a novel fibreglass-reinforced polyamide custom dynamic AFO for foot drop patients: A pilot study

BACKGROUND

Ankle-foot orthoses (AFOs) are orthopaedic devices often prescribed to treat foot drop. For patients who are not satisfied with off-the-shelf solutions, custom AFOs personalized to the patient's lower limb anatomy are required. Dynamic AFOs provide stability while allowing for physiological ankle mobility in the stance phase of walking.

RESEARCH QUESTION

Can a morphology-based dynamic custom AFO made of fiberglass-reinforced polyamide restore a quasi-normal gait pattern and improve comfort in patients with foot drop?

METHODS

In this pilot study, the legs and feet of ten foot drop patients (age=64.9 ± 11.4 years; BMI=26.2 ± 2.1 kg/m2) were scanned using a Kinect-based 3D scanner. A custom AFO was designed and produced for each patient using a fiberglass-reinforced polyamide through selective laser sintering. To assess kinematics, skin markers were placed on relevant bony landmarks according to a validated protocol. Each patient was instructed to walk at a self-selected comfortable speed under three conditions: wearing the custom AFO, wearing an off-the-shelf orthosis (Codivilla spring), and without any AFO (shod condition). Muscle activation in the tibialis anterior, gastrocnemius, rectus femoris and biceps femoris muscles in both legs was recorded using wireless sEMG sensors. The comfort and of each AFO was evaluated using a Visual Analogue Scale.

RESULTS

The custom AFO resulted in significant increase of stride length and walking speed compared to the shod condition. Except for the hip joint, which exhibited greater maximum flexion and reduced range of motion, the kinematic parameters of all other joints were similar to those observed in a healthy control population. Furthermore, the custom AFO received significantly higher comfort scores compared to the Codivilla spring.

SIGNIFICANCE

This study has provided evidence supporting the effectiveness of custom orthotic solutions in restoring lower limb kinematics and improving the perceived comfort in foot drop patients compared to off-the-shelf solutions.

A novel apparatus to assess the mechanical properties of Ankle-Foot Orthoses: Stiffness analysis of the Codivilla spring

Ankle-Foot Orthoses (AFOs) are the most common devices prescribed to support the ankle and restore a quasi-normal gait pattern in drop-foot patients. AFO stiffness is possibly the main mechanical property affecting foot and ankle biomechanics. A variety of methods to evaluate this property have been reported, however no standard procedure has been validated and widely used. This study is reporting the repeatability of a novel apparatus to measure AFO stiffness in ideal frictionless conditions. The apparatus is based on a servo-hydraulic testing machine and allows to apply a displacement-controlled rotation of the AFO shell, simulating the physiological ankle dorsi/plantarflexion movement. The repeatability of the apparatus in measuring AFO stiffness in dorsiflexion and plantarflexion was assessed intra- and inter-session in a sample of standard polypropylene AFOs of different sizes (Codivilla spring). The repeatability of the apparatus in measuring the AFO stiffness was high. The Intra- and Inter-session Coefficient of Variation ranged between 0.02 ÷ 1.3 % and 1.3 ÷ 5 %, respectively. The Intra Class Correlation Coefficient ranged between 0.999 ÷ 1 intra- and 0.993 ÷ 0.997 inter-session. AFOs stiffness was observed to increase with the AFO size. The setup is easy to replicate and can be implemented with any torsion-controlled servo-hydraulic testing machine and has resulted simple to use and flexible enough to adapt to AFOs with different sizes. The frictionless contacts characterizing the apparatus make it possible to measure the ideal AFO stiffness by excluding the effect of the fixation methods to the leg and help to improve the repeatability of measurements.

Oral versus standard antimicrobial treatment for pyogenic native vertebral osteomyelitis: a single center, retrospective, propensity score balanced analysis

Background

Interest toward shorter antimicrobial regimens and oral treatment for osteoarticular infections is growing. The aim of this study is to assess whether there is an association between the administration of an entirely oral antibiotic therapy (OT) and the clinical outcome of native vertebral osteomyelitis (NVOs).

Methods

Single center, retrospective, observational study on consecutive patients with pyogenic NVOs over a 10-year period (2008-2018). Multivariate logistic regression analysis was carried out to identify risk factors for clinical failure, both in the whole population and in subgroups. The impact of OT versus standard treatment (intravenous induction followed by oral treatment whenever possible) was assessed in patients with a non-multidrug resistant microorganism (MDRO) etiology and the impact of a rifampin-containing regimen was assessed in patients affected by NVOs caused by staphylococci or of unknown etiology.

Results

Study population included 249 patients, 33 (13.3%) experienced clinical failure; OT group consisted of 54 patients (21.7%). Multivariate regression analysis of the whole population selected Charlson Comorbidity Index (aOR 1.291, 95% CI 1.114-1.497, p = 0.001) and MDRO etiology (aOR 3.301, 95% CI 1.368-7.964, p = 0.008) as independent factors for clinical failure. Among patients affected by a non-MDRO NVO, OT was not associated with an increased risk of clinical failure (aOR 0.487, 95% CI 0.133-1.782, p value = 0.271), even after adjustment for the propensity score of receiving OT. In the subgroup of patients with staphylococcal or unknown etiology NVO rifampin was independently associated with favorable outcome (aOR 0.315, 95% CI 0.105-0.949, p value = 0.040)

Conclusions

An entirely oral, highly bioavailable treatment, including rifampin, may be as effective as parenteral treatment in selected patients with NVOs.

Spine Infections: the role of Fluorodeoxyglucose Positron Emission Tomography (FDG PET) in the context of the actual diagnosis guideline

Spondylodiscitis is an infectious process that requires numerous health care professionals to be clearly diagnosed and eventually successfully treated. It implies a variety of microbiological agents and conditions; during the diagnostic workup, it is difficult to correctly identify them, and the clinician has to rapidly choose the correct treatment to avoid permanent injuries to the patient. In this context, we conducted a review to better understand the most suitable use of Positron Emission Tomography with 18-Fluoro-deossi-glucose (FDG PET) in a patient suspected of spondylodiscitis, based on current guidelines and literature.. We wanted to review the role of FDG PET in the spondylodiscitis diagnosis and follow up in the context of the current guidelines.

Vertebroplasty in the treatment of osteoporotic vertebral compression fractures: patient selection and perspectives

Osteoporotic vertebral fractures represent a constantly increasing pathology that may compromise life quality and general health. Among various treatment options, percutaneous vertebroplasty has been used widely over the past 20 years. Although there is a vast amount of retrospective reports in the literature, high-level evidence has emerged only recently. In this paper, the authors provide a synopsis of the current literature on the efficacy and safety of percutaneous vertebroplasty while also presenting a step-by-step description of the surgical procedure, focusing on details that may help in optimizing quality and safety.

In vitro gene and chromosome characterization of expanded bone marrow mesenchymal stem cells for musculo-skeletal applications

OBJECTIVE

A number of studies have shown the role of expanded Bone Marrow-derived Mesenchymal Stem Cells in the repair and regeneration of musculo-skeletal tissues. The current European regulations define in vitro expanded cells for clinical purposes as substantially manipulated and include them in the class of Advanced-Therapy Medicinal Products to be manufactured in compliance with current Good Manufacturing Practice. Among the characteristics that such cells should display, genomic stability has recently become a major safety concern. The aim of this study is to perform a chromosomal and genetic characterization of Bone Marrow-derived Mesenchymal Stem Cells expanded in compliance with Good Manufacturing Practice for a potential clinical use in orthopaedics.

MATERIALS AND METHODS

Mesenchymal Stem Cells, isolated from bone marrow, were expanded for six weeks in compliance with current Good Manufacturing Practice. DNA profiling analyses were applied to test cross-contamination absence. Genomic stability was evaluated by means of karyotyping, sequencing of TP53, p21/CDKN1A and MDM2 genes and the expression analysis of c-MYC and H-RAS oncogenes, p21/CDKN1A, TP53, p16/CDKN2A, RB1 and p27/CDKN1B tumor suppressor genes and hTERT gene.

RESULTS

The DNA profiling analysis showed a unique genetic profile for each Mesenchymal Stem Cell culture, indicating the absence of cross-contamination. Karyotyping evidentiated some chromosomal abnormalities within the 10% limit set by the Cell Products Working Party review, except for one patient. In all cases, the molecular biology analyses did not revealed DNA point mutations, acquisition or changes in gene expression. hTERT levels were undetectable.

CONCLUSIONS

Cultured Mesenchymal Stem Cells do not seem to be prone to malignant transformation. In fact, although some chromosomal aberrations were found, molecular biology analyses demonstrated that the expansion phase did not induce the acquisition of de novo genetic changes.

Endoscopic excision of C2 Osteoid Osteoma: a technical case report

PURPOSE

The Authors illustrate the feasibility of an open biopsy and complete excision of Osteoid Osteoma involving the C2 vertebral body performed via endoscopic anterior cervical approach.

METHODS

A 23-year-old male patient with history of delayed diagnosis of cervical Osteoid Osteoma underwent evaluation and surgical treatment: the minimally invasive procedure and techniques were described. The clinical features, the radiological findings and the outcome were assessed. Complications and local recurrences were also recorded.

RESULTS

There were no intra- or post-operative complications. Immediately after surgery the typical Osteoid Osteoma related pain disappeared. At three years follow-up the patient was asymptomatic and considered disease-free: CT-scan and x-Ray showed no local recurrence and C2-C3 interbody fusion with cervical plate in site.

CONCLUSIONS

The endoscopic transcervical surgery represents an interesting option for the treatment of these diseases in difficult areas of the upper cervical spine, also minimizing soft tissue trauma and collateral damage allows patients a faster and complete return to normal function. To our knowledge this is the first report of cervical spine tumor removal using this minimally invasive approach.

Biopsy for suspected spondylodiscitis

BACKGROUND

Vertebral biopsy is fundamental in determining whether a spinal lesion is of infectious or neoplastic etiology. Accurate diagnosis is critical for proper medical and/or surgical treatment and consequently for the prognosis of the patient. CT-guided percutaneous spinal biopsy (CTSB) may minimize the risk of contamination and complications.

AIM

To demonstrate the importance and efficacy of CTSB and subsequent microbiologic/histological examination in the diagnosis of spinal lesions, particularly for those of an infectious nature.

MATERIALS AND METHODS

Two series of spinal infection patients. Prospective series of 69 patients (2009-2011), 24 of whom underwent CTSB. Retrospective series of 130 patients (1999-2008), 65 of whom underwent CTSB. All patients had microbiologic and histological testing of biopsy samples, when possible.

RESULTS

For the 2009-2011 patient series, histological examination yielded a diagnosis in 81.8% of cases, microbiologic culture and PCR for Mycobacterium tuberculosis in 45.8%. For the 1999-2008 series, histological examination yielded a diagnosis in 69% of cases, culture in 38.5%. Spinal lesions in 4 patients with previous histories of malignancy were assumed to be metastatic and treated with radiation at outside institutions. After biopsy, all were revealed to be spondylodiscitis.

CONCLUSIONS

Percutaneous CT-guided needle biopsy is the mainstay of diagnosis for spine lesions of unknown etiology, thus guiding appropriate treatment. Histological diagnosis, when possible, is critical before initiation of therapy and may be helpful in cases where cultures are negative. In the case of a spinal lesion of unknown origin, even in the setting of a previous malignancy, metastasis should not be assumed; infection and new primary lesions should always be considered as part of the differential diagnosis.

Postoperative infection treatment score for the spine (PITSS): construction and validation of a predictive model to define need for single versus multiple irrigation and debridement for spinal surgical site infection

BACKGROUND CONTEXT

There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps.

PURPOSE

The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment.

STUDY DESIGN

A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database.

METHODS

More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated.

RESULTS

Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46.

CONCLUSIONS

Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.

Osteoporotic vertebral fractures: a disabling and expensive disease of our century. A minimally invasive surgical technique to reduce the pain, the hospitalization, and restore the function

BACKGROUND AND OBJECTIVES

Minimally invasive spine surgery has gained a great consent in the treatment of vertebral osteoporotic fractures. We perform a retrospective clinical and radiographic review on 32 consecutive patients (22 female and 10 male) surgically treated for a thoracolumbar osteoporotic fracture (type A) by a minimally invasive system. By this study, we propose to determine the safety and efficacy of an expandable, percutaneous, minimally invasive technique to reduce the disability caused by vertebral osteoporotic fractures.

MATERIAL AND METHODS

We retrospectively reviewed 32 patients who were operated on between 2003 and 2004 by means of an innovative technique which employs an expandable system inserted by a minimally invasive approach into the vertebral body. Average age at surgery was 64.8 years (range, 27-82). All patients were mobilized in first post-operative day with no external immobilization and discharged from the Hospital in the second post-operative day.

RESULTS AND CONCLUSIONS

This innovative technique which employs an expandable system inserted by a minimally-invasive approach into the vertebral body permits to obtain a double mechanical support for the vertebral plate, to partially reduce the fracture, to mobilize the patient immediately, reducing disability and costs related to the vertebral osteoporotic fractures.

Spinal Infection Multidisciplinary Management Project (SIMP): From Diagnosis to Treatment Guideline

Spine infections require a multidisciplinary approach to be treated and solved. A guide line to drive physicians in the deep complexity of such a disease is extremely helpful. SIMP suggests a flow-chart built up on clear concepts such as right and well managed antibiotic therapy, sound stability of the spine, correct and smart use of the standard and functional imaging techniques, such as f18 FDG PET/CT. In 16 months a total of 41 patients have been treated for spondylodiscitis, discitis and vertebral osteomyelitis by our team of physicians and 25 patients have been enrolled in a prospective study whose target is the assessment of the SIMP flow-chart and of every single aspect that characterize it.

Transpharyngeal bone grafting for a dens delayed union in a toddler

The authors report a case of dens fracture and complete quadriplegia in a 14-month-old child. Three months after reduction with a halo vest, there was no evidence of callus formation, so transoral transpharyngeal bone grafting and Minerva immobilization was performed, resulting in prompt healing without complications after 2 months, and a full neurological recovery and normal cervical spine motion at the 4-year follow-up.

68Ga-citrate PET/CT for evaluating patients with infections of the bone: preliminary results

The aim of this work was to preliminarily evaluate the sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of (68)Ga-citrate PET/CT in a population of patients with suspected bone infections.

METHODS

We enrolled 31 patients with suspected osteomyelitis or diskitis who underwent a total of forty (68)Ga-citrate PET/CT scans. The results were compared with different combinations of diagnostic procedures (MRI, radiography, CT, or white blood cell scintigraphy), biopsy (when diagnostic), and follow-up data (at least 1 y) to determine the performance of (68)Ga-citrate PET/CT.

RESULTS

We found a sensitivity of 100%, a specificity of 76%, a positive predictive value of 85%, a negative predictive value of 100%, and an overall accuracy of 90%.

CONCLUSION

Although preliminary, these data confirm a possible role for (68)Ga-citrate in the diagnosis of bone infections, especially in consideration of its favorable characteristics.

Osteochondral allograft in a femoral head chondroblastoma: a case report

Osteoarthritis of the hip joint secondary to femoral head collapse may develop after curettage of lesions in the femoral head. We report the case of a patient with chondroblastoma of the femoral head who was treated with wide curettage of the lesion and implantation of an osteochondral allograft to prevent femoral head collapse.

Management of bone metastases

Bone metastases are only apparently similar lesions, considering the large varieties of istotypes and the spread of the primary tumour. Although these metastases develop early and are not terminal events, they have to be considered as severe complications. When possible, surgical treatment can improve the history of the patient in terms of life expectancy and quality of life. The approach to these lesions should be multidisciplinary in collaboration with oncologists and radiotherapists. In fact the average of survival of these patients has increased in recent years. The evolution of anesthesiological techniques permits surgical treatments that once were considered prohibitive. The application of new adjuvant therapies increases the effectiveness for surgical treatment. Controversy exists over the most appropriate treatment for patients with bone metastatic disease. The purpose was to determine the best sequential process to arrive at the most appropriate treatment considering the individual general conditions and the parameters of the metastases. As the number of treatment options for metastatic bone disease has grown, it has become clear that effective implementation of these treatments can only be achieved by a multidisciplinary approach.

Total knee arthroplasty in patients with poliomyelitis

We performed a retrospective chart and radiograph review of 10 patients with a history of poliomyelitis involving a limb that subsequently underwent primary total knee arthroplasty between 2000 and 2008. One posterior stabilized (PS), two condylar constrained (CCK), and seven rotating hinge (RHK) prostheses belonging to the same system were implanted. Eight patients were followed for a minimum of 2 years (mean 4.3 years, range 2 to 8.5 years); one patient required revision for prosthesis infection. The last patient was followed for just six months reporting excellent pain relief, and without complications. American Knee Society Score (AKSS) improved postoperatively in all eight patients with at least 2 years follow-up. The improvement was more marked for the knee score, which increased from a mean of 37 points preoperatively (range 20 to 51) to 75.7 points postoperatively (range 50 to 92); for the functional score the mean increase was only 15.8 points, from a mean of 38.5 points (range 20 to 70) to 54.3 points (range 20 to 80) after the intervention. One patient had a recurrence of the recurvatum deformity after implanting a CCK prosthesis. We found that a rotating hinge prosthesis that allowed hyperextension was suitable treatment for patients with knee osteoarthritis and polio as this compensated for loss of quadriceps power.

Bilateral total hip arthroplasty in Morquio-Brailsford's syndrome: a report of two cases

We report two cases of bilateral cementless total hip arthroplasty in two young women affected by Morquio-Brailsford syndrome. Morquio-Brailsford disease belongs to the mucopolysaccharidoses; it shows growth retardation with disproportional dwarfism. Usually patients are affected by a severe joint degeneration from their 2nd or 3rd decade. Young age, severe dysplasia, and joint size are the main technical problems for a total hip replacement. Accurate radiographic and CT planning allows the use of standard prostheses instead of custom-made ones.

Metastatic behaviour of giant cell tumour of the spine

Lung metastases from giant cell tumours (GCT) of the spine have not been specifically addressed in the literature. We reviewed our cases and compared the incidence, treatment, and outcomes with those from the extremities. Between 1970 and 2006, we identified seven cases (three females and four males) of lung metastases from a total of 51 cases of GCT of the spine (13.7%). Four of the seven patients had presented to our institution with a spine recurrence after previous treatments and the rest developed recurrences later. The treatments for the lung nodules consisted of metastectomy in two and chemotherapy in six patients. At the latest follow-up (ranging from 18 to 126 months), two had died of the disease, two had no evidence of the disease, and three were alive with disease. Our series shows a higher metastatic rate from spine GCT as compared to those from the extremities, but the overall behaviour and treatment outcomes of the lung metastases are similar. When there is a recurrence of GCT, with or without metastases, the local and possibly the metastases should be biopsied to confirm the original diagnosis. Progression of benign GCT into an aggressive sarcoma has been documented, and the method of management should be altered.

En bloc resection of a C4 chordoma: surgical technique

The prognosis of aggressive benign and low-grade malignant tumors in the spine as in the limbs, seems to be mostly related to the feasibility of en bloc resection, while in the treatment of high-grade malignant tumors the protocols of treatment include the combination of chemotherapy, radiation and surgery. Indications, criteria of feasibility and surgical technique are extensively reported for the thoracic and lumbar spine. In the cervical spine few cases are reported of resection, due not only to anatomical constraint, but also to the rarity of finding a tumor accomplishing the criteria of feasibility. A case of double-approach vertebrectomy finalized to remove en bloc the body of C4 for a stage IA chordoma is reported. The first stage was posterior, aiming to remove the posterior healthy elements by piecemeal technique. The anterior approach consisted of contemporary right and left prevascular presternocleidomastoid approaches The specimen was submitted for the histological study of the margins, which resulted tumor-free. This technical note is finalized to confirm that en bloc resection of the vertebral body through total vertebrectomy is feasible in the midcervical spine by double approaches, provided the tumor involves only layers B and C, maximum extension sectors 5-8.

Chordoma of the mobile spine: fifty years of experience

STUDY DESIGN

A consecutive series of 52 chordomas of the mobile spine observed over a 50-year period includes a retrospective review of 15 cases treated prior to 1991 and a prospective group of 37 cases treated from 1991 to 2002.

OBJECTIVES

This series reviews epidemiologic issues as well as clinical patterns of spinal chordomas. We attempt to correlate tumor extent, treatment, and outcomes over time.

SUMMARY OF BACKGROUND DATA

Chordoma is the most frequent primary tumor of the mobile spine. Due to slow growth, both initial symptoms and recurrences after treatment arise later, making it difficult to evaluate the effectiveness of treatment protocols.

METHODS

A prospective series of 37 cases is compared with a retrospective group of 15 patients observed between 1954 and 1991. In the prospective study, all patients had imaging studies, and oncologic and surgical staging. When en bloc resection was not feasible, intralesional extracapsular excision was combined with radiation therapy. The prospective patients were clinically evaluated and imaged. Patients in the retrospective group were evaluated by chart and available images; of these, only one en bloc resection (intralesional margin) was performed. Survivors were all evaluated clinically and had radiographic studies.

RESULTS

Forty-eight patients were available for long-term follow-up. Four died due to post-operative complications, and six due to disease less than 2 years after treatment. Forty-two patients were followed over 2 years; 26 patients had over 5 years follow-up. All patients having radiation alone, intralesional excision, or a combination had recurrences in less than 2 years, and died in some cases after a long survival with symptomatic disease. Intralesional extracapsular excision with radiation had a high rate of recurrence (12 of 16 at average 30 months), but 3 patients are continuously disease-free (CDF) at mean 52 months and 5 are alive with disease at average 69 months (ranging 24 to 146). Twelve of 18 patients having en bloc resection are CDF at average 8 years (48 to 155 months). The remaining 6 recurred and of these 1 died. All of these (6) had been previously treated and/or had en bloc resections with contaminated margins.

CONCLUSIONS

The only treatment protocol associated with CDF at follow-up longer than 5 years is margin-free en bloc resection.

Management of severe ulcerative colitis with the help of high resolution ultrasonography

OBJECTIVES

The prognosis of attacks of ulcerative colitis is clearly linked to the extent and activity of the disease. The aim of this study was to investigate the value of high resolution ultrasonography in assessing both the extent and activity of severe ulcerative colitis and its response to medical treatment.

METHODS

Fifty-seven consecutive patients affected by a severe (32 patients) or moderately severe (25 patients) attack of ulcerative colitis underwent ultrasonographic examination. The ultrasonographic extent of the disease was evaluated in 32 patients by comparing ultrasonography and scintigraphy.

RESULTS

Compared with scintigraphy, sensitivity, specificity, and overall accuracy of ultrasonographic extent were 89%, 100%, and 91%, respectively. These results were also confirmed in a subgroup of patients submitted to surgery, comparing ultrasonographic and scintigraphic data versus specimens. Using the ultrasonographic score of activity, it was possible to discriminate severe and moderately severe attacks with a specificity, sensitivity, and diagnostic accuracy of 96%, 90.3%, and 92.9% respectively. A close correlation was also found between ultrasonographic and scintigraphic activity (r = 0.78; p < 0.001). After 10 days of intensive treatment, the ultrasonographic activity significantly decreased in severe and moderate groups (p < 0.001) and in both subgroups of nonoperated patients (p < 0.001) but not in operated patients (p = NS).

CONCLUSIONS

High resolution ultrasonography can be useful in assessing both extent and activity of severe ulcerative colitis, in monitoring the patient's condition, and in objectively evaluating the response to medical therapy.

Doppler ultrasonographic evaluation of splanchnic blood flow in coeliac disease

BACKGROUND

Current knowledge on splanchnic haemodynamics in coeliac disease is limited and incomplete.

AIM

To evaluate splanchnic arterial and venous blood flow in coeliac disease.

METHODS

In 22 coeliac (13 untreated, nine treated) patients and in nine healthy subjects the following variables were assessed: vessel diameter and mean flow velocity in portal vein, splenic vein, superior mesenteric vein, and superior mesenteric artery. Peak systolic velocity, end diastolic velocity and pulsatility index were also determined in the superior mesenteric artery. Five patients of the untreated group were re-evaluated after nine months on a gluten free diet.

RESULTS

Significant differences in haemodynamic variables between the three groups were shown only in the superior mesenteric artery. An increase in both mean flow velocity and end diastolic velocity and a reduction in pulsatility index occurred in untreated patients compared with treated patients (p < 0.002; p < 0.04; p < 0.035) and with healthy controls (p < 0.001; p < 0.025; p < 0.0003). Similar results were obtained for the five patients evaluated before and after treatment (p < 0.03; p < 0.02; p < 0.03), in whom the mean flow velocity in the superior mesenteric vein also decreased after treatment (p < 0.05). No significant differences were noted between treated coeliac patients and healthy controls.

CONCLUSIONS

In untreated coeliac disease there is a hyperdynamic mesenteric circulation that decreases after treatment.

The effects of levosulpiride on gastric and gall-bladder emptying in functional dyspepsia

BACKGROUND

50% of patients with functional dyspepsia have delayed gastric emptying. Levosulpiride is an orthopramide drug that stimulates gastrointestinal motility. Aim of our study was to evaluate the effect of levosulpiride on symptoms and gastric and gall-bladder emptying, in dyspeptic patients.

METHODS

Thirty adult patients, treated for 20 days with levosulpiride (75 mg/day) or placebo, were evaluated in a randomized double-blind study. Symptoms were assessed by a cumulative index and overall intensity (visual analogue line). Gastric and gall-bladder emptying were evaluated by epigastric impedance (liquid meal) and real-time ultrasonography (mixed meal).

RESULTS

Levosulpiride, with respect to placebo, accelerated the mean gastric half-emptying time of liquids (P < 0.05), gastric emptying (P < 0.001 at 180 min; P < 0.05 at 240 min), and gall-bladder emptying (P < 0.05 at 60 and 120 min) emptying after a solid-liquid mixed meal. Both the mean cumulative index (P < 0.05) and the overall intensity (P < 0.025) of dyspeptic symptoms were reduced significantly by levosulpiride.

CONCLUSIONS

Our results showed that levosulpiride can be usefully employed in patients affected by functional dyspepsia.

Effect of single dose of oral erythromycin on gastric and gallbladder emptying. Simultaneous assessment by ultrasound

To evaluate the effects of a single oral dose of erythromycin on gastric and gallbladder emptying, 10 volunteers, without a known history of gastrointestinal disease, were investigated. Erythromycin stearate (500 mg) or placebo was given on separate mornings 30 min before a standard solid meal in a randomized, double-blind, crossover study. Gastric and gallbladder emptying rates were simultaneously evaluated by means of real-time ultrasonography. Gastric antral area and gallbladder volume were determined before the meal and 30, 60, 120, 180, 240, and 300 min after commencing eating. Erythromycin, compared to placebo, significantly accelerates and increases the degree of both gastric and gallbladder emptying. As previously reported for intravenous and chronic oral assumption, also a single dose of oral erythromycin is able to accelerate gastric and gallbladder emptying in normal human subjects.

Comparison of scintigraphy with indium-111 leukocyte scan and ultrasonography in assessment of X-ray-demonstrated lesions of Crohn's disease

The aim of this study was to compare the results obtained with an indium-111 scan with those obtained with less expensive and harmless ultrasonography to evaluate the location and inflammatory activity of Crohn's disease. Thirty-one patients previously studied with x-ray underwent abdominal 111In scans and ultrasonography (US). Sensitivity and specificity of US in detecting lesions seen with 111In scan were 77% and 92.8%, respectively. Sensitivity and specificity of 111In scan in detecting x-ray-defined lesions were 69.2% and 92.7%; the figures for US were 73% and 93.3%, respectively. Considering the evaluation of disease activity, ultrasonographic bowel wall thickness was significantly related to scintigraphic intensity of emission (r = 0.75 P < 0.01). Our experience suggests that US provided information about the location and inflammatory activity of lesions similar to that obtained from 111In scan.

Hepatocellular carcinoma. Prognostic factors and survival analysis in 135 Italian patients

This is a retrospective study to evaluate the history of hepatocellular carcinoma and find the relationship between clinical, biochemical and ultrasonographic features and survival in Italian patients. In 135 consecutive patients median follow-up was 16 months (range 1-66 months) and median survival from the time of diagnosis was 12 months. Univariate analysis showed that individual variables associated with significantly decreased survival included: absence of therapy, Okuda's Stage III, Child-Pugh's Class C, alpha-fetoprotein greater than 400 ng/ml, presence of symptoms, moderate or severe ascites, tumor involving both lobes, mixed internal echo pattern, and multinodular or massive type. Multiple regression analysis (Cox model) revealed that the mixed internal echo pattern of hepatocellular carcinoma, the presence of moderate or severe ascites and Okuda's Stage III were independent predictors of high risk of death. These data can help in selecting patients whose probability of survival is considered high enough to undergo treatment and may be useful for stratifying patients in randomized controlled trials.

[Effects of bicarbonated-alkaline water (Uliveto) on gastric and gallbladder emptying in normal subjects. Ultrasonic evaluation]

In 10 healthy patients gastric and gallbladder emptying after a standard meal (800 cal, 60% glucides, 20% protides, 20 lipids) associated with 400 ml alkaline bicarbonated water or tap water were evaluated by ultrasonography. An increase of gastric emptying was noted after alkaline bicarbonated water versus tap water with significant differences at 30' (p less than 0.05), 60' (p less than 0.01) and 120' (p less than 0.05). No significant differences exist in final gastric emptying time. Alkaline bicarbonated water induced less intensive gallbladder emptying with statistical difference versus tap water at 60' and 120' from the standard meal (p less than 0.01).