Cementless total hip replacement for severe developmental dysplasia of the hip: our experience in Crowe’s group IV

Total hip replacement in developmental dysplasia of the hip grade IV of Crowe’s classification presents some difficulties. In this study, we present our results of the treatment for this pathology, also describing the surgical techniques used and the complication we had. In this paper, 18 total hip replacements in developmental dysplasia of the hip Crowe IV were studied clinically and radiologically before and after surgery, with a mean follow-up of 4.2 years (min: 1 year). The average Harris Hip Score improved from 52 to 89. The average leg lengthening was 36 mm. When a subtrochanteric shortening osteotomy was performed, the healing occurred in all cases, in an average time of 5.3 months. At now, the implant survivorship is 100 % (no revision required). The techniques and principles described in this paper allow to achieve good results in this surgery. An accurate preoperative evaluation and the availability of specific materials are also important steps. The subtrochanteric shortening is a safe procedure to avoid neurovascular injuries.     

Current perspective on the pathogenesis of central diabetes insipidus

Diabetes insipidus is a heterogeneous condition characterised by polyuria and polydipsia caused by a lack of secretion of vasopressin, its physiological suppression following excessive water intake, or kidney resistance to its action. The clinical and laboratory diagnosis is confirmed by standard tests, but recent advances in molecular biology and imaging techniques have shed new light on the pathophysiology of this disease. In many patients, central diabetes insipidus is caused by a germinoma or craniopharyngioma; Langerhans' cell histiocytosis and sarcoidosis of the central nervous system; local inflammatory, autoimmune or vascular diseases; trauma from surgery or accident; and, rarely, genetic defects in vasopressin biosynthesis inherited as autosomal dominant or X-linked recessive traits. Thirty to fifty percent of cases are considered idiopathic. Tumour-associated central diabetes insipidus is uncommon in children younger than 5 years old. Biopsy of enlarged pituitary stalk should be reserved for patients with hypothalamic-pituitary mass and progressive thickening of the pituitary stalk since spontaneous recovery may occur. Molecular biology in selected patients may identify those with apparently idiopathic diabetes insipidus carrying the vasopressin-neurophysin II gene mutation.     

Setting priorities in the prevention and control of nosocomial infections: an economic perspective

Nosocomial infections are a good indicator of the quality of health care provided by hospitals. Despite their cost-effectiveness, nosocomial infection programs are rarely applied in Italy. Epidemiological surveillance is the simplest measure to adopt because it allows us to monitor the baseline endemic rates, identify new epidemics and assess the improvements achieved by interventions provided. The presence of continuous epidemiological surveillance must be considered the exception rather than the rule in Italy. In this paper, the prevention of nosocomial infections was analysed through two economic evaluation techniques (i.e. cost-benefit and cost effectiveness). A hierarchy of intervention based on cost effectiveness, hospital size and organisational setting was also provided. The main conclusions are the following: 1. Benefits associated to prevention of nosocomial infections are considered small because of the uncertainty associated to the future. Therefore a discount factor must be applied. 2. Local factors and specific reasons are usually advocated to explain the simple fact that infection control programs are only formally implemented and usually limited to the constitution of a nosocomial infections committee. 3. The prevention of nosocomial infections must be provided for under specific laws which take into account the various organisations and structures found in different hospitals.     

Preference for sweet foods and higher body mass index in patients being treated in long-term methadone maintenance

Opiate use has been associated with preference for sweets in both humans and animals. In 2002, the food preferences and eating habits of non-institutionalized patients in methadone treatment and controls were measured and compared. Questionnaires were administered to 14 patients and 14 controls with similar demographic characteristics (there were 19 women and 9 men ranging in age from 19 to 59 years). The patients reported higher consumption of sweets, higher eagerness to consume sweet foods, and a wish to consume quantities larger than that desired by controls. Patients had a significantly higher body mass than controls. The study's limitations are noted. These findings suggest a link between methadone and a desire for calorically dense foods. A study of eating behavior is warranted.     

Radiological exams on end-stage oncologic patients before hospice admission

Purpose

To evaluate frequency, type, and cost of diagnostic and interventional radiological exams performed on end-stage oncologic patients in the 90 days before Hospice admission.

Materials and methods

Data of patients admitted to Hospice from January 2012 through June 2013 (18 months) were cross-checked with data from the digital archive of the Radiology Department. Frequency and type of exams performed before admission were analyzed across three 1-month periods, namely M_?3, M_?2, M_?1, corresponding to 90–61, 60–31 and 30–1 days before admission. The Regional Range of Fees was used to determine the costs.

Results

A total of 389 patients were admitted to Hospice. Before admission, 335 patients (86%) underwent 1543 radiological exams: 919 X-rays, 555 CTs, 39 MRs, and 30 interventional procedures. The cost of these services was € 106,988 (€ 19,918 for X-rays, € 73,956 for CTs, € 9502 for MRs, and € 3612 for interventional procedures). Across the pre-Hospice periods, the proportions of examined patients increased as admission approached: 36% in M_?3, 43% in M_?2 (P = .038), 65% in M_?1 (P < .001). The mean number of exams increased significantly, too (P < .001).

Conclusions

A substantial number of end-stage oncologic patients underwent radiological exams in the 90 days before Hospice admission, and these numbers grew as Hospice access approached. In the end-of-life span, diagnostic excesses should be avoided.

     

Contrast-enhanced versus conventional and color Doppler sonography for the detection of thrombosis of the portal and hepatic venous systems

OBJECTIVE: We conducted a prospective study to compare sonography, color Doppler sonography, and contrast-enhanced sonography for the detection and characterization of portal and hepatic vein thrombosis complicating hepatic malignancies. SUBJECTS AND METHODS: Three hundred sixteen patients with biopsy-proved hepatic tumors were studied at baseline and 3 months later with sonography, color Doppler sonography, and contrast-enhanced sonography. Thrombosis was defined as the presence of intraluminal echogenic material at sonography, absence of intraluminal color signals at color Doppler sonography, and presence of nonenhancing intraluminal area at contrast-enhanced sonography. Thrombi were considered malignant if they displayed continuity with tumor tissue at sonography, intrathrombus color signals at color Doppler sonography, and enhancing signals at contrast-enhanced sonography, both having arterial waveforms at Doppler spectral examination. Definitive diagnoses were obtained by sonographically guided biopsy except for thrombi displaying at conventional sonography unequivocal continuity with tumor tissue. RESULTS: Thrombosis was detected in 79 (25.0%) of 316 patients at baseline and in 83 (26.3%) of 316 patients after 3 months. Eighty-one (97.6%) of the 83 thrombi were malignant. Definitive diagnosis was performed by imaging in 60 (72.3%) of the 83 cases and by biopsy in 23 cases (27.7%). For thrombus detection, contrast-enhanced sonography displayed significantly higher sensitivity than color Doppler sonography (p = 0.004) and borderline superiority over sonography (p = 0.058). For thrombus characterization, contrast-enhanced sonography was significantly more sensitive than color Doppler sonography (p < 0.0005) and conventional sonography (p = 0.02). CONCLUSION: Contrast-enhanced sonography is superior to sonography and color Doppler sonography for the detection and characterization of portal and hepatic vein thrombosis complicating hepatic malignancies.