Giuseppe Migliaretti

Traumatic peripheral nerve injuries: epidemiological findings, neuropathic pain and quality of life in 158 patients

The objectives of this study were (1) epidemiological analysis of traumatic peripheral nerve injuries; (2) assessment of neuropathic pain and quality of life in patients affected by traumatic neuropathies. All consecutive patients with a diagnosis of traumatic neuropathies from four Italian centres were enrolled. Electromyography confirmed clinical level and site diagnosis of peripheral nerve injury. All patients were evaluated by disability scales, pain screening tools, and quality of life tests. 158 consecutive patients for a total of 211 traumatic neuropathies were analysed. The brachial plexus was a frequent site of traumatic injury (36%) and the radial, ulnar, and peroneal were the most commonly involved nerves with 15% of iatrogenic injuries. Seventy‐two percent of the traumatic neuropathies were painful. Pain was present in 66% and neuropathic pain in 50% of all patients. Patients had worse quality of life scores than did the healthy Italian population. Moreover, there was a strong correlation between the quality of life and the severity of the pain, particularly neuropathic pain (Short Form‐36 [SF‐36] p < 0.005; Beck Depression Inventory [BDI] p < 0.0001). Traumatic neuropathies were more frequent in young males after road accidents, mainly in the upper limbs. Severe neuropathic pain and not only disability contributed to worsening the quality of life in patients with traumatic neuropathies.

Use of Nickel-Titanium Rotary PathFile to Create the Glide Path: Comparison With Manual Preflaring in Simulated Root Canals

The study compared changes to canal curvature and incidence of canal aberrations after preflaring with hand K-files or with nickel-titanium rotary PathFile in S-shape Endo Training Blocks. The influence of the operators expertise was also investigated. One hundred training blocks were colored with ink, and preinstrumentation images were acquired digitally. Preflaring was performed by an endodontist with PathFile (group 1) and hand stainless steel K-files #10-15-20 (group 2); an inexpert clinician performed preflaring with PathFile (group 3) and hand stainless steel K-files (group 4). Preinstrumentation and postinstrumentation images were superimposed to evaluate the outcomes investigated. Differences in canal curvature modification and incidence of canal aberration were analyzed with the Kruskall-Wallis plus post hoc tests and by the Monte Carlo method, respectively, (P < .05). The PathFile groups demonstrated significantly less modification of curvature (P < .001) and fewer canal aberrations (P < .001). No expertise-related difference was found within instrument groups (P > .05), whereas the inexpert clinician produced more conservative shaping with Pathfiles than did the expert with manual preflaring (P < .01).

Efficacy of citalopram in anorexia nervosa: a pilot study.

INTRODUCTION Anorexia nervosa (AN) still lacks a defined treatment. Since fluoxetine proved effective in weight-restored anorexics, this pilot study evaluates the efficacy of another SSRI, citalopram, in restricting-type AN. EXPERIMENTAL PROCEDURES Fifty-two female anorectic outpatients were randomized in the citalopram (n=26) and waiting list (n=26) as a control group. Efficacy was assessed using Eating Disorder Inventory-2, Eating Disorder Inventory-Symptom Checklist, State-Trait Anger Expression Inventory, Beck Depression Inventory, Symptom Checklist-90 and Structured Clinical Interview for DSM-IV Axis II Disorders. RESULTS Thirteen patients dropped-out, thus 19 patients received citalopram and 20 remained in the control group. After 3 months of treatment, the citalopram group showed a decrease on BDI and SCL-90 Depression subscale and an improvement of baseline obsessive compulsive features on SCL-90, EDI-2 impulsiveness and Trait-anger on STAXI. Weight gain was similar in the two groups. DISCUSSION These preliminary results support the efficacy of citalopram in anorectics. Citalopram seems to improve depression, obsessive-compulsive symptoms, impulsiveness and Trait-anger.

Postoperative Pain after Manual and Mechanical Glide Path: A Randomized Clinical Trial

INTRODUCTION This prospective randomized clinical trial evaluated the incidence of postoperative pain after glide path performed with PathFile (PF) (Dentsply Maillefer, Ballaigues, Switzerland) versus stainless-steel K-file (KF). METHODS In 149 subjects, the mechanical glide path was performed with nickel-titanium (NiTi) rotary PF; in 146 subjects, the manual glide path was performed with stainless-steel KFs. Postoperative pain, analgesics consumption, and the number of days to complete pain resolution were evaluated in the following 7 days. An analysis of variance model for repeated measures was used to compare the variation of pain-scale values (P < .05). The Students t test for continuous variables normally distributed, the nonparametric Mann-Whitney U test for the nonnormally distributed variables, and the chi-square test for dichotomous variables were used (P < .05). Despite homogeneous baseline conditions at diagnosis, tooth type, pain prevalence, and scores, the postoperative pain prevalence curves in PF group evidenced a more favorable trend in terms of time to pain resolution compared with the KF group (P = .004). The difference was also evident in the model adjusted for analgesics consumption in both groups (P = .012). The mean analgesics intake per subject was significantly higher in the KF group (3.7 ± 2.2) compared with the PF group (2 ± 1.7) (P < .001). Mean pain stop values were also significantly higher in the KF group (2.7) compared with the PF group (1.7) (P = .001). CONCLUSIONS The glide path with NiTi Rotary PF leads to less postoperative pain and faster symptom resolution.

Hysteroscopic management of large symptomatic submucous uterine myomas.

STUDY OBJECTIVE To evaluate the feasibility of hysteroscopic resection of large submucous uterine myomas. DESIGN Prospective study (Canadian Task Force classification II-3). SETTING Surgery unit of minimally invasive gynecology. PATIENTS Thirty-three women with submucous myomas 5 cm or larger in diameter with menorrhagia, dysmenorrhea, or infertility. INTERVENTION Hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS Satisfaction with the surgery and an improvement in symptoms were the primary outcomes. Possibility of 1-step resection; complication rate, and disease recurrence were also considered. Menorrhagia was the most frequent indication (91%). According to the Wamsteker classification, 84.8% were type II myomas, whereas 93.9% scored 5 or higher according to the classification of Lasmar and colleagues. Mean operating time was 50 minutes (interquartile range, 35-65). One-step excision was achieved in 81.8% of patients. Of 5 women with incomplete resection, 3 needed a second surgery, and 2 were symptom-free. Patients with myomas larger than 5 cm or with a Lasmar score higher than 7 were more likely to undergo a 2-step procedure. In patients with myomas larger than 6 cm, recovery time was significantly longer than in those with smaller myomas. We recorded 3 complications: intravasation, uterine perforation, and postoperative anemia, in 1 patient each; at present, all 3 women are symptom-free. Median (range) follow-up was 10 (6-22) months. Twenty-seven patients (81.2%) reported they were very satisfied; 5 patients (15.2%) were satisfied; and 1 patient (3%) was dissatisfied. CONCLUSIONS Hysteroscopic myomectomy can be the treatment of choice in symptomatic patients with a submucous myoma with diameter of 6 cm or less. Although this technique raises the possibility that complete resection may require 2 surgical sessions, it is a feasible surgical procedure. However, for myomas 6 cm or larger in diameter, this approach is less attractive. Nevertheless, we believe that all of the limiting criteria defined in the available literature should be evaluated individually, bearing in mind each patients particular condition and the surgeons experience and skill.

Metabolic and cardiovascular profile in patients with Addison’s disease under conventional glucocorticoid replacement

Objective: Although two studies have shown that Addison’s disease (AD) is still a potentially lethal condition for cardiovascular, malignant, and infectious diseases, a recent retrospective study showed a normal overall mortality rate. Differently from secondary hypoadrenalism, scanty data exist on the role of conventional glucocorticoid replacement on metabolic and cardiovascular outcome in AD. Subjects and methods: In 38 AD under conventional glucocorticoid replacement (hydrocortisone 30 mg/day or cortisone 37.5 mg/day) ACTH, plasma renin activity (PRA), DHEAS, fasting glucose and insulin, 2-h glucose after oral glucose tolerance test, serum lipids, 24-h blood pressure and intima-media thickness (IMT) were evaluated and compared with 38 age-, sex- and body mass index (BMI)-matched controls (CS). Results: AD had ACTH and PRA higher and DHEAS lower (p<0.0005) than CS. Mean waist was higher (p<0.05) in AD than in CS. Although no differences were found for mean gluco-lipids levels, a higher percentage of AD compared to CS were IGT (8 vs 0%), hypercholesterolemic (18 vs 8%), and hypertriglyceridemic (18 vs 8%); none of the AD and CS showed either HDL<40 mg/dl or LDL>190 mg/dl. At the multiple regression analysis, in both AD and CS, BMI was the best predictor of 2-h glucose and age of total and LDL cholesterol; in AD, no significant correlation was found between the above mentioned metabolic parameters and either hormone levels or disease duration. In both AD and CS 24-h blood pressure and IMT were normal. Conclusions: Our study shows a higher prevalence of central adiposity, impaired glucose tolerance and dyslipidemia in AD patients.

Terminal latency index in polyneuropathy with IgM paraproteinemia and anti‐MAG antibody

Criteria for the diagnosis of chronic inflammatory demyelinating polyneuropathy (CIDP) are met by the polyneuropathy associated with immunoglobulin M (IgM) paraproteinemia and anti‐myelin–associated glycoprotein (MAG) antibody (MAG‐CIDP). However, MAG‐CIDP differs from other types of CIDP, mainly in its poorer response to treatment. The utility of terminal latency index (TLI) as an electrophysiological marker for MAG‐CIDP has been debated. In this study we confirmed its diagnostic usefulness and evaluated TLI threshold values for motor nerves investigated in routine nerve conduction studies. Median, ulnar, peroneal, and tibial TLIs of 11 subjects with MAG‐CIDP, 18 with CIDP, and 76 healthy controls were compared, and threshold values for MAG‐CIDP evaluated as the lowest value with a likelihood ratio higher than 10. Mean TLI values and TLIs of all but the peroneal nerve were significantly lower in MAG‐CIDP. Median nerve TLI of 0.26 and ulnar nerve TLI of 0.33 were identified as the threshold TLI values for MAG‐CIDP.

Functional Role and Prognostic Significance of CD157 in Ovarian Carcinoma

BACKGROUND CD157, an ADP-ribosyl cyclase-related cell surface molecule, regulates leukocyte diapedesis during inflammation. Because CD157 is expressed in mesothelial cells and diapedesis resembles tumor cell migration, we investigated the role of CD157 in ovarian carcinoma. METHODS We assayed surgically obtained ovarian cancer and mesothelial cells and both native and engineered ovarian cancer cell lines for CD157 expression using flow cytometry and reverse transcription-polymerase chain reaction (RT-PCR), and for adhesion to extracellular matrices, migration, and invasion using cell-based assays. We investigated invasion of human peritoneal mesothelial cells by serous ovarian cancer cells with a three-dimensional coculture model. Experiments were performed with or without CD157-blocking antibodies. CD157 expression in tissue sections from ovarian cancer patients (n = 88) was examined by immunohistochemistry, quantified by histological score (H score), and categorized as at or above or below the median value of 60, and compared with clinical parameters. Statistical tests were two-sided. RESULTS CD157 was expressed by ovarian cancer cells and mesothelium, and it potentiated the adhesion, migration, and invasion of serous ovarian cancer cells through different extracellular matrices. CD157-transfected ovarian cancer cells migrated twice as much as CD157-negative control cells (P = .001). Blockage of CD157 inhibited mesothelial invasion by serous ovarian cancer cells in a three-dimensional model. CD157 was expressed in 82 (93%) of the 88 epithelial ovarian cancer tissue specimens. In serous ovarian cancer, patients with CD157 H scores of 60 or greater had statistically significantly shorter disease-free survival and overall survival than patients with lower CD157 H scores (CD157 H score > or =60 vs <60: median disease-free survival = 18 months, 95% confidence interval [CI] = 5.92 to 30.07 vs unreached, P = .005; CD157 H score > or =60 vs <60: median overall survival = 45 months, 95% CI = 21.21 to 68.79 vs unreached, P = .024). Multivariable Cox regression showed that CD157 is an independent prognostic factor for recurrence (hazard ratio of disease recurrence = 3.01, 95% CI = 1.35 to 6.70, P = .007) and survival (hazard ratio of survival = 3.44, 95% CI = 1.27 to 9.31, P = .015). CONCLUSIONS CD157 plays a pivotal role in the control of ovarian cancer cell migration and peritoneal invasion, and it may be clinically useful as a prognostic tool and therapeutic target.

Association among oral health, apical periodontitis, CD14 polymorphisms, and coronary heart disease in middle-aged adults.

INTRODUCTION There is evidence to suggest that an association exists between oral infections and coronary heart disease (CHD). Subjects presenting lesions of endodontic origin (LEOs) or pulpal inflammation had an increased risk of developing CHD. However, findings concerning systemic manifestations of apical periodontitis (AP) remain controversial. An association between CD14 gene polymorphisms and atherosclerosis-associated diseases has been shown, but there are no data regarding an association between CD14 polymorphism and AP. This study evaluated associations between clinical oral health status, CD14 polymorphisms, and CHD. METHODS A case-controlled clinical trial was designed to compare middle-aged adults with acute myocardial infarction or unstable angina (n = 51) within 12 months of the acute event defined as first manifestation with healthy controls (n = 49). Participants were matched for age, sex, and socioeconomic status. Indicators of oral disease and compliance were evaluated. CD14 polymorphisms were analyzed by restriction fragment length polymorphism-polymerase chain reaction. RESULTS CHD subjects had a higher prevalence of oral diseases and lower compliance to oral preventive strategies than healthy controls. Multivariate analysis showed a positive association between missing teeth (odds ratio [OR] = 1.37; 95% confidence interval [CI], 1.02-1.85), the number of LEOs (OR = 4.37; 95% CI, 1.69-11.28), chronic periodontitis (OR = 5.87; 95% CI, 1.17-29.4), and CHD. No statistically significant association emerged between the CD14 C(-260)T and the CD14 C(-159)T polymorphism, endodontic or periodontal disease, and CHD. CONCLUSIONS Chronic oral diseases may increase the risk of CHD and may be an unconventional risk factor for CHD.

Laparoscopy and body mass index: feasibility and outcome in obese patients treated for gynecologic diseases.

STUDY OBJECTIVE To compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women. DESIGN Retrospective case control study (Canadian Task Force classification II-3). SETTING Surgery Unit of Minimally Invasive Gynaecology. PATIENTS A total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies. INTERVENTIONS Four main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m(2)), normal-weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI ≥30 kg/m(2)). MEASUREMENTS AND MAIN RESULTS Selected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 +/- 47 min vs 65 +/- 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes. CONCLUSION Laparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.