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Experience in the treatment of acute cholecystitis with percutaneous cholecystostomy in 29 high-risk and elderly patients is reported. The treatment group included 14 men and 15 women, 21 of whom were over 70 years of age. The suspected clinical diagnosis of acute cholecystitis was confirmed in all cases by ultrasonography (accuracy: 95.6%). The percutaneous cholecystostomy was successful in 27 of 29 cases and these patients had a sudden improvement in their clinical condition; failure of the procedure was due in one patient to dislodgement of the catheter and in another patient to the guide-wire slipping out of the gallbladder. Six patients complained of pain radiating to the right shoulder which disappeared within 30-60 minutes after the procedure. Twenty-three of the 27 patients subsequently underwent elective cholecystectomy. In 22 patients the ultrasonographic findings were compared with the histology; thus enabling us to establish an ultrasonographic staging of acute cholecystitis related to the seriousness of the disease. Percutaneous cholecystostomy is the treatment of choice in high-risk patients, in the elderly, as well as in young patients with impending perforation.

In Europe there are about 300,000 paraplegics and in every country approximately 1000 new cases per year. Treatment requires a multidisciplinary approach with scientific cooperation targeted to exchange personal knowledge and expertise. At present a completely disrupted spinal cord cannot heal for recovery of motor and/or sensory functioning, although some promising treatment modalities in laboratory animal experiments have been reported. No interventional stem cell procedure so far has shown evidence to restore impaired functioning in human paraplegics. However, functional electrical stimulation (FES) via an implanted neuroprosthesis (SUAW concept) and central nervous system-peripheral nervous system (CNS-PNS) connection have successfully been used for alternative compensatory strategies for voluntary locomotion. This report is to analyse the authors' experience from two European projects in paraplegic. Factors will be identified that might have caused the one or other pitfall since so far both surgical reconstructive procedures have not been adopted by rehabilitation physicians and/or restorative (neuro-)surgeons despite the promising functional results we have achieved. Unexpected plasticity of single neurons following CNS-PNS by-pass procedures is discussed. Future interventions, for example the present phase 1 prospective multiple centre study on the side effects, effectiveness, and reliability of intrathecal treatment of anti-Nogo-A antibodies, are presented and the Chinese stem cell implantation is critically reviewed.

This short paper demonstrates that the Finkelstein's test in De Quervain's tenosynovitis is based on an incorrect assumption. The correct basis for a pathognomic manoeuvre in De Quervain is the provocation of tendons attrition of the first wrist dorsal compartment against their pulley which elicits pain. The Brunelli's test induces this friction and pain by asking the patient to hardly adduct the thumb with the wrist in radial deviation.

Paraplegia means a live long sentence of sensory loss, paralysis and dependence with approximately 1000 new victims in every European country every year and 11.500 new traumatic SCI cases in the US. respectively. Sixty percent are injured before age 30. More than 90% of SCI victims may survive with nearly normal experience of live. Most patients will recover somewhat from SCI over time but no patient who remained plegic for one year regains voluntary motor function after that time period. Despite remarkable efforts and recent achievements in rehabilitation no treatment can be recommended so far to enhance functional recovery and restoring locomotion in paraplegic humans. FES as a technical compensation has become therefore a challenging treatment to restore muscle function and to prevent atrophy and to improve mobility and quality of life at the same time. In paraplegics FES could be the basis to restore locomotion. One of the advantages of an implanted FES version (neuroprosthesis) is that the FES system, electrodes, and cables remain permanently implanted within the body, so that the patient can stay without cables, the programmer attached to the crutches. The SUAW project, supported under BIOMED II Programme by the European Community was aimed to finalize and to put into practice the results of previous research and development. The novel implant with an ASCI-Chip has 16 channels, 8 on each side, 20 mA for monopolar and 2 mA for bipolar stimulation, only one electrode can be stimulated at a given time. Stimulation of 6 muscle groups of both legs are known to be sufficient for locomotion: M. ileopsoas (erector of the body, hip flexor), M. gluteus maximus (hip extensor), M. gluteus medius (lateral hip stabilisator, knee abductor), Mm. hamstrings (knee flexor) stimulated by epimysial electrodes, Mm. sartorius and rectus femoris (knee extensor) stimulated by neural, bipolar electrodes. Patient's selection criteria were: stable spinal cord lesion between T7 and T11, minimum 1 year after the accident without deformity of the spine, the muscle groups for locomotion responding to external FES with the EXOSTIM programmer with the same programme used later for the neuroprosthesis. Two paraplegic male patients, T8, 38 and 31 years old respectively, were operated on by an international group of surgeons according to the protocol in 09/1999, respectively 7/2000. The postop. course was uneventful. Because the threshold of the primary implant was too low regarding scare tissue around the electrodes, this implant was changed in 01/2000 and worked perfectly. Both patients are happy with the success of the novel treatment modalities.

The International Headache Society (IHS) classification system (1988) was developed primarily for headache disorders in adults and its validity for paediatric age is currently under discussion; in 1995 Seshia et al. proposed a revision of the criteria for migraine without aura to make diagnostic criteria more applicable to children. The purposes of the current study were to: (1) compare the IHS classification with the Seshia proposal, (2) compare the children affected by migraine without aura (MO) with the children affected by tension headache (TH) as defined by Seshia, for characteristics which are not included in the classification. The patients are a series of 320 children (mean age 9.9, SD 2.6 years; 144 males, 176 females) with recurrent or chronic headaches referred to a headache clinic in Milan, Italy. Using the Seshia criteria instead of the IHS criteria a higher number of children were included in the MO category: bilateral pain and family history of migraine were the most important factors which allowed a shift of children into this category. However, with the Seshia classification there was no reduction in the number of unclassifiable children. The reason why some children could not be classified was a short duration of attacks; the majority of unclassifiable children were 6 years old or less. No relevant difference was found between children with MO and children with TH for the following variables: occurrence of attacks in the afternoon or evening after school, reduction of attacks during school holidays, full-time schooling, after-school activities on school days, disordered daily life. On the contrary children with MO when compared with those with TH showed a higher number of precipitating factors and for the following factors a significant difference was found: exposure to TV or a computer, sleep deficiency, and strong emotions. Furthermore, children with MO showed a greater severity of attacks.

The arterial supply of the dorsal surface of 25 thumbs was studied by light microscopy. An artery, located on the dorso-ulnar side and connecting the head of the first metacarpal bone with the dorsal arcade of the nail matrix, was constantly found in all dissections. The authors report the results of the anatomical study and the clinical applications of a skin flap which can be raised on the dorso-ulnar surface of the M.P. joint with a distal pedicle. Clinical experience is based on 22 flaps. In 18 cases this flap was used for distal skin loss coverage (palmar or dorsal) of the thumb as an island flap. In 4 cases it was used for reconstruction of the finger pulp in the form of a cross finger flap.

The authors point out how infection of heterologous prosthesis, widely used in surgery, can be a dramatic event. On the other hand, antibiotic prophylaxis is difficult because of the difference between "in vitro" and "in vivo" activity of many antibiotics, due to the production, by many bacteria, of the so-called glycocalyx. This would allow bacteria to clump and adhere to many surfaces, forming micro-colonies, causing delay in phagocytosis, and reducing the efficacy of antibiotics. On the basis of their, although limited, experience, the authors suggest, for the prophylaxis of prosthesis infection, the use of antibiotics such as clindamycin, able to reduce glycocalyx production.

Sensory reeducation is very important. Many methods are used but it is difficult to assess their efficiency. Besides the routine methods we are using the gnostic rings which have on their periphery 5 symbols: a letter = A, a number = 3, a geometrical figure = a circle, a rough surface and a smooth convex surface. The symbols of the rings are in 3 different sizes (1.5 - 1 and 0.5 cm). The gnostic rings have 3 advantages: 1) they allow a precise evaluation in percentage. 2) they require an important brain effort, 3) they may be kept in the pocket and used several times during the day.

The authors report on their personal experience with percutaneous cholecystostomy (PC) in 36 cases of acute cholecystitis (AC). PC was successful in 34 cases, improving the clinical condition of the patients within the first hour following treatment and normalizing the laboratory data within 24-48 hours. Twenty-seven patients with calculous AC underwent cholecystectomy within 4-15 days. In 6 cases (3 calculous and 3 acalculous ACs) PC was the only treatment performed; in one case (calculous AC) PC was combined with lithotomy, the stone fragments being extracted via the cholecystostomy. According to literature reports, to date PC has been performed mainly--as an alternative to surgical cholecystostomy--on the patients unsuitable for cholecystectomy due to their age or to severe impairment of their conditions. In our experience, the procedure can be performed on a wider range of patients as a final (notably in acalculous AC) or temporary step (notably in calculous AC where it may allow cholecystectomy to be delayed and thus performed under better clinical conditions, with decreased morbidity and mortality risks).

Free microvascular grafts have many advantages over conventional bone grafts. Above all they do not undergo creeping substitution and live on their own vessels, thus being able to heal quickly and fight infection. Research in rabbits has been done with radiographic, scintigraphic and light and fluorescence histologic examination which demonstrated the high superiority of quality, reliability and rapidity in healing of the microvascular bone transfer as related to avascular ones. Eighty-five cases of free microvascular fibular transfers starting in 1975 are presented including six congenital cases, 12 non-unions, eight osteitis, seven tumors, seven large losses of bone and 45 femoral head necrosis. The failure ratio is very low. Six primary failures were cured by plaster or additional cancellous bone grafts. Four failures (in femoral head necrosis) did not cure due to recession of the graft, its reabsorption or progression of avascular necrosis in two corticosteroid cases.

The authors present a technique of direct muscular neurotization consisting of re-innervation by direct implantation of a nerve into one or several muscles in cases of avulsion of the nerve supplying the muscle or traumatic or surgical avulsion of the neural part of the muscle. The biological basis for this operation is that a denervated muscle can accept a new innervation by a foreign nerve even in an aneural zone because its sensitivity to acetylcholine is present throughout the muscle, while, in a normally innervated muscle, sensitivity to acetylcholine is confined to the motor endplates. The results of 47 cases are presented: 42 of them obtained good or very good results.

Arthrodesis of the wrist in cases of paralysis of the upper limb, although rejected by certain authors, is a valid operation provided it is confined to certain indications such as paralyses requiring minimal muscle transfers. Arthrodesis of the wrist is particularly useful in the sequelae of brachial plexus lesions with dissociated paralysis and in total paralysis of the radial nerve with hand drop and preservation of the wrist flexors. Numerous techniques of arthrodesis have been proposed. Over the last 27 years, the authors use a technique with a direct dorsal incision. The first row of carpal bones and the radius are roughened with chisel. A cortico-cancellus graft is then raised from the dorsal surface of the radius, leaving a distal cortical bridge. The graft is slid under this bridge, placed onto the roughened surface of the carpus and pushed under the operculum raised at the base of the 2nd and 3rd metacarpals. The arthrodesis is fixed with two Kirschner pins and a plaster for 3 months. We have used this technique in 31 patients with nerve paralyses since 1971 and have obtained complete consolidation with total patient satisfaction in all but one case.

The interaction of leukotriene C4 (LTC4) with the contractile activity of histamine (H), serotonin (5HT) and norepinephrine (NE) has been investigated in isolated vascular preparations. Threshold concentration of LTC4 (5 × 10−9 M) significantly potentiated the vasoconstricting effect of these compounds on guinea-pig pulmonary artery (GPPA). This phenomenon was long-lasting for H since it was still present 40 min after LTC4 had been washed. FPL-55712 (10−5M) counteracted the increased H response on GPPA induced by LTC4. Potentiation of H activity due to LTC4 was also observed on guinea-pig thoracic aorta (GPTA) indicating that LTC4-induced hyperreactivity is not a phenomenon restricted to the pulmonary vascular bed. In the experiments carried out in presence of indomethacin (3 × 10−6M), LTC4 still potentiated H-induced vasoconstriction on GPPA, however the time course of the phenomenon was significantly shorter than that observed in absence of the cyclooxygenase inhibitor. The contractile activity of H and NE on guinea-pig portal vein (GPPV) was not potentiated by LTC4 These results demonstrate that LTC4 induces hyperreactivity of the arterial vascular tissue to vasoactive compounds and suggest that cysteinyl-leukotrienes may have pathological significance in the hemodynamic changes occurring during anaphylactic reactions. Preliminary experiments carried out on human intralobar pulmonary artery strongly support this hypothesis.

A follow-up of 78 patients with acromio-clavicular dislocation who have been operated on since 1956 is reported. The tendon of the short head of the biceps is transferred to the clavicle to obtain, and maintain, reduction. The site of transfer in the last 51 cases has been to a point on the clavicle immediately above the coracoid process. The acromio-clavicular joint is only opened when an obstruction to reduction is present. The functional results in this group of patients are very good.

Immediate mobilisation after flexor tendon suture produces a conflict between the muscle force and resistance of the sutures. Sutures within the tendon after repair are weak and need contrived measures (e.g. wrist and metacarpophalangeal flexion, rubber bands etc.) to prevent dehiscence, while pull-out sutures do not allow mobilisation because of their anchorage. A new technique is presented which consists of a simple slip-knot suture which transmits the tension generated by the muscle to the distal tendon stump and its bony insertion, allowing immediate mobilisation. Results in ninety eight cases repaired by this technique during nine years are presented.

The study was performed on a group of 91 children with their first febrile convulsion whose parents were then instructed in the use of rectal diazepam in the event of a further seizure. later, the families were periodically recalled for interviews. The aim was to study the acceptance and cooperation of the families, the psychological attitude and the relation between the findings and parents' educational level. At the end of the follow-up, 80% of the 91 families showed good cooperation and psychological benefits. There was no relationship between the findings at the end of the follow-up and families' educational level. Even in the presence of a favorable psychological attitude, recurrences of febrile convulsions were still a frightening experience for many parents.

Previously, when part of a muscle and the terminal part of its nerve with its branches were removed through trauma, no technique for repair was available. A new technique for direct neurotization of denervated muscles is presented. This consists of the insertion of the distal stump of a nerve graft, divided into many small branches, directly into the muscle. Very good results were obtained in eight clinical cases of severely damaged muscles which were operated on according to this technique.

Immediate mobilization of flexor tendons repairs creates a conflict between muscle strength and suture solidity. Non removable sutures are brittle and require to prevent extension by means of either a cast in flexion of the wrist and of the metacarpo-phalangeal joints or a rubber band traction. Pull-out sutures do not permit early mobilization because of their anchorages. The authors present a new technique they have been using for the last five years. It consists in a simple solid slip-knot which tightening the tendon when the muscle pulls. This knot is fixed at the distal bone insertion of the tendon, which makes immediate mobilization possible. Sixty three patients have been treated with by this technique over the past five years. We have not encountered any rupture of the suture. The results, even in the least favorable cases have been considered as very good.

Fractures of the intercondylar tibial eminence are produced by a mechanism similar to that of rupture of the cruciate ligaments, in particular excessive internal rotation in varus and external rotation in valgus. When combined with other types of force there may be associated lesions of other structures, which naturally complicates the treatment and prognosis. Screw fixation is not considered satisfactory, both because of its difficulty when the posterior tuberosity is involved, the need for a second operation to remove the screw, the frequency with which the fragments break during or after the application of the screw, and the possibility that the screws may loosen. Fixation is performed by means of a metal wire transfixing the fracture, passed through two tunnels in the tibia, and anchored on the anterior surface of the tibia over a small metal plate, in order to prevent cutting through the bone under tension. It is important that the two small tunnels drilled in the tibia should exactly meet the fracture line.

In summary, this technique provides a number of well-differentiated sensory and voluntary motor fibers. This number is certainly less than that of a normal plexus but is much more and of much better quality than that of intercostal nerves. If we distribute these fibers to well-chosen branches of the brachial plexus, limiting the neurotization to few selective components, we have the possibility of a useful recovery of essential movements of the shoulder and elbow. Sensation to the hand will also recover to a certain extent. Subsequent palliative operations (as for instance different kinds of arthrodesis) can supply a limb that, although paralyzed and severely impaired, can still be useful.

The authors present the results of twenty-five tendon grafts performed between 1972 and 1982. The end results were evaluated according to these parameters: the pre-operative condition, the donor tendon, the level of the lesion, the age of the patient, and the time elapsed from injury to operation.

S-(+)-2-(4-Fluorophenyl)-alpha-methyl-5-benzoxazolacetic acid (flunoxaprofen, Priaxim is a new antiinflammatory compound, which in various biological systems interferes with the generation and release of arachidonic acid metabolites of the cyclo-oxygenase pathways without affecting the formation of 5- and 12-lipoxygenase products. Flunoxaprofen reduces the concentration of thromboxane (TX)B2 (ED50 = 35.4 mg/kg p.o.) and prostaglandin (PG)E2-like activity (ED50 = 39.9 mg/kg p.o.) in the inflammatory exudate of rats 8 h after implantation of sponges soaked with carrageenan, whereas the concentration of leukotriene (LT)B4 remains in the range of that of the untreated animals (3.1 ng/ml). Flunoxaprofen inhibits cell infiltration in the exudate and this suggests that LTB4 does not initiate cell recruitment but may represent a mechanism for amplifying the inflammatory response. Using human platelets challenged with collagen, flunoxaprofen only at higher concentration (10(-4) mol/l) reduces TXB2 formation without altering generation of 12-hydroxy-5,8,10,14-eicosatetraenoic acid. This suggests a low capacity of flunoxaprofen of affecting platelet aggregation regulated by arachidonic acid metabolites. Flunoxaprofen prevents pulmonary changes due to secondary release of TXA2 in the guinea-pig. In fact this drug prevents changes due to immunological reaction and antagonizes bronchoconstriction due to exogenous administration of histamine and LTC4.(ABSTRACT TRUNCATED AT 250 WORDS)

In order to avoid the risks of local and general complications encountered in replantations after long ("critical") periods of ischemia, or in cases of severe open fractures with crushed muscles, a so-called "muscle elementarization" technique has been devised. This technique consists of removing the muscular masses which have undergone prolonged ischemia with a priority for the least important muscles. In this manner, we believe that edema and the consequent risks of compartment syndromes as well as of life threatening complications can be reduced. Functional impairment is limited as well. Eleven cases of severe crushing or critical time limit ischemia replantation have been treated in this manner without any complications.

The trapeziometacarpal (TM) joint is often the site of painful arthrosis, particularly in women at the onset of the fourth decade. It is generally associated with capsuloligamentous laxity of the joint or with work requiring the repetitive use of the thumb and index finger and thus work which is typically done by women. It may also be of traumatic origin following joint fracture, but this is not discussed in the present paper. The treatment of this syndrome by stabilisation of the joint is described.

Denervation, provosed at the turn of the century and abandoned because of inconstant results, has again been taken up in principle, but with a notable change in technique. It is necessary to do a careful examination of the muscles that are to be denervated (of the median and ulnar nerves) and to determine the nature of the spasticity. The incision, longer than in the original technique, allows a better view of the median and ulnar nerves. The nerve branches to each muscle are thus easily identified, and by electric stimulation during the operation one judges how much denervation to subject the muscles to while taking into account the phenomenon of the take-over of the denervated muscles by the remaining nerve fibers. Part of the nerve branches are then sectioned under microscopic control near the muscle, taking care to cauterize the proximal stump. It may be necessary to do associated tenotomies or capsulotomies. This method gives good results if the technique and the contraindications, (athetosis, chorea and cerebral deficits) are respected. It must be emphasized that the results depend on the degree of denervation, which is hardly quantifiable, and is subject to the operator's experience.

The present evaluations of hand invalidity are based on parameters that can give correct assessment for amputations or for single stiffness, but these parameters are not able to evaluate the majority of lesions. A nerve lesion does not repair at 100% or at 0%; all degrees are possible. The same is true for vascular, tendon and muscular lesions. We studied a new global evaluation on a large number of patients and we compared it with the tables in use today. The assessed parameters are: the active and passive movement, ability of the hand, strength, duration of the effort or of the fatigue, trophism, sensibility, pain, aesthetics.

The Authors report their experience with 222 esophagoenteric anastomoses, performed in 211 cases for malignant neoplasms (middle and lower third) of the esophagus or stomach. Particularly, they have performed 4 Sujura operations, 31 esophagogastric, 4 esophagocolic, 183 esophagojejunal anastomoses utilizing SPTU, ILS and EEA circular stapler. GIA was used in the preparation of the stomach before esophagogastroplasty. Mortality rate of the manual period (1970-1980: 114 cases operated) was 14.5% versus 2.2% of the stapling period (1981-1987: 222 cases operated). From the technical point of view reasons of the superiority of stapled technique are discussed and summarized as follows: 1) space not favourable for handsewn anastomoses; 2) stapled technique allows the surgeon to save anastomoses vascularization; 3) the stapler performs the suture simultaneously so to reduce tensile strength on the anastomoses and the fragile esophageal wall especially; 4) stapled agraphes are fixed in three points vs. the two points of the handsewn stitches.

We report the data of 878 selected children between 1 month and 6 years, presenting a first episode of seizure with fever. Two-hundred-fifty-five children underwent lumbar puncture. In 7 cases the CSF findings showed a bacterial meningitis, in 14 cases a viral meningitis. In 598 of the 623 children who did not undergo LP, a bacterial meningitis could be excluded on the basis of the clinical course. The data show that the probability of finding a bacterial or viral meningitis is high in children under 6 months of age even if no significant neurological signs are found on examination performed shortly after the seizure. In our study, older children affected by bacterial meningitis were clinically identifiable. In children aged 6 months to 3 years without important neurological signs, a complex seizure has been found to be a significant discriminating factor between patients with and without viral meningitis.

In this paper the results of treatment in 19 cases of postactinic paralysis of the brachial plexus are reported. The surgical technique aimed at resolving this condition, which is serious and often extremely painful, involves neurolysis and a long, narrow free omental graft and removal of the clavicle; the donor vessels are the left gastroepiploic arteries and veins; the recipient vessels are those distant from the irradiated area (often in the neck, transverse and facial arteries, veins affluent to the external jugular).