Il capitalismo municipale e le esternalizzazioni fredde

La novella legislativa del 2003 (d.l. 269/2003) ha inciso sull\u2019assetto dei servizi pubblici locali aumentando le fattispecie nelle quali l\u2019ente locale pu\uf2 assumere la veste di soggetto proprietario, attraverso l\u2019acquisizione di partecipazioni in societ\ue0 a capitale totalmente pubblico o a capitale misto pubblico-privato0. Questo scenario istituzionale \ue8 diventato cornice ideale per l\u2019affermazione definitiva del fenomeno del gruppo comunale, che vede il Comune assimilato ad una holding che controlla un sistema di entit\ue0 formalmente indipendenti, strumentale alla realizzazione dei suoi fini sociali e alla promozione dello sviluppo economico e civile delle comunit\ue0 locali. Alla crescita esponenziale del peso dei servizi gestiti dal Comune per il tramite di entit\ue0 partecipate, non \ue8 corrisposta l\u2019evoluzione del suo sistema informativo-contabile verso un modello che dia conto dei risultati, di natura reddituale, patrimoniale e monetaria, ottenuti grazie al complesso delle attivit\ue0 sulle quali estende il suo potere di controllo. Il modello che coglie le interrelazioni operative fra le unit\ue0 del gruppo e la loro complementarit\ue0 rispetto ad un progetto strategico unitario \ue8 il bilancio consolidato. Allorch\ue9 si progetti di adottare il bilancio consolidato nel contesto pubblico locale, ci si imbatte in alcune problematiche da risolvere preventivamente. Merita di riflettere sostanzialmente su tre momenti: a) l\u2019individuazione delle unit\ue0 appartenenti al gruppo comunale (definizione dell\u2019area di gruppo); b) l\u2019individuazione delle unit\ue0 del gruppo comunale i cui bilanci di esercizio dovranno essere consolidati analiticamente (definizione dell\u2019area di consolidamento); c) la ricerca delle condizioni di uniformit\ue0 che devono sussistere perch\ue9 la procedura di consolidamento possa generare valori significativi e attendibili. Gli indubbi vantaggi informativi che si attribuiscono al bilancio consolidato non devono per\uf2 generare l\u2019erronea convinzione che esso debba sostituire i bilanci di esercizio delle unit\ue0 appartenenti al gruppo comunale. In particolare, l\u2019elisione dei valori reciproci, pur rispondendo appieno allo scopo per il quale il bilancio consolidato \ue8 redatto, cela informazioni sull\u2019intensit\ue0 e la direzione delle operazioni infragruppo che potrebbero rivestire molta importanza nell\u2019ottica di determinati soggetti: chi si occupa di problemi della finanza pubblica, ad esempio, \ue8 interessato a conoscere l\u2019importo e la distribuzione dei trasferimenti che il Comune concede agli enti gestori dei servizi pubblici, posto che la scelta dei servizi, e quindi degli enti erogatori, che potranno godere in misura minore o maggiore dei contributi (ad integrazione, ad esempio, di tariffe pi\uf9 o meno remunerative) \ue8 un\u2019informazione importante per valutare la politica di redistribuzione dei redditi attuata dal Comune nell\u2019ambito della collettivit\ue0 amministrata, tenuto conto che i servizi erogati sono destinati a categorie di utenti differenziate, con diversa capacit\ue0 di spesa. Ecco perch\ue9 il bilancio consolidato deve essere correttamente inteso quale porzione di un sistema informativo pi\uf9 vasto, comprendente i bilanci delle singole societ\ue0 del gruppo

Fracture with loss of the proximal femur in a child. A case report.

An 8 year old child was involved in a road accident and sustained a large wound in the left groin; radiographs showed a fracture with loss of the proximal femur. After skeletal traction for 80 days, there was bony regeneration of the proximal femur. At 8 months she was able to walk without support and her left leg was 2 cm only shorter than the right

Use and effectiveness of dapagliflozin in routine clinical practice. An Italian multicenter retrospective study

In randomized controlled trials (RCTs), sodium-glucose co-transporter-2 (SGLT2) inhibitors have been shown to confer glycaemic and extra-glycaemic benefits. The DARWIN-T2D (DApagliflozin Real World evIdeNce in Type 2 Diabetes) study was a multicentre retrospective study designed to evaluate the baseline characteristics of patients receiving dapagliflozin vs those receiving selected comparators (dipeptidyl peptidase-4 inhibitors, gliclazide, or glucagon-like peptide-1 receptor agonists), and drug effectiveness in routine clinical practice. From a population of 281 217, the analysis included 17 285 patients initiating dapagliflozin or comparator glucose-lowering medications (GLMs), 6751 of whom had a follow-up examination. At baseline, participants starting dapagliflozin were younger, had a longer disease duration, higher glycated haemoglobin (HbA1c) concentration, and a more complex history of previous GLM use, but the clinical profile of patients receiving dapagliflozin changed during the study period. Dapagliflozin reduced HbA1c by 0.7%, body weight by 2.7 kg, and systolic blood pressure by 3.0 mm Hg. Effects of comparator GLMs were also within the expected range, based on RCTs. This real-world study shows an initial channelling of dapagliflozin to difficult-to-treat patients. Nonetheless, dapagliflozin provided significant benefits with regard to glucose control, body weight and blood pressure that were in line with findings from RCTs

Chronic intoxication by ethane-1-hydroxy-1,1-diphosphonate (EHDP) in a child with myositis ossificans progressiva.

Chronic intoxication by ethane-1-hydroxy-1,1-diphosphonate (EHDP) in a child with myositis ossificans progressiva.

Neonatal mucolipidosis 2. The spontaneous evolution of early bone lesions and the effect of vitamin D treatment. Report of two cases.

Evolution of the early bone lesions in two children with mucolipidosis 2 was followed from birth. The progression of the bone changes did not differ from healing of rickets. Low levels of 1,25-(OH)2-D3 were found in one child and he was treated with vitamin D; resolution of the rachitic changes was more rapid than in the untreated child. It is suggested that in mucolipidosis 2 bone reacts to two independent factors, one controlling calcium metabolism, the other depending on the primary lysosomal enzyme defect. Since ricket-like features are not present in the other mucolipidoses or mucopolysaccharidoses, the defect of calcium metabolism seems to be related to the specific enzyme defect of mucolipidosis 2

Inhibitory effect of salmon calcitonin on bone resorption: morphological study of the tibial growth plate in rats.

Salmon calcitonin (sCT) at doses of 100 and 50 UI given subcutaneously to growing rats produced in vivo evidence of osteoclastic activity inhibition. Histological assessment was carried out by measuring the perichondrial ring of Lacroix height, and a dose-correlated effect was found. These aspects were coupled with an increase in the osteoclast number and suggested that in studies with bone resorption inhibitors, morphological evaluation based on osteoclasts count is not reliable. The changes of the metaphysis suggested also that sCT affects the activity of hypertrophic chondrocytes of the growth plate. Plasma calcium levels did not differ significantly between treated rats and controls; an increased phosphatemia was observed in sCT-treated animals

Femoral revision with the modular ZMR stem. Clinical and x-rays results at medium term follow-up

A retrospective review was conducted to evaluate the medium-term results of the ZMR modular revision taper stem. From March 1999 to December 2002, 65 consecutive hip revision surgeries were performed mostly for aseptic loosening. Femoral bone stock defects were classified according to AAOS\u2019s criteria and consisted mainly in type II and type III. A Wagner osteotomy was performed in 25 cases to remove primary implants that were cemented in 35 cases. Mean post-operative follow-up was 69 months (range, 36 to 91months). Clinical assessment at follow-up showed a significantly improved mean Harris Hip Score from 42 points preoperatively to 81 points postoperatively, while the x-ray examination did show a satisfactory distal integration of the stem in all cases and satisfactory reconstitution of the femoral bone stock in 47% of cases. The average subsidence of the stem at follow-up was under one millimeter. According to the data leg length discrepancy exceeding 15 millimeters caused significantly higher functional impairment and more pain

Lateral parapatellar approach in primary total knee arthroplasty of the valgus knee

Background Anatomic and pathological characteristics of the valgus knee deformity represent a challenging issue for the implant of a total knee arthroplasty. The surgical approach in such cases should allow a direct ad easy exposure of the joint, easy lateral soft tissue balancing and adequate patellar tracking. Materials and Methods Twenty-four total knee arthroplasties were implanted in valgus knees between January 2002 and September 2005. A mean preoperative valgus deformity of 18\ub0 was assessed on standing x-rays. Four posterior stabilized, eighteen posterior stabilized rotating platform prosthesis and two superstabilized prosthesis were implanted in 21 patients. The surgical approach has been in all cases a lateral parapatellectomy. Follow-up assessments were obtained for all patients at a mean 23 months. They consisted of a Knee Society Score and a Patellar Score evaluation, standing AP and lateral radiograms and skyline x-rays obtained at a flection of 45\ub0. Results A mean preoperative Knee Society Clinical Score of 32,7 points (range, -4 to 64 points) significantly improved at follow-up to an average 88,8 points (range, 57 to 99 points; p<0,05). The Knee Society Function Score significantly increased from a preoperative mean score of 32,7 points (range, -20 to 75 points) to an average followup score of 81,2 points (range, 30 to 100 points; p<0.05). The Patella Score revealed absence of anterior pain in all cases but one that reported severe pain. A satisfactory patello-femoral alignement of 4.7\ub0 (range, 1\ub0 to 10\ub0) was obtained at last follow-up x-rays. One intraoperative condilar fracture occured and was treated with a single screw. Discussion The lateral approach of valgus knees led to satisfactory results in primary total knee arthroplasties in a percentage of cases comparable or superior to those presented in literature for different approaches. In addition, lateral release is performed as a part of the approach itself, allows preservation of the blood supplies of the extensor apparatus and an optimal patellar tracking in most cases. Conclusions In conclusion, the lateral approach for a primary total knee arthroplasty could be recommended in valgus knees affected by osteoarthritis because as it proved to be effective in achieving a satisfactory implant positioning and functional outcome while reporting minor complications

The relevance of hydroxyapatite and spongious titanium coatings in fixation of cementless stems. An experimental comparative study in rat femur employing histological and microangiographic techniques.

Pure titanium rods plasma-spray coated with hydroxyapatite (HA) or porous titanium (Ti) of controlled roughness were implanted bilaterally in the distal femur of Sprague-Dawley rats to compare the extent of bone growth on the two types of coating. The relevance of other factors, like mechanical stability and biological adaptation of the bone to the insertion of a foreign body implant, were investigated in femora which were over-reamed (absence of primary fit) or reamed without insertion of the rod. Continuous tetracycline labeling for the first 30 days and for the last 2 weeks in the 90-day group was performed; histological/histometric, fluorescence and microangiographic studies were carried out on serial sections of the implanted and control femora. In the group of stable implants, HA-coated rods showed 90% integration versus 53% with Ti-coated implants (P < 0.001); in over-reamed implants neither surface bone growth nor endosteal fixation occurred, and both types of rods were surrounded by a thick layer of connective tissue. The study documented early adhesion of osteoblasts and direct deposition of bone matrix on the substrate, while on spongious titanium osteogenesis was observed only in proximity to the surface. Remodeling of the reactive, primary bone to mature, lamellar bone took the form of a capsule surrounding the implants and radial bridges connecting the latter to the endosteal surface. The number, height and thickness of these bridges appeared to be the factors determining implant stability, rather than the extent of the bony capsule on the perimeter of the implant. Integration was a function not only of mechanical conditions and surface geometry, but also of the biological response of the whole bone to changes in the vascularization pattern. The reported phenomena can be seen more easily in experimental models involving small rodents because of their fast bone turnover and revascularization, but it is expected that they take place, even at a lower speed, in clinical situations like cementless stems of total hip replacement

Treatment of periprosthetic femoral fractures with distal fixation modular revision stems

Background Late periprosthetic fractures of the femur are the third most frequently reported cause of surgery after total hip artroplasty. Revision total hip artroplasty can be difficult, especially when poor bone stock is encountered. The aim of this study was to examine the results of late periprosthetic fractures complicated with primary implant loosening performed with distal fixation modular revision stem. Methods From November 1999 to May 2006, 16 late periprosthetic fractures were treated with distal-fixation, modular, straight stem. There were 13 females (82%) and 3 males (18%) whose mean age at surgery was 76.7 years (range, 48 to 95 years). Femoral revision surgery was performed with the Revitan (2 cases) and ZMR (14 cases) to get a stable distal primary fixation. X-rays were assessed accordingly to the Vancouver classification: there were 3 type B2 and 13 type B3 fractures. Mean post-operative follow-up was 52 months (range, 10 to 88 months). At the time of the last follow-up visit 4 patients already passed away, all of them for causes unrelated to the procedure. The clinical outcome was monitored with the Harris Hip Score, subjective VAS, pain and satisfaction evaluation. Standard AP and lateral x-rays of the hip were obtained at each follow-up visit. Leg-length discrepancy was also investigated as a factor possibly affecting outcome. Complications included one septic loosening that was treated with a two-stage revision. Results All the patients but one were finally able to walk and had minimal to no pain at all. A satisfactory functional outcome was achieved with an average 76 (range, 25 to 100) Harris Hip Scores points. The subjective pain and satisfaction scores were respectively 2.4 and 7.8 points. As far as radiograms are concerned, all the sixteen femur did show a good healing of the fracture, with no secondary stem subsidence. Discussion Generally, considering the severity of an event such as a periprosthetic late fracture in an elderly patient, results were satisfactory. The average Harris Hip Score and subjective satisfaction would have been even higher if one patient wouldn\u2019t have been so much disappointed because of her severe leg-length discrepancy, dependent on the acetabular side. From a surgical point of view, the employed devices proved to be handy in bridging the fracture with distal fixation while adequately stabilizing it. Conclusions According to the reported results, straight modular-revison stems provide an adequate treatment option of Vancouver type B3 and in selected cases of B2 type periprosthetic femoral fracture