Gel piastrinico. Trattamento del piede diabetico e dell’osteomielite fistolizzata. Revisione della letteratura e nostra esperienza in 61 casi clinici

GEL PIASTRINICO: TRATTAMENTO DEL PIEDE DIABETICO E DELL’OSTEOMIELITE FISTOLIZZATA. REVISIONE DELLA LETTERATURA E NOSTRA ESPERIENZA IN 61 CASI CLINICI Introduzione: la nostra esperienza evidenzia l’utilità del gel piastrinico (GP) nel trattamento ambulatoriale delle piaghe torpide della pianta del piede in paziente diabetico e delle ulcerazioni torpide che richiedevano periodi lunghissimi di medicazioni complesse, senza raggiungere il risultato atteso. Materiali e Metodi: la metodica personale prevede il curettage dopo disinfezione e debridement della piaga, l’inoculazione di 1-4 UI di insulina pronta alla base del cratere ulcerativo e quindi l’applicazione di 5 ml di GP con 1 ml di Trombina autologa attivata. L’applicazione si esegue facendo gocciolare il concentrato piastrinico su Hyalofill-F Fidia® Italia sul quale si fa, quindi, gocciolare l’attivatore ottenendo un panno morbido, elastico-gelatinoso, pronto a riempire la cavità da trattare. Il supporto inerte riassorbibile in acido ialuronico impedisce la dispersione della parte liquida o non completamente gelificata, ricca dei fattori di crescita (PDGF, TGF, EGF) che stimolano la moltiplicazione dei fibroblasti i quali aumentano di numero e depositano matrice connettivale, trasformando la piaga torpida con la fioritura dei bottoni di granulazione. In caso di ferite più piccole o man mano che l’ampiezza della ferita si riduce, il prodotto può essere aliquotato e congelato per successive somministrazioni. Nel caso di paziente affetto da ulcerazione da osteomielite occorre un lungo periodo di terapia antibiotica parenterale con Ampicillina-Sulbactam o Piperacillina-Tazobactam o Ertapenem o Meropenem associata a Vancomicina, oppure, alternativamente Daptomicina. Discussione: in generale, la terapia deve essere mirata sulla base dell’isolamento del germe patogeno, ma spesso l’infezione è polimicrobica e quindi si somministra una terapia empirica ad ampio spettro. Principio guida nella terapia empirica è la somministrazione di antibiotici contro lo Staphylococcus aureus meticillino resistente (MRSA). Nei pazienti ambulatoriali è essenziale tenere in considerazione la presenza di germi meticillino resistente associati alla comunità di appartenenza (CA-MRSA) e quindi occorrono colture batteriche ripetute. Conclusioni: l’approccio multidisciplinare tra chirurgo, immunotrasfusionista, infettivologo, dermatologo, ortopedico, diabetologo e cardiologo, risolve brillantemente la problematica. Lo stretto coordinamento tra ambulatorio chirurgico ed il centro trasfusionale, evita inutili attese al Paziente, accorcia i tempi di esecuzione della medicazione, abbatte i costi per l’impiego di materiali e diventa conveniente rispetto al trattamento tradizionale.Our study proves the usefulness of platelet gel in the treatment of the diabetic foot. We started in January 2006 to treat diabetic wounds of the foot in the outpatients’ surgical department with encouraging results. Despite its expensive and complex preparation, the platelet gel is useful and convenient because it succeeds in shortening the ambulatory treatment period. Besides, in our opinion, the multidisciplinary approach of this treatment is rather important: actually, it implies the cooperation of dermatologist, surgeon, orthopaedist, immunologist, diabetologist and, if necessary, the cardiologist. That is why it reduces wastes of work-time and the expenses for consultants, medications and dressing material

Posterolateral arthrodesis in lumbar spine surgery using autologous platelet-rich plasma and cancellous bone substitute: an osteoinductive and osteoconductive effect

Study Design Prospective cohort study. Objectives To analyze the effectiveness and practicality of using cancellous bone substitute with platelet-rich plasma (PRP) in posterolateral arthrodesis. Methods Twenty consecutive patients underwent posterolateral arthrodesis with implantation of cancellous bone substitute soaked with PRP obtained directly in the operating theater on the right hemifield and cancellous bone substitute soaked with saline solution on the right. Results Computed tomography scans at 6 and 12 months after surgery were performed in all patients. Bone density was investigated by comparative analysis of region of interest. The data were analyzed with repeated-measures variance analyses with value of density after 6 months and value of density after 12 months, using age, levels of arthrodesis, and platelet count as covariates. The data demonstrated increased bone density using PRP and heterologous cancellous block resulting in an enhanced fusion rate during the first 6 months after surgery. Conclusions PRP used with cancellous bone substitute increases the rate of fusion and bone density joining osteoinductive and osteoconductive effect

Successful Management of a Chronic Refractory Leg Ulcer in an Adolescent with Sickle Cell Anemia

Sickle cell disease (SCD) is an inherited hemoglobinopathy characterized by a wide range of clinical manifestations. Chronic leg ulcers are a disabling complication with repercussions on the quality of life. We report the case of a 14-year-old girl with a diagnosis of SCD who developed a chronic leg ulcer that was successfully treated with a multi-disciplinary approach, including local and systemic therapies. The role of different treatments, in particular low molecular weight heparin, in the refractory chronic leg ulcer healing process will be discussed. </p

The use of platelet-leukocyte membrane in arthroscopic repair of large rotator cuff tear: A prospective randomized study.

Background: Arthroscopic rotator cuff repair generally provides satisfactory results including decreased shoulder pain and improved shoulder motion. Unfortunately, imaging studies demonstrate that the retear rate associated with the available arthroscopic techniques may be high. The purpose of this study was to evaluate the clinical and magnetic resonance imaging (MRI) results of arthroscopic rotator cuff repair with and without the use of platelet-leukocyte membrane in patients with a large posterosuperior rotator cuff tear. Methods: Eighty consecutive patients with a large full-thickness posterosuperior rotator cuff tear were enrolled. All tears were repaired using an arthroscopic single-row technique. Patients were randomized to treatment either with or without a platelet-leukocyte membrane inserted between the rotator cuff tendon and its footprint. In patients treated with this membrane, one membrane was utilized for each suture anchor. The primary outcomes were the difference between the preoperative and postoperative Constant scores and the repair integrity assessed by MRI according to the Sugaya classification. The secondary outcome was the difference between the preoperative and postoperative Simple Shoulder Test (SST) scores. Results: The only significant differences between the two groups involved the patient age and the preoperative and postoperative Constant scores; the differences in the Constant score were due to differences in the shoulder pain subscore. At a mean of thirteen months of follow-up, rotator cuff retears were observed only in the group of patients in whom the membrane had not been used, and a thin but intact tendon was observed more frequently in this group as well. The use of the membrane was associated with significantly better repair integrity (p = 0.04). Conclusions: The use of the platelet-leukocyte membrane in the treatment of rotator cuff tears improved repair integrity compared with repair without membrane. However, the improvement in repair integrity was not associated with greater improvement in the functional outcome. In fact, the Constant scores of the two groups would have been similar if the shoulder pain component (which had differed preoperatively) had been excluded. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence

Peri-operative blood management of Jehovah's Witnesses undergoing cytoreductive surgery for advanced ovarian cancer

Background - The aim of this study was to evaluate the efficacy and feasibility of a peri-operative bloodless medicine and surgery (BMS) protocol in reducing severe post-operative anaemia (haemoglobin [Hb] &lt;7 g/dL) in Jehovah’s Witnesses undergoing cytoreductive surgery for advanced epithelial ovarian cancer. Materials and methods - This was a single-institution retrospective study enrolling Jehovah’s Witnesses who underwent elective bloodless surgery for advanced epithelial ovarian cancer between October 2017 and April 2020. All patients followed a standardised bloodless medicine and surgery protocol based on ferric carboxymaltose and erythropoietin if indicated. Results - Twenty-five patients with a mean age of 61.7 years (range, 35-80) were enrolled. Pre-operatively, ten patients (40%) were mildly anaemic (mean Hb of 10.2 g/dL [range, 9.2-11.4]) and received ferric carboxymaltose. Only four (16%) patients had severe anaemia after surgery (mean Hb of 6.1 g/dL [range, 4.1-6.9]) and received ferric carboxymaltose and erythropoietin. Compared to patients with a post-operative Hb ≥7 g/dL, those with Hb &lt;7 g/dL had higher mean body mass index (25.8±1.8 vs 30.7±1.8 kg/m2; p&lt;0.001), mean baseline CA125 (236.1±184.5 vs 783.7±273.5 IU/mL; p&lt;0.001), median surgical complexity score (2 vs 10; p&lt;0.001), and rate of post-operative complications (14.3 vs 100%; p&lt;0.001). Moreover, these patients had a longer mean operating time (3.4±0.6 vs 5.5±0.4 h; p&lt;0.001), duration of stay in hospital (5.5±0.7 vs 24.0±9.8 days; p&lt;0.001), and time to adjuvant chemotherapy (27.2±2.6 vs 65.3±13.4 days; p&lt;0.001). Discussion - The use of a multidisciplinary bloodless medicine and surgery protocol is safe and effective in reducing the rate of severe post-operative anaemia and improving surgical and oncological outcomes of Jehovah’s Witnesses with advanced epithelial ovarian cancer

The relative influence of serum ionized calcium and 25-hydroxyvitamin D in regulating PTH secretion in healthy subjects

BACKGROUND: While the inverse relationship between serum ionized calcium (Ca(2+)) and PTH is well-established, the relationship between 25(OH)D and PTH showed conflicting results. The study aimed to evaluate the relative contributions of age, sex, serum Ca(2+), ionized magnesium (Mg(2+)), 25(OH)D and 1,25(OH)2D in regulating PTH secretion in healthy subjects. METHODS: This is a secondary analysis of an observational study performed from March 2014 to July 2015 carried out in 2259 blood donors (1652 men and 607 women, age range 18-68years). Subjects with parathyroid disorders and taking drugs that affect mineral metabolism were excluded. RESULTS: Significant correlations [between Ca(2+) and PTH (r=-0.223, p\u3c0.001), 25(OH)D and PTH (r=-0.178, p\u3c0.001) and between PTH and age (r=0.322, p\u3c0.001)] were found. As a preliminary step to multivariate analysis, a regression tree analysis was performed using PTH as response variable and age, Ca(2+), Mg(2+), 25(OH)D, 1,25(OH)2D and sex as explanatory variables to determine the effect of each covariate on the response variable. For subjects \u3c38years, 25(OH)D was the most important parameter in regulating PTH. For subjects \u3e/=38 both 25(OH)D and Ca(2+) levels regulated PTH secretion. Subjects with 25(OH)D\u3c13ng/mL had average higher PTH; in this group only, subjects with Ca(2+)\u3e/=1.30mmol/L had average lower PTH compared to subjects with Ca(2+)\u3c1.30. The multivariate analysis showed that all variables had a significant effect (p\u3c0.001) on PTH. Anova Type III errors c indicated that 25(OH)D accounted for 32.1% of the total variance in PTH, Ca(2+) accounted for 18% of the total variance, BMI for 14.3%, and 1,25(OH)2D for 11.1%. The remaining percentage was attributable to age and sex. This was confirmed by the regression tree approach, where 25(OH)D and Ca(2+) accounted for the largest variation in the average levels of PTH. DISCUSSION: Under stable conditions 25(OH)D plays a significant role in regulating PTH secretion. Under conditions of relative vitamin D sufficiency, Ca(2+) also plays an important role