Tuberculous neck lymphadenopathy: A diagnostic challenge.

Tuberculosis (TB) continues to be a major health problem for the developing world and a rise in the number of cases has been noted in the western hemisphere too. TB can affect most organs in the head and neck region, such as the lymph nodes, larynx, middle ear, oral cavity and pharynx. In particular, as for cervical tuberculosis lymphadenopathy, a predominant involvement of the posterior triangle, supraclavicular, and internal jugular group of nodes bilaterally can be observed. As the early manifestation of Head and Neck TB is often similar to neoplasms, clinical consideration usually occurs only after an ineffective anti-inflammatory treatment, fine-needle aspiration, or biopsy/resection. In fact, this type of presentation often represents a diagnostic and therapeutic challenge to the clinician. Therefore, the aim of the present article is to present and discuss the management of a case of cervical tuberculosis lymphadenopathy.

Oncological and functional results of CO2 laser cordectomy.

Laser surgery represents the evolution of endoscopic surgery and, as far as concerns treatment of laryngeal tumours, CO2 laser cordectomy is considered a valid alternative to conventional surgery (laryngofissure cordectomy) and to exclusive radiotherapy for glottic carcinomas, classified as T1a, T1b and T2. The present report focuses on personal experience with CO2 laser cordectomy over the last 11 years, evaluating oncological and functional results. Between October 1990 and December 2001, micro-laryngoscopy has been performed with CO, laser, in 606 cases (benign and malignant lesions), of which 150 laser cordectomies, at the ORL Department, Eastern Piedmont University of Novara. An analysis is made of 63 patients (mean age 64.3 years) who underwent laser cordectomy for glottic carcinoma, observed at follow-up for at least 3 years. Vocal function has been studied on a sample of 20 patients. Of those who underwent CO2 laser cordectomy for T1a and T1s, 95.8% were disease free after a minimum of 3 years follow-up. Video-larynx-stroboscopic test highlighted the presence of a "satisfying" fibrous neocord in cases treated with Type III cordectomy. The speech compensation was of the "cord-neocordal" type (35%), false cordal (40%) and with arytenoideus hyperadduction (25%). The electro-acoustical analysis of the voice highlighted a "serious dysphonia" compatible with Type IV cases according to Yanagihara (70%) and moderate-severe dysphonia (30%). Mean values of vocal parameters were 5.8% for Jitter, 12.2% for Shimmer, 0.34 for NHR. CO2 laser cordectomy is first choice treatment for T1a glottic carcinoma, offering intra- and post-operative advantages: reduced traumatism, lack of tracheostomy, low bleeding, fast functional recovery (deglutition and speech), brief hospital stay, and low management costs. Dysphonia resulting from treatment, characterised by breathed voice, allows the patient to lead a normal life.

[Renal stone ileus in xanthogranulomatous pyelonephritis. A case report]. / Occlusione intestinale da calcolo renale in pielonefrite xantogranulomatosa. Descrizione di un caso.

A peculiar case of intestinal occlusion caused by a renal stone in a patient with nephroduodenal fistula due to previous xanthogranulomatous pyelonephritis is reported. Only few cases of nephroduodenal fistula are described in the literature, generally as a single case report or in small series. A nephroduodenal fistula as a result of chronic renal inflammatory disease such as xanthogranulomatous pyelonephritis, is usually associated with renal stones, recurrent urinary tract infections or endocrine disorders. Finally, renal stone as a cause of ileus is an event rarely described in the literature. In the case described, a correct preoperative diagnosis was possible with computerized tomography. During the operation a big renal stone was found and removed from the small bowel, but a limited resection was necessary because of the vascular impairment of the tract. At 8-month follow-up from operation, the patient was in good health, and no symptoms of renal or intestinal diseases were found.

Pyrotechnic shock response predictions combining statistical energy analysis and local random phase reconstruction.

Numerous pyrotechnic devices are used on satellites to separate structural subsystems, deploy appendages, and activate on-board operating subsystems. The firing of these pyrotechnic mechanisms leads to severe impulsive loads which could sometimes lead to failures in electronic systems. The objective of the present investigation is to assess the relevance of a method combining deterministic calculations and statistical energy analysis to predict the time overall shock environment of electronic equipment components. The methods are applied to the low- and high-frequency ranges, respectively, which may be defined using a modal parameter based on the effective transmissibility. Initially, in order to address the problem of the low-frequency content of the mechanical shock pulse, the linear dynamic response of the equipment was calculated using direct time integration of a finite element model of the structure. The inputs in the form of the accelerations measured in all three directions at each of the four bolted interfaces were injected into the model. The high-frequency content of the shock response is taken into account by considering the intrinsic dynamic filtering of the equipment. This frequency filter magnitude is extrapolated from the transfer function given by statistical energy analysis between the different imposed accelerations and the response accelerations. Their associated phases are synthesized by considering pseudo-modal phase variations around the group velocity of the structural flexural waves. Combining the effects of the high-frequency filter outputs and the low-frequency finite element calculations yields good predictions of the equipment shock time response over the whole frequency range of interest.

Early dobutamine echocardiography for the assessment of coronary stenosis after first Q-wave myocardial infarction.

We assessed the accuracy of early dobutamine stress echocardiography to detect infarct-related coronary artery and multivessel disease in patients with first Q wave myocardial infarction after withdrawal of cardioactive drugs. Dobutamine-atropine echocardiography was performed in 91 consecutive patients (mean age 59+/-6 years) 7+/-4 days after myocardial infarction. Dobutamine was infused at incremental doses of 5, 10, 20, 30 to 40 microg/kg/min each one dose for 3 min. Peak heart rate was 134+/-17 bpm. All patients underwent coronary angiography before discharge. Sensitivity, specificity and accuracy of ischemic and biphasic response to detect residual stenosis of infarct-related coronary artery were 70, 92 and 73%, respectively. The sensitivity, specificity and accuracy of ischemic or biphasic response were similar in the vascular territories of left anterior descending (74, 86 and 75%, respectively), right (67, 100 and 70%, respectively) and circumflex coronary arteries (64, 100, and 69%, respectively). Sensitivity, specificity and accuracy of heterozonal wall motion abnormalities for multivessel coronary artery disease were 64, 82 and 76%, respectively. Dobutamine stress echocardiography is sensitive and specific in detecting residual coronary stenosis and multivessel disease in patients with first Q-wave myocardial infarction. The test is safe even without pharmacological protection.

Potential influence of pre-infarction angina on myocardial viability and residual ischemia.

BACKGROUND: The effects of recent pre-infarction angina on myocardial viability and residual ischemia are unknown. This study evaluates them in 90 patients with a first Q-wave myocardial infarction using early dobutamine stress echocardiography. METHODS: Patients were classified according to the absence or presence of recent pre-infarction angina, defined as chest pain lasting < 30 min during a period of 7 days before the acute myocardial infarction. The infarct zone wall motion score index was calculated at baseline and at low- and peak-dose dobutamine stress echocardiography. All subjects underwent coronary angiography. RESULTS: Patients with unheralded myocardial infarction showed, in comparison with patients with recent pre-infarction angina, a significantly higher peak of creatine kinase serum levels (2630 +/- 1360 vs 1865 +/- 1562 IU/l, p = 0.002) and a higher number of leads with pathologic Q waves (3.2 +/- 1.3 vs 2.8 +/- 0.8, p = 0.002). The groups did not differ with regard to the infarct zone wall motion score index at rest (2.15 +/- 0.42 vs 2.18 +/- 0.31, p = 0.72) and at low- (1.86 +/- 0.52 vs 1.80 +/- 0.41, p = 0.55) and peak-dose (2.24 +/- 0.55 vs 2.19 +/- 0.58, p = 0.68) dobutamine stress echocardiography. The prevalence of myocardial viability (31 vs 48%, p = 0.15), homozonal (52 vs 58%, p = NS) or heterozonal ischemia (36 vs 23%, p = NS) was not statistically different between the groups of patients without and with recent pre-infarction angina. The angiographic patterns were similar. CONCLUSIONS: Recent pre-infarction angina is associated with a smaller infarct size but it does not seem to influence the ventricular contractile improvement or residual ischemia, detected at early dobutamine echocardiography, in patients with a first Q-wave myocardial infarction.

[Gasless laparoscopic cholecystectomy. Our experience with 130 cases compared with 450 cases treated with the CO2 technique]. / Colecistectomia laparoscopica gasless. La nostra esperienza su 130 casi confrontati con 450 casi trattati con la tecnica con CO2.

Alongside the technique based on the creation of an abdominal cavity for surgery following the introduction of gas (usually CO2) into the peritoneal cavity, a new method has been developed. This involves the use of an atraumatic mechanical lifting device connected to the same abdominal wall (gasless laparoscopy). The authors report a technique that uses an inflatable cushion inserted into the abdomen through a periumbilical incision. The cushion is connected to an external motorized hydraulic jack fixed to the operating table, fitted with an electric motor and friction gear. Between May 1991 and June 1998, 580 patients underwent laparoscopic cholecystectomy. Since December 1995 a total of 130 patients have undergone surgery using gasless laparoscopy. Shoulder pain and pain in the upper abdominal quadrant were no longer reported; pain was present in 70% of the patients operated using the CO2 technique. There was also a marked reduction in the anesthesiological risks, above all in elderly patients with cardiopulmonary insufficiency. Surgical manoeuvres are made easier owing to the possibility of using traditional surgical instruments. Washing and continuous aspiration allow a good control of intraoperative hemostasis, and reduce the phenomenon of lens misting without the risk of losing pneumoperitoneum. Less visibility of the surgical field was reported, particularly in obese patients, above all because of the reduced diaphragmatic distension and the lack of displacement of the intestinal loops. In the authors' opinion the gasless technique is suitable above all in patients affected by cardiopulmonary disorders in whom hypercapnia might represent a significant operating risk.

[Intermittent diastolic dysfunction of a mechanical aortic prosthesis: a clinical case]. / Disfunzione diastolica intermittente di protesi aortica meccanica: un caso clinico.

We describe the case of a 48 year-old man whose Sorin bileaflet aortic prosthesis presented persistent systolic and intermittent diastolic failure due to fibrous tissue overgrowth in the left ventricular outflow tract.

[Frontal mucocele: open surgery]. / Mucocele frontale: open surgery.

This work presents 13 cases of frontal mucoceles, 9 with endo-orbital extension. All were treated with 'open surgery': 11 using a fronto-orbital approach, 2 with a bicoronal Cairns-Unterberger approach. Four patients had recurrent mucoceles 1-20 years after the previous surgery. In one case there was an association with frontal osteoma. In 10 cases, conservative treatment was applied through repermeabilization of the infundibular region through an external, endonasal pathway and positioning of a nasal sinus drainage tube (kept in place for 4 weeks). In the remaining 3 cases, the sinus cavity was obliterated with autologous abdominal fat. This choice was made because of the presence of osteomyelitic foci, in one case mucopioceles, or by the widespread dural exposure encountered during the course of surgery. Two cases of post-operative sinus reinfection were encountered: one underwent surgical revision, the other was an orbital site recurrence arising 7 years after previous surgical obliteration of the frontal sinus. The esthetic result was unsatisfactory in 2 patients treated with a trans-facial approach. Ten patients were disease free after an average 56 months of follow-up. Although functional endoscopic surgery undoubtedly makes it possible to achieve excellent results in the treatment of most sinus mucoceles, open surgery remains a valid procedure in frontal mucoceles with orbital and/or endocranial extension and in cases where the district anatomy is unfavorable for a purely endonasal approach. The indications and limitations of open surgery are critically discussed in the light of personal experience and current literature.

Significance of T-wave changes during early dobutamine stress echocardiography in patients with Q-wave acute myocardial infarction.

The relation between T-wave changes and regional contraction during dobutamine stress echocardiography at low (5 to 10 microg/kg/min) and high (20 to 40 microg/kg/min) doses in 43 consecutive patients, early (7+/-2 days) after first recent Q-wave acute myocardial infarction has been evaluated. T-wave changes detected in > or =2 infarct-related electrocardiographic leads during dobutamine infusion were defined as follow: (1) negative T waves becoming positive, (2) positive T waves becoming upright > or =2 mm, and (3) negative T waves becoming upright > or =2 mm from baseline. Wall motion score index (WMSI) was defined as the sum of the echocardiographic scores of 16 segments divided by total segments considered at baseline, and at low and peak doses of dobutamine. Patients were classified according to the absence or presence of dobutamine T-wave changes. Those without T-wave changes had a significantly higher WMSI at rest (1.68+/-0.23 vs 1.50+/-0.21; p <0.05) and at peak (1.77+/-0.34 vs 1.51+/-.30 p <0.05) of dobutamine stress testing, without higher incidence of viability, homozonal, and heterozonal ischemia and chest pain. The angiographic patterns were similar between groups. Regression analysis showed a significant correlation between WMSI and T-wave amplitude at baseline (R = 0.38, p = 0.01) and at peak dobutamine stress testing (R = 0.50, p = 0.0006). The sensitivity sensitivity, specificity, and accuracy of T-wave changes to detect myocardial viability were 0.27, 0.84, and 0.70, respectively. The sensitivity, specificity, and accuracy of T-wave changes to detect homozonal ischemia were 0.76, 0.27, and 0.46, respectively. In conclusion, dobutamine-induced T-wave changes are associated with a greater extent of wall motion abnormalities both at rest and at peak stress echocardiography, but they are of little value in predicting myocardial viability when analyzed early after myocardial infarction.

Anomalous origin of the right coronary artery from the left anterior descending coronary artery: a case report.

We report on a 59-year-old man with effort angina of recent onset and a very uncommon right coronary artery originating from the middle portion of the left anterior descending; a tight stenosis of the left anterior descending coronary artery was also detected which involved the origin of the aberrant vessel.

[Superior mesenteric artery syndrome after surgical correction of severe dorso-lumbar deformities. Authors' experience]. / La sindrome da compasso aorto-mesenterico dopo correzione chirurgica delle gravi deformità del rachide dorso-lombare. Nostra esperienza.

The authors report two cases of superior mesenteric artery syndrome observed in 22 operations for severe spinal deformities. Medical, dietary and postural treatment enabled the situation to be resolved in one case; whereas an intestinal derotation according to Strong-Valdoni was successfully performed in the other. The various surgical alternatives are discussed.

[Antibiotic prophylaxis with ++vancomycin in corrective surgery with alloplastic material]. / Antibioticoprofilassi con vancomicina nella chirurgia riparativa con materiale alloplastico.

The authors report a controlled series of 40 patients treated for recidivating inguinal hernia and laparocele with the implant of alloplastic material. Short-term prophylaxis with vancomycin was performed in all cases. The antibiotic was found to be well tolerated at the doses used and this was associated with a good clinical success rate. The use of vancomycin in prophylaxis for this type of surgery is considered a rational choice and the use of short-term prophylaxis reduces the risks linked to possible collateral effects.

Relation between respiratory function and pulmonary hemodynamics before and after intravenous administration of furosemide in acute myocardial infarction.

Static lung volumes, flow volume curve in air and in a helium-oxygen mixture, PaO2 and pulmonary vascular pressures were measured in 16 patients 2 weeks after uncomplicated acute myocardial infarction and repeated 2 h after furosemide 40 mg i.v. administration. The patients with wedge pressure (WP) greater than 18 mm Hg had significantly lower values of FEV1, FEV1/VC%, MEF40 and MEF 25 in comparison with the patients with WE less than 18 mm Hg. A negative correlation was found between both PAP and WP and MEF25 values (p less than 0.001). After furosemide respiratory function tests improved only in patients with a good hemodynamic response to the drug. PaO2 did not change significantly. Airflow response to helium seemed to be a useful test for determining the site of major bronchial compression.