Atraumatic vertebral compression fractures: differential diagnosis between benign osteoporotic and malignant fractures by MRI.

Atraumatic vertebral compression fractures are a common clinical problem, especially in elderly population. Metastases are the most frequent source of bone tumors, and the spine is a common site of metastatic disease; in case of cortical involvement or osteolysis, they may result in pathological compression fractures. Atraumatic compression fractures may result from other primary neoplasms of vertebrae and also from osteomyelitis, Paget's disease, hyperparathyroidism and other metabolic processes. Osteoporosis is a common source of vertebral compression fractures in elderly population, which may be indistinguishable from those of metastatic origin. The differentiation between osteoporotic compression fractures and malignant fracture is necessary to establish an appropriate staging and a therapeutic planning, especially in the acute and subacute stages. Anamnestic data about preexisting disease can be useful to individuate the potential cause of vertebral collapse. Plain radiography shows some difficulties in distinguishing whether the fracture represents a consequence of osteoporosis, a metastatic lesion or some other primary bone neoplasm. Computed tomography is one of the most suitable imaging techniques for the evaluation of bone structure and fragments and to establish the degree of cortical bone destruction; MR imaging (MRI) is the most helpful radiological investigation in order to provide the basis for the distinction between metastatic and acute osteoporotic compression fractures. The most relevant MRI findings to establish a differential diagnosis are described.

[Hepatic haemorrhage in pregnancy: a case report]. / Emorragia epatica in gravidanza: caso clinico.

Spontaneous hepatic haemorrhage in pregnancy (SHHP) is a rare event (1 woman out of 15,000). It is generally considered as an advanced state of the microangiopathic hemolytic anemia (HELLP, Hemolysis, Elevated Liver enzyme levels, Low Platelet count). Furthermore, the HELLP is considered as a different form of preeclampsia. The patient, a 33-year-old-woman at 30 weeks' gestation, was admitted to hospital for preeclampsia, underwent an emergency Stark caesarean section with the extraction of an alive foetus and evidence of massive intraperitonal haemorrhage from a large hepatic haematoma. A haemostasis with gauzes of Surgicel was performed, with consequent arrest of the haemorrhage. After approximately 6 hours, a recurrence of the intraperitonal haemorrhage led to a new surgical intervention with hepatic packing with gauzes. After 4 days the patient died. The etiopathogenesis of disease is uncertain, both foetal and maternal mortality are high, and the slight number of reported cases (27) of SPPH from HELLP in international literature offer elements for debate. The following points have been put forward: 1. the monitoring of the counts of the platelets represent the only valid predictive test of HELLP. These concerned women in the third trimester of pregnancy, especially those with a history of preeclampsia; 2. the treatment must be immediate, intensive and multidisciplinary, the plasmapheresis has remarkably improved the prognosis; 3. surgical treatment performed in order to control the SPPH makes use of packing, embolization and/or fastening of the common hepatic artery and, in extreme cases, total hepatectomy with transplantation. The Authors believe it is useful to suggest a national epidemiological research in order to estimate the real incidence of the syndrome in Italy and to establish the guidelines for the medico-surgical treatment.

[Emergency surgery for neoplastic left colon obstruction: resection and primary anastomosis (RPA) versus Hartmann resection (HR)]. / Chirurgia d'urgenza per occlusione neoplastica del colon sinistro: resezione ed anastomosi primaria (RPA) versus resezione secondo Hartmann (HR).

UNLABELLED: This retrospective study compares: hospitalization time, morbidity and mortality (patients operated for neoplastic occlusion of the left colon in emergency, without perforation), considering hanestesiologic risk and surgical technique (RPA versus RH). MATERIALS AND METHODS: From April 1999 to February 2003 the Emergency Surgery of AORN of Caserta has operated, in urgency, 60 neoplastic patients with left colon occlusion realizing: 46 (76.5%) RPA [36 ASA < or = III, low hanestesiologic risk (LAR), 10 ASA = or > IV high hanestesiologic risk (HAR)], 12 (20%) RH (2 LAR and 10 HAR) 2 (3.5%) palliative colostomics. RESULTS: 36 LAR patients with RPA had 5% of specific complications and 5% of medical complications. 2 LAR patients with R-H: no complication. 10 HAR patient with RPA brought 10% of specific complications and 10% of medical complications. 10 HAR patients with RH had 20% of specific complications and 10% of general complications. The middle hospitalization of LAR patients with RPA was 11 days versus 9 days of RH pz. (equal hanestesiologic risk ). The HAR pz., treated with RPA, had as middle hospitalization 15 ggs in comparison to the 9 ggs of the HRA pz. treated with RH. MORTALITY: 1/36 for LAR pz. with RPA (3%), and 0/0 for LAR pz. with RH; 1/10 for HAR pz, with RPA (10%) and 1/10 for HAR pz. with RH (10%). CONCLUSIONS: Resection and primary anastomosis, (correct indications and expert surgeon), gives prevalence of complications and mortality similar to the repeated surgical procedure, a better life quality, but an higher number of post-operating hospitalisation days.

[Nosocomial fungal infections in surgical patients. Older age as factor of risk and early presumptive and systemic therapy versus prophylactic therapy]. / Le micosi nosocomiali nel paziente chirurgico. Età geriatrica come fattore di rischio e terapia sistemica e presuntiva precoce versus terapia profilattica.

Objective of our study has been to verify if the age is a factor of additional risk for the opportunistic fungal infections and if prophylactic therapy cause real advantages in terms of reduction of morbidity, mortality and times of hospitalization. To such we report the experience of the Operational Unity of Emergency Surgery of the Hospital of Relief National and High Specialization of Caserta relatively to the patients submitted to intervention of great abdominal surgery. In the year 2000 antifungal therapy has been administered to 20 patient (of which 18 over 65 years) on the escort of an laboratory diagnosis; in the year 2001 we have administered prophylactic therapy to 53 high-risk patient (of which 48 over 65). In the group of patients essays with preventive therapy the middle hospitalization has been slightly inferior with a reduction of around 2 days of refuge for the elderly patients and of around 1.5 days in the youngest patients. Mortality in the elderly patients has been reduced from 38% of the year 2000 at 23% of the year 2001. Our data confirm that the age is an important factor of risk for the fungal infections in the surgical departments and we believe to a prophylactic therapy can be of benefit in well selected patient, although an ordinary application of antifunfal therapy can not have recommended without an laboratory diagnosis because to emerge of new resistances to the medicines.

[Intraperitoneal hemorrhage from rupture of an aneurysm of splenic artery: case report and literature review]. / Emoperitoneo da fissurazione di aneurisma dell'arteria splenica: case report e revisione della letteratura.

Splenic artery aneurysm presented with rupture is an unusual and potentially deadly reason of intraperitoneal hemorrhage. There are a lot of pathogenetic hypothesis; timing according to disease severity and surgical choices aren't definitely codified authors present one patient with hemoperitoneum for ruptured splenic artery aneurysm affected by chronic lymphatic leukaemia too and review international literature; they underline pathogenesis, symptoms, preoperative investigations and therapy. Degeneration of the media, atherosclerotic changes and high blood flow due to pregnancy and portal hypertension could be the main pathogenetic factors. Ultrasonography is the first investigation we have to practice if we suspect hemoperitoneum. We can practice computed tomography and angiography too if cardiovascular condition are good. Rupture showing acute abdominal pain and cardiovascular collapse suggest strongly urgent operation. The choice of operation is determined by location of the aneurysm. When located in the distal third of the splenic artery, the aneurysm is resected with spleen; alternatively, when it is located in prossimal third we can perform conservative operation.

[Pica: a clinical case and therapeutic problems]. / Il picacismo: caso clinico e problematiche terapeutiche.

Pica is a psychotic disorder characterized by compulsive ingestion of nonfood substances; the primary treatment is the prevention with antipsychotic therapy. When the patient ingests foreign body, endoscopical removal is recommended. Surgical treatment is necessary when an acute abdomen is present, with intestinal occlusion and/or bowel perforation. The Authors report a peculiar case of pica, and analyse the problems of organization and assistance, besides surgical approach, also on the base of international literature.

Quantitation of endopeptidase 24.11 and endopeptidase 24.15 in human blood leukocytes.

Endopeptidase 24.11 (EP 24.11; also called neutral endopeptidase, enkephalinase, CALLA, or CD10) and endopeptidase 24.15 (EP 24.15) are widely distributed neutral metalloendopeptidases that degrade a number of bioactive peptides including substance P, bradykinin, neurotensin, and chemotactic peptides. In this study we used sensitive substrates and specific inhibitors to quantitate the levels of these enzymes in purified peripheral human blood leukocytes obtained from healthy blood donors. We found that neutrophils did not contain detectable amounts of EP 24.15. In contrast, T lymphocytes, B lymphocytes, and monocytes contained significant amounts of the enzyme (446 +/- 248,314 +/- 183, and 484 +/- 212 nmol/mg protein/h, respectively). Neutrophils contained significant amounts of EP 24.11 (266 +/- 130 nmol/mg protein/h). Significantly lower levels of the enzyme were found in T lymphocytes, B lymphocytes, and monocytes (94 +/- 31, 87 +/- 38, and 20 +/- 13 nmol/mg protein/h, respectively). These findings suggest that the effects of some bioactive peptides on peripheral blood leukocyte function may be modulated by these enzymes.

Decreased efficacy of inhaled pentamidine in the prevention of Pneumocystis carinii pneumonia among HIV-infected patients with severe immunodeficiency.

STUDY OBJECTIVE: To determine the relationship between the degree of immune deficiency and the risk of Pneumocystis carinii pneumonia (PCP) among HIV-infected patients receiving inhaled pentamidine prophylaxis. DESIGN: Retrospective chart review. SETTING: AIDS clinic of inner-city hospital. PATIENTS: Patients attending inhaled pentamidine clinic between 1989 and 1991. INTERVENTION: Review of medical records of patients receiving inhaled pentamidine, 300 mg/month, via nebulizer (Respirgard II) as primary or secondary prophylaxis of PCP. Statistical analysis of lymphocyte subset results and selected clinical data. RESULTS: Ten of 57 patients developed PCP during the period of analysis. Patients with CD4 counts less than 60/mm3 were significantly more likely to develop PCP (p = 0.01; Fisher's exact test) with a relative risk of 7.55 compared to patients with CD4 lymphocyte counts greater than 60/mm3. CONCLUSION: Failure of inhaled pentamidine prophylaxis is seen almost exclusively among patients with CD4 lymphocyte counts below 60/mm3.

Hypertonic solutions in the treatment of hypovolemic shock: a prospective, randomized study in patients admitted to the emergency room.

BACKGROUND: The infusion of small volumes of hypertonic saline solution or hypertonic saline plus dextran 70 is remarkably effective in restoring adequate hemodynamic conditions after hypovolemic shock. This prospective double-blind study compares the immediate hemodynamic effects of a bolus infusion of 7.5% NaCl or 7.5% NaCl plus 6% dextran 70 (both 2400 mOsm/L) in severe hypovolemia. METHODS: One hundred five adult patients admitted in hypovolemic shock (systolic blood pressure less than 80 mm Hg) were revived on arrival to the emergency room and administration of a 250 ml intravenous bolus of hypertonic saline solution (n = 35), hypertonic saline plus dextran (n = 35), or isotonic saline solution (n = 35). This infusion was immediately followed by standard crystalloid and blood replacement until systolic pressure reached 100 mm Hg. Mean arterial pressure (MAP) was measured every 5 minutes, and all intravenous infusions were registered. Plasma volume expansion was calculated from plasma protein concentration measurements. Patients were followed up throughout their hospital course, and results of treatment were recorded. RESULTS: At the end of the infusion period, and 5 and 10 minutes after infusion, MAP was significantly higher in patients receiving either hypertonic solution, compared with the group receiving isotonic solution. All groups showed similar trends toward restoration of hemodynamic parameters thereafter. The calculated plasma volume expansion, immediately after the bolus infusion, was significantly higher (24.1% +/- 1.8% and 24.9% +/- 1.1%) in the hypertonic groups, compared with isotonic groups (7.9% +/- 1.3%). Significantly greater volumes of fluids were required to restore systolic pressure in the patients receiving isotonic saline solution than in the groups receiving hypertonic solution. There were no significant differences between the groups receiving hypertonic solutions. The incidence of complications was low, and the mortality rate was similar in all groups. CONCLUSIONS: Infusion of 250 ml hypertonic saline solution in patients with severe hypovolemia was not related to any complications, nor did it affect mortality rates; it improved MAP significantly, acutely expanded plasma volume by 24%, and reduced significantly the volumes of crystalloids and blood required in their resuscitation.

Muscle glycogen: Comparison of iodine binding and enzyme digestion assays and application to meat samples.

A rapid assay for tissue glycogen is described. Bovine liver and muscle glycogen were solubilized with perchloric acid (7-10%) and incubated with an iodine (I(2)-KI) solution containing saturated CaCl(2). The optical density of the amber-brown color was determined at 460 nm. Color development was immediate, stable for up to 2 h, and was linear with respect to glycogen concentrations up to 600 µg glycogen/ml. The iodine assay was applied to fresh, frozen, and aged bovine muscle samples and was compared to enzymic (amyloglucosidase) digestion of glycogen followed by glucose determination. The correlation between the iodine and enzyme methods was linear over the range of 0-1400 g glycogen/g tissue (corr = 0·875; P < 0·01; n = 172). The iodine binding assay can be employed with confidence as an indicator of tissue [glycogen] and is faster and more reliable than the enzyme assay. Comparison of the iodine enzyme assays on aged meat samples revealed marked decreases in muscle glycogen during the first 48 h post slaughter. The decreases were identical whether determined by iodine binding or enzyme assay. Regardless of assay method, post-mortem concentrations of glycogen in bovine sternomandibularis muscle were more variable than in longissimus dorsi samples.