Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.

STUDY OBJECTIVES: Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. METHODS: We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. RESULTS: The patients' median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92-0.97). CONCLUSIONS: Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

Brain natriuretic peptide and insulin resistance in older adults.

AIMS: Higher levels of brain natriuretic peptide (BNP) have been associated with a decreased risk of diabetes in adults, but whether BNP is related to insulin resistance in older adults has not been established. METHODS: N-terminal of the pro hormone brain natriuretic peptide (NT-pro BNP) was measured among Cardiovascular Health Study participants at the 1989-1990, 1992-1993 and 1996-1997 examinations. We calculated measures of insulin resistance [homeostatic model assessment of insulin resistance (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), Gutt index, Matsuda index] from fasting and 2-h concentrations of glucose and insulin among 3318 individuals with at least one measure of NT-proBNP and free of heart failure, coronary heart disease and chronic kidney disease, and not taking diabetes medication. We used generalized estimating equations to assess the cross-sectional association of NT-proBNP with measures of insulin resistance. Instrumental variable analysis with an allele score derived from nine genetic variants (single nucleotide polymorphisms) within or near the NPPA and NPPB loci was used to estimate an un-confounded association of NT-proBNP levels on insulin resistance. RESULTS: Lower NT-proBNP levels were associated with higher insulin resistance even after adjustment for BMI, waist circumference and other risk factors (P < 0.001 for all four indices). Although the genetic score was strongly related to measured NT-proBNP levels amongst European Americans (F statistic = 71.08), we observed no association of genetically determined NT-proBNP with insulin resistance (P = 0.38; P = 0.01 for comparison with the association of measured levels of NT-proBNP). CONCLUSIONS: In older adults, lower NT-proBNP is associated with higher insulin resistance, even after adjustment for traditional risk factors. Because related genetic variants were not associated with insulin resistance, the causal nature of this association will require future study.

Massive Retro-Pneumoperitoneum and Lower Limb Subcutaneous Emphysema After Pediatric Heart Transplantation: A Case Report.

An emphysema in a lower limb is usually a clinical sign of a severe and life-threatening infection. We report a rare case of subcutaneous emphysema of the left lower limb associated with a massive retro-pneumoperitoneum and pneumatosis intestinalis after cardiac transplantation in a 4-year-old girl. The child was nearly asymptomatic beside an abdominal distension. A benign pneumoperitoneum associated with an extensive pneumatosis intestinalis is a rare complication after organ transplantation and should be treated conservatively. The association with an emphysema in a lower limb in a child has not been previously reported to our knowledge in the literature.

Radiological and forensic medicine aspects of traumatic injuries in child abuse.

Child abuse is a topical issue in modern society and has social and medical implications which directly concern the doctor, both as a private citizen and as a health professional. Abuse injuries can be of very different types, e.g. physical, psychological or sexual. Hence they require a multidisciplinary and multispecialty approach, which must begin with an accurate medical examination, conducted in compliance with the lege artis principles and with respect for the victim's dignity. Diagnostic imaging becomes essential, together with epicrisis, which is useful to distinguish between accidental and abusive injuries. This paper describes the radiologist's key role in identifying physical injuries due to child abuse, in accordance with current regulations.

Engagement of CD30 shapes the secretion of cytokines by human gamma delta T cells.

CD30 is a member of the TNF receptor superfamily, previously shown to be expressed on Hodgkin's lymphoma cells and on normal activated lymphocytes. We here show that CD30 is highly expressed on recently activated human gamma delta T cells. Elevated surface levels of this molecule persisted in long-term cultures of gamma delta cells, without further cell stimulation. CD30 acted as a co-stimulus in gamma delta T cells by potentiating the intracellular Ca(2+) fluxes induced by CD3 cross-linking. The engagement of CD30 enhanced the expression of several cytokines induced upon CD3 stimulation such as IL-4 and IFN-gamma but not IL-10. The CC chemokines RANTES and macrophage inflammatory protein-1beta were constitutively expressed and not affected by stimulation. The inducible expression of the neutrophil chemoattractant IL-8 was enhanced by CD30 co-stimulation, as well as that of the CC chemokines I-309 and MDC, whereas the secretion of the monocyte chemotactic protein-1 was not detected. Triggering of CD30 may therefore modulate the expression of several cytokines released by gamma delta cells; the expression of its physiologic ligand by APC and neutrophils at the site of infection may contribute to determine the outcome of an immune response.

Human immunodeficiency virus replication induces monocyte chemotactic protein-1 in human macrophages and U937 promonocytic cells.

We have recently described a significant correlation between human immunodeficiency virus-1 (HIV-1) RNA replication and monocyte chemotactic protein-1 (MCP-1) levels in the cerebrospinal fluid (CSF) of individuals with the acquired immunodeficiency syndrome (AIDS) with HIV encephalitis (E). Because local macrophages (microglia) are the cells predominantly infected in the brain, we investigated whether in vitro HIV infection affects MCP-1 production in mononuclear phagocytes (MP). MCP-1 secretion and expression were consinstently upregulated over constitutive levels in human monocyte-derived macrophages (MDM) infected with the M-tropic R5 BaL strain of HIV-1. HIV replication was required for this effect, as demonstrated by the absence of chemokine upregulation after infection in the presence of 3'-azido-3'-deoxythimidine (AZT) or cell-exposure to heat-inactivated (triangle up degrees ) virus. MCP-1 induction was not restricted to HIV-1 BaL, but was also observed during productive infection of MDM with two primary isolates differing for entry coreceptor usage and of U937 cells with the X4 HIV-1 MN strain. Based on the observation that exogenous HIV-1 Tat induced MCP-1 expression in astrocytes, we also investigated its role in MDM and U937 cells. Exogenous Tat induced MCP-1 production from MDM in a concentration-dependent manner, however, it was not effective on uninfected U937 cells or on the chronically infected U937-derived cell line U1. Transfection of Tat-expressing plasmids moderately activated HIV expression in U1 cells, but failed to induce MCP-1 expression in this cell line or in uninfected U937 cells. HIV replication-dependent expression of MCP-1 in MP may be of particular relevance for the pathogenesis of HIV infection in nonlymphoid organs such as the brain.

Diagnostic imaging of the early slipped capital femoral epiphysis.

INTRODUCTION: Early slipped capital femoral epiphysis (ESCFE) can be treated surgically, with excellent results, if it is diagnosed in its initial stage; however, the rate of late or missed diagnoses remains surprisingly high. PURPOSE: We compared radiography, US and MR sensitivity in ESCFE diagnosis. MATERIAL AND METHODS: We examined 21 symptomatic overweight patients (15 boys and 6 girls) aged 9 to 15 years with anteroposterior radiographs; frog leg images were not acquired in 3 cases only. US was performed in 19 cases and the images acquired with 5-7.5 MHz probes on the sagittal plane parallel to the femoral neck. MRI was performed in 9 cases, with coronal and sagittal T1 SE and T2* GE images. RESULTS: Our sensitivity rates were 66% for anteroposterior radiography (6 false negatives), 80% for combined anteroposterior and frog leg images (3 false negatives), 95% for US (1 false negative) and 88% for MRI (1 false negative). DISCUSSION AND CONCLUSION: We believe that US is the method of choice in ESCFE diagnosis; if it is negative, but pain persists, MRI should be performed.

Dialysis hypersensitivity: a fading problem?

Allergic-type reactions experienced by patients on chronic hemodialysis are frequently reported in the literature, often related to compounds released during the hemodialysis sessions, in particular ethylene oxide (ETO). In these studies, dialysis patients seem to have higher values of IgE than those observed in a reference population. The aim of our work was to investigate IgE-related parameters of 126 dialysis patients in comparison with two control groups composed of healthy subjects and predialysis patients. IgE values were not significantly different in nonallergic dialysis patients, with a geometric mean (X) of 27.5 kU/l, when compared to healthy controls (X = 38 kU/l) and predialysis subjects (X = 40.7 kU/l). Higher values of IgE (X = 74.1 kU/l) were detected in allergic dialysis patients. However, only 3 patients, all without detectable antibodies against ETO, complained of anaphylactic symptoms during dialysis sessions in a 4-year surveillance period. At variance, 6 symptom-free patients carried IgE antibodies against ETO (range 0.7-15 kU/l), usually with high total IgE. Our results suggest a reduced frequency of hypersensitivity reactions during dialysis sessions. Furthermore, uremia does not alter IgE reactivity in the predialysis period or after long-term maintenance dialysis treatment.

Diamond-Gardner syndrome: a case report.

We present a 13-year-old girl who came to our attention for an erythematous bruised lesion which appeared spontaneously without any apparent coagulopathy. The history, histology, and positive "skin-test," carried out by subcutaneously injecting autologous erythrocytes obtained from heparinized blood, confirmed the suspected diagnosis of Diamond-Gardner syndrome. No alterations of blood vessel walls or thromboses were found. Evaluation of hemocoagulative parameters revealed an increased factor VIII level and reduced platelet aggregation after stimulation by adenosine diphosphate (ADP.)

Uraemic pruritus is not related to plasma histamine concentrations.

Pruritus is a common symptom in uraemic patients and its aetiology is poorly understood, although several factors have been implicated, including high histamine plasma levels. The aim of the study was to evaluate plasma levels of histamine in patients on maintenance haemodialysis in relation to the presence of itching (35 pruritic patients = group A; 50 non-pruritic patients = group B). Furthermore, we compared the values obtained with those of a healthy control group (64 subjects). We observed increased plasma histamine levels in uraemic patients compared with healthy controls. However, no relationship was found between plasma histamine values and itching because groups A and B showed overlapping values and there was no correlation between the intensity of pruritus and plasma histamine concentrations in group A patients. In conclusion, we suggest that there is no evidence for plasma histamine playing a significant part in uraemic pruritus.

[Diagnostic considerations on sinusitis in childhood]. / Considerazioni diagnostiche sulla sinusite in età pediatrica.

The presence of a radiographic sinusal opacification without any other clinical sign or symptom cannot lead to the diagnosis of "Sinusitis", if considered alone. In a previous paper we observed a high prevalence of patients with both clinical and radiographic signs of sinusitis and a high prevalence of neutrophils in the nasal secretions, now we tried to discover which clinical signs and symptoms are more likely to indicate an acute sinusitis. We compared cough, headache, bacteriological culture of nasal secretions with a sinusal CT scan, without finding any relationship. On the contrary, neutrophils in the nasal secretions and Rx are strictly inter-related with CT scan, with a sensitivity of 77% and a specificity of 100%.

[Reflections on unexpected onset of Kaposi's sarcoma in a case psoriasis]. / Riflessioni su un sarcoma di Kaposi insorto repentinamente su una psoriasi.

A case of Kaposi's classic sarcoma with a particularly rapid and aggressive onset is reported in an 80-year-old patient affected by psoriasis for about 30 years. The therapies previously used to treat the patient's psoriasis are discussed.

[AIDS and the skin]. / AIDS e cute.

Numerous skin symptoms are observed during the course of HIV infection, including a wide spectrum of affections which range from infective pathologies to tumours. Some of these, for example villous leukemia, oral hairy leukoplakia are only seen in AIDS subjects: others, even if not specific to AIDS, are often found in severe and aggressive forms, probably due to the extensive immunodepression which characterises these patients.

[Reticular erythematous mucinosis (REM). A report of 2 cases]. / Mucinosi reticolare eritematosa (REM). Osservazioni su due casi.

Cases of reticular erythematous mucinosis have not been frequently observed since Steinglender discovered the disease in 1971. The two patients with a dermatosis having the clinical and histologic characteristics of REM came to our clinic. The biopsies then taken underwent elective colouring for the mucin and was observed under an electron microscope.