Oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal neoplasm.

During the last decade the number of cases of abdominal tuberculosis diagnosed in Western countries has dramatically increased. There are many reasons, including the appearance of AIDS and the increased morbidity of people across the world due to the westward migration of many people coming from areas with a high incidence of tuberculosis. Oesophageal involvement is rare in tuberculosis, occurring mainly as an extension of the disease from the adjacent tuberculous lymph nodes. Fifty-eight cases of oesophageal tuberculosis have so far been reported. We describe a patient affected by oesophageal tuberculosis mimicking secondary oesophageal involvement of mediastinal malignancy.

[Cranial trauma: the predictability of the presentation symptoms as a screening for radiologic study]. / Trauma cranico: predittività dei sintomi di presentazione come screening per lo studio radiologico.

A prospective study was performed on 4,262 consecutive patients who had had skull examinations for recent head trauma. Clinical signs and symptoms and patient history were correlated with skull fractures and intracranial sequelae as identified on CT studies, in order to evaluate the predictive value of each clinical finding and to identify high-yield referral criteria. Ninety-seven skull fractures (3%) and 32 intracranial sequelae (0.7%) were observed. All the intracranial complications were observed in patients with fractures and with altered consciousness of some degrees (Glasgow Coma Scale score less than 13). Most patients were asymptomatic (41%) or showed "low risk" symptoms (29%): among them, neither fractures nor complications were observed. High-risk clinical signs, mainly expressing basilar fractures (as rhinorrhea, otorrhea, focal neurologic signs, retroauricular hematoma) demonstrated high predictive value (100%) for intracranial sequelae. Other "moderate risk" findings for intracranial injury--i.e. loss of consciousness at any time, antegrade or retrograde amnesia, multiple trauma, and possible skull penetration--showed a high correlation with skull fractures and a slightly lower one with intracranial sequelae. The most predictive finding for brain injury was the depressed level of consciousness: brain injuries were never observed in fully conscious patients; in altered consciousness with GCS 15-13 we observed 4% of skull fractures with no sequelae; at GCS values 12-9, 61% of skull fractures and 20% of sequelae were present, whereas at GCS less than 8, 100% of complicated fracture were observed. The finding of skull fracture showed 33% of predictivity for brain damage, which was, however, always associated with "high or moderate risk" clinical signs. Therefore, the authors suggest some guidelines for the management of patients with recent head trauma, including referral criteria for X-rays or CT studies, based on signs and symptoms with high, intermediate and low risk of developing intracranial sequelae.

[The use of a questionnaire to test the reliability of protocols for the indication of radiologic tests in emergencies]. / Impiego di un questionario a verifica dell'affidabilità dei protocolli di indicazione agli esami radiologici nelle urgenze.

The authors developed a series of protocols for selecting patients who need emergency radiography, based on clinical criteria that maximize the yield of abnormal radiographs. In order to test safety and reliability of the protocols and to define the reasons for requesting emergency radiographs, a prospective analysis was carried out, by means of a questionnaire, on 1000 consecutive patients referred to our Accident and Emergency Department for radiography. Seven hundred and twenty-nine patients were considered as negative according to protocol criteria: none of them was found positive on X-ray examination. Of them, 639 exams were requested for medico-legal reasons and 90 for patient reassuring. Of 271 patients considered as true positive or probably positive according to the screening criteria, all the true positive cases were such also on X-ray examinations, whereas, among the probably positives, only 31 were confirmed as positive on radiological studies. Our results demonstrate the efficacy of the suggested protocols: had these referral criteria been used for the patients in our study, only 271 examinations would have been performed with no radiographic abnormalities missed. In addition, this grid included 94 cases evaluated as "probably" positive which were subsequently found negative at X-rays, which makes a further safety margin. Our analysis also shows the low therapeutic value of emergency radiographs in both nasal bone injury and post-traumatic oblique rib views. Therefore we suggest selecting patients who need X-rays based on the clinical criteria shown in our protocols: this could result in economic saving and decreased radiation exposure, with no risks of clinical underestimation of the pattern.