[The correlation between the type of positivity of the tilt test and a simultaneous electroencephalogram: the preliminary results]. / Correlazione tra tipo di positività del tilt test ed elettroencefalogramma simultaneo: risultati preliminari.

BACKGROUND: Today the first-choice examination to study neurally-mediated syncope is the tilt test. There are still many aspects to be clarified on the pathophysiology of neurally-mediated syncope, and much uncertainty remains on the therapeutic procedure to adopt. Recent research has investigated the role of neurohumoral agents, thus shifting interest to the pathogenetic role of the central nervous system, over and above that of the already widely studied vegetative nervous system. This is why we decided to carry out the tilt test with simultaneous electroencephalogram (EEG) recordings, with the aim of documenting any possible correlation between test positivity, according to Sutton's classification, and the EEG results. METHODS: We studied 15 patients (8 males, 7 females, age range 18-74 years) with a history of repeated syncopal and presyncopal episodes who had formerly undergone numerous clinical and instrumental examinations, including EEG, with negative results. The tilt test was carried out with continuous measurement of blood pressure (Ohmeda Finapres System) and simultaneous EEG recording. RESULTS: Ten patients (66%) were positive, 6 had experienced syncope episodes (4 type 2A and 2 type 1) and 4 presyncope (1 type 2A and 3 type 1). In all the syncope positive patients the EEG showed modifications in comparison with basal EEG, whereas only 50% of the presyncope positive patients showed slight alterations. There was no EEG alteration for tilt negative patients. The EEG result was markedly different in patients with tilt-induced type 2A syncope in comparison with those with type 1. Type 2A showed the following: 1) slowdown and reduced amplitude of electrical activity during the prodromes; 2) during the syncope, first pseudorhythmic then polymorphic delta activity were followed by total disappearance of activity ("flat" EEG); 3) then, in inverse sequence, reappearance of polymorphic then pseudorhythmic delta activity (average duration of syncope 37 s); 4) lastly, slowdown and reduced amplitude of electrical activity similar to that preceding the syncope. Whereas type 1 revealed: 1) no alteration of electrical activity during the prodromes; 2) during the syncope, first theta then polymorphic delta activity (average duration of syncope 16 s); 3) subsequent normal EEG. CONCLUSIONS: These observations indicate a correlation between the type of tilt test positivity and the EEG results, the latter being markedly more serious in type 2A than in type 1. EEG behavior, different in the two types also during the prodromes and the post-syncopal phase, would suggest a cerebral circle vasoconstriction mechanism in type 2A but not in type 1 mixed with a prevalent vasodepressive component. Should these preliminary results be confirmed by further data there will be evident clinical, prognostic and therapeutic implications. In the light of the considerably different involvement of the central nervous system, we believe it will be necessary to redefine the various types of neurally-mediated syncope in terms of seriousness. Simultaneous EEG could be proposed routinely in tilt test execution and become a determining factor in the choice of a therapeutic option.

Contact dermatitis caused by sesquiterpene lactones.

BACKGROUND: Compositae dermatitis involves workers such as gardeners, florists, and farmers, and less commonly people not employed in occupations at risk. OBJECTIVE: To report a case of contact sensitization caused by Compositae, the source of sensitization being both pesticides and plants. METHODS: A 65-year-old man, whose hobby was gardening, was affected by a chronic eczema of the face and the hands for 6 months that reoccurred after using fertilizers and handling plants. Patch tests with the International Contact Dermatitis Research Group standard series, the plants series and pesticides series (Hermal Trolab) were performed. RESULTS: We found the following positive reactions at day 2 and day 3: sesquiterpene lactone mix, 0.1% in petrolatum; arnica tincture, 20% in petrolatum; pyrethrum, 2% in petrolatum; captafol, 0.1% in petrolatum. CONCLUSION: Pyrethrum and its derivatives are made from Compositae plants; the arnica tincture is obtained from Arnica montana, which is also a member of the Compositae family. In our patient, the clinical manifestations were certainly caused by the exposure to sesquiterpene lactones, confirmed by the positive patch test to sesquiterpene lactone mix.

[Echo-Doppler evaluation of hemodynamic response during exercise in patients with rate-responsive respiration-dependent pacemakers]. / Valutazione eco-Doppler di risposta emodinamica durante sforzo in pazienti portatori di pacemaker rate responsive dipendenti dal respiro.

The aim of this study was the 2D-echocardiographic and Doppler evaluation of the hemodynamic behaviour under stress in a group of 7 patients bearing Biotec BioRate RDP 3 and MB1 rate-responsive respiration-dependent pacemakers, programmed with the same heart rate/respiratory frequency correlation curve. The following parameters were monitored in basal conditions and during each level of the stress test at the horizontal cycloergometer: cardiac output (CO), cardiac index (CI), stroke volume (SV) and pacing rate (HR). All the 7 patients presented a progressive increase in CO and CI, but with a marked range of SV and HR increase. Two types of hemodynamic response under stress were consequently found: the first was characterized by a conspicuous increase in SV during the initial and middle levels of the stress, concomitant with scarce HR increase. The second, instead, was characterized by scarce or no SV increase during the same levels, concomitant with marked HR increase. At the highest stress levels, the CO increase was, in both types, almost exclusively due to HR increase. By analyzing the clinical features and the basal echocardiographic aspects of the patients studied, the first type was found to represent normal contractility features, while the second type was characterized by compromised contractility with reduced ejection fraction. It was thus demonstrated that there are 2 ways of increasing the CO under stress: by means of predominant increase of either the SV or the HR. This hemodynamic behaviour, very similar to the spontaneous behaviour of the heart, occurred in a group of constantly paced patients, thanks to the highly physiological guide parameter of their pacemakers: respiratory activity, which is bound to O2 consumption by a linear relationship.

Power staple fixation in hallux valgus surgery: a preliminary report.

The authors describe a relatively new power staple device for foot surgery. Their preliminary review has been very favorable, as studied in 40 cases of hallux valgus repair. Their discussion includes the indications, contraindications, and potential for future use in the foot.

Intra-articular fractures of the calcaneus: a review.

Intra-articular fractures of the calcaneus can result in prolonged or permanent disability. The systematic approach to analysis based on anatomy, mechanism of injury, and x-ray films allows determination of the various elements of the lesion. Management is difficult because treatment is not standardized, and, even when good reduction has been achieved, long-term complications are commonplace. The authors review different types of intra-articular calcaneal fractures, various methods of treatment, and examples of possible complications.

Fractures of the neck of the talus and the Blair fusion: a review of the literature and case report.

Historically, fractures of the neck of the talus have been serious injuries with sometimes devastating results. Several mechanisms have been reviewed to explain the types of injuries most commonly seen. Hawkin's classification of the types of talar neck fractures has been explained and used as a guideline in a review of treatment and results of talar neck fractures. Hawkin's group I fractures generally require only immobilization and are frequently without serious sequelae. Hawkin's group II fractures are more serious injuries, which may frequently be treated with closed reduction. Open reduction is occasionally necessary. Hawkin's group III fractures have the most potentially devastating results. These generally require open reduction with internal fixation or occasionally primary salvage procedures. Secondary salvage procedures are also sometimes necessary. Avascular necrosis of the talar body is reviewed in detail, including correlation with the type of fracture as well as diagnostic techniques and treatment. Other complications, including soft-tissue damage, osteomyelitis, malunion, and posttraumatic arthrosis, are discussed. The Blair tibiotalar arthrodiesis is reviewed in detail, with the consideration that it may be used as a primary or secondary salvage procedure with good results. Finally, a case in which the Blair fusion was used successfully is reported with 1-year follow-up.

The neuropathic joint in diabetes mellitus.

This article discusses the development and treatment of Charcot's joints in patients with diabetic peripheral neuropathy. Historical and clinical reviews are presented, as are case illustrations. This article provides the practitioner with a comprehensive review of diagnosis and treatment of this clinical entity.

Congenital convex pes valgus. The condition and its treatment.

The congenital convex pes valgus deformity has been presented in reference to its etiology, pathologic anatomy, diagnosis, and treatment. It is imperative that this deformity be diagnosed immediately and treatment instituted rapidly to achieve a functional plantigrade and asymptomatic foot.

Calcaneal bone graft after enchondroma excision.

Enchondroma is a commonly encountered bone tumor in the foot, frequently necessitating excision. The calcaneus is a convenient source of bone for a bone graft, should that be required. The patient's own calcaneus offers the advantages of both cortical and cancellous bone, accessibility, dependable bone healing, and the superior osteogenic potential of autologous bone.

Injuries to the talus.

The unique anatomic, functional, and vascular aspects of the talus predispose the area to difficulty in the management of its injuries. This article provides a practical guide to the treatment of fractures and dislocations of the talus.

Tuberculous arthritis: a case study and review of the literature.

Tuberculosis of the bones and joints is a rare but treatable disease. This curable condition is frequently overlooked in the differential diagnosis, and often serious cases are not diagnosed until after severe joint destruction has already taken place. The literature on tuberculosis of the bones and joints is reviewed and the incidence, etiology, pathogenesis, diagnosis, and treatment of this condition are discussed. A case history of ankle joint involvement is presented in which antibiotic treatment before clinically significant joint destruction had occurred might have prevented surgery. Tuberculous involvement should thus be considered in any patient with chronic and subacute monoarticular arthritis.