Oxigenoterapia de alto flujo: Experiencia en pediatría en un hospital general / High-flow oxygen therapy: Experience in pediatrics at a general hospital

Introducción: La Oxigenoterapia de Alto Flujo (OAF) es una técnica de soporte respiratorio no invasiva, que ofrece un flujo de aire y oxígeno, caliente y humidificado, por encima del flujo pico inspiratorio del paciente, a través de una cánula nasal. En este artículo se presenta la experiencia con OAF en una sala de pediatría de mediana y baja complejidad para el tratamiento de bronquiolitis/ infección respiratoria aguda baja (IRAB). Materiales y métodos: Se diseñó un protocolo para la implementación de OAF. Criterios de inclusión: Pacientes cursando bronquiolitis/ IRAB con: Score de Tal modificado ≥6, Sat O2 < 92% y/o mala mecánica ventilatoria, a pesar de recibir más de 2 lt/ min de O2 por cánula nasal ó FiO2 >40%. Criterios de exclusión, pCO2 ≥55 mmHg; pH: < 7,20; Apneas ≥20 segundos; Glasgow ≤10; Peso >15 kg. Inestabilidad hemodinámica; Alteraciones craneofaciales. Resultados: En el periodo 2017- 2018 se internaron 441 pacientes con infección respiratoria aguda baja. Se administró OAF a 54 pacientes (12%). La mediana de edad mediana 7,4 meses (r: 27 días-36 meses). Los pacientes ingresados no presentaban comorbilidades asociadas. El 22,2% (12/54) fueron trasladados a UTIP (2,7% del total de los internados). El 64.8% de los pacientes que permanecieron en sala de internación, mostró mejoría en FC y FR a las 4 hs. Por el contrario, en el 75% de los pacientes que requirieron UTIP no se evidenció mejoría en estos parámetros. Conclusiones: La OAF es una alternativa terapéutica que podría disminuir el ingreso a UTIP en pacientes con dificultad respiratoria moderada. En nuestra experiencia resultó fácil de implementar, sin efectos adversos graves (AU)

Introduction: High-flow oxygen (HFO) therapy is a non-invasive oxygen support technique that provides hot and humidified air and oxygen flow above the peak inspiratory flow of the patient through a nasal cannula. In this study we present our experience with HFO on a intermediate and low complexity ward for the treatment of bronchiolitis/acute lower respiratory tract infection (LRTI). Material and methods: A protocol for the implementation of HFO was designed. Inclusion criteria: Patients with bronchiolitis/ALRI with: Modified Tal score ≥6, Sat O2 < 92%, and/or poor ventilatory mechanism, in spite of receiving more than 2 L/ min O2 by nasal cannula or FiO2 >40%. Exclusion criteria: pCO2 ≥55 mmHg; pH: < 7.20; Apnea ≥20 seconds; Glasgow score ≤10; Peso >15 kg. Hemodynamic instability; Craniofacial abnormalities. Results: During 2017- 2018, 441 patients were admitted with LRTI. HFO was administered to 54 patients (12%). Median age was 7.4 months (r: 27 days-36 months). The patients that were included in the study did not have associated morbidities. Overall, 22.2% (12/54) were transferred to the PICU (2.7% of all hospitalized patients). Of the patients who remained on the ward, 64.8% improved FC and FR after 4 hours. On the other hand, in 75% of the patients that required PICU admission these parameters did not improve. Conclusions: HFO is a therapeutic option to decrease PICU admission of patients with moderate respiratory difficulties. The protocol was easy to implement and was not associated with severe adverse effects (AU)

Randomised, double-blind, placebo-controlled, assessment of the efficacy and safety of dietary supplements in prehypertension.

We aimed to evaluate efficacy and tolerability of a protocol including lifestyle modifications and a novel combination of dietary supplements in prehypertension. A prospective, double-blind, randomised, placebo-controlled trial was conducted in 176 subjects (103 men, aged 52±10 years), with blood pressure (BP) of 130-139 mm Hg systolic and/or 85-89 mm Hg diastolic entered. After a single-blind run-in period, participants were randomised to twice daily placebo (n=88) or a commercially available combination pill (n=88). Primary endpoints were the differences in clinic BP between the two groups at the end of the trial. Secondary endpoints included intragroup differences in clinic BP during the study period and response rates (that is, BP <130/85 mm Hg or a BP reduction >5 mm Hg on week 12). Baseline characteristics were similar among the treatment groups. At 12 weeks, the supplement group had lower systolic BP (124±9 versus 132±7 mm Hg, P<0.0001) and similar diastolic BP (81±8 versus 82±7 mm Hg, P=0.382) compared to the placebo group. With respect to baseline measures, changes in BP with supplements were statistically significant for systolic (-9.3±4.2 mm Hg, P<0.0001) and diastolic values (-4.2±3.6 mm Hg, P<0.0001). Changes versus baseline in systolic and diastolic BP, conversely, were not different on placebo. The overall response rate at week 12 was significantly greater with supplements than placebo (58% (51 of 88) and 25% (22 of 88), respectively, P<0.0001). This randomised trial shows that combination of supplements with BP-lowering effect is an effective additional treatment to conventional lifestyle modifications for a better control of systolic BP in prehypertension.

Circulating endothelial progenitor cells in postmenopausal women with and without coronary artery disease.

BACKGROUND: Middle-aged women have a lower prevalence of coronary artery disease (CAD) compared with age-matched men, but mechanisms underlying this phenomenon remain controversial. To verify whether there is a link between circulating endothelial progenitor cells (EPCs) and gender-specific difference of CAD, we compared subpopulations of EPCs among postmenopausal normal women, patients with CAD, and age-matched men. METHODS: We studied 71 consecutive middle-aged patients with stable CAD (30 postmenopausal women and 41 men) and 40 middle-aged normal controls (20 postmenopausal women and 20 men). Blood samples were drawn at time of coronary angiography and subpopulations of EPCs were measured by flow cytometry. RESULTS: Women and men with CAD had similar age, risk factors, clinical presentation, left ventricular function, extension of CAD, and medical therapy at time of coronary angiography. Hematologic analysis showed that men and women with CAD had similar white cell count, mononuclear cells, and subpopulations of EPCs. Postmenopausal normal women, conversely, had significantly higher absolute numbers of CD34+, CD133+, CD105+ and CD14+ cells than other groups. CONCLUSIONS: Increased numbers of subpopulations of EPCs in normal postmenopausal women might contribute to the gender-specific difference of CAD in middle age. Lack of difference in EPCs between women and men with CAD suggests that stem cells become unable to play a protective role when the disease is clinically evident.

[Idiopathic ischaemic infarction of the stomach. Case report]. / Infarto ischemico idiopatico dello stomaco: case report.

Idiopathic ischaemic infarction of the stomach is an extremely rare condition since only 2 other cases have been published in the Literature so far. The Authors report a case of such entity on a 75 year old male patient, admitted from the accident and emergency department because of a upper digestive tract haemorrhage with clinical signs of hypovolemic shock. The patient subsequently underwent an upper gastro-intestinal endoscopy that suspected an ulcerated gastric neoplasm. The patient therefore underwent a total gastrectomy and was discharged home on p.o. day X. The pathology report showed an Ischaemic infarction of gastric mucosal tissue with pomphoid Oedema of submucosal layer. Ulcerative superficial necrosis with venous haemorragic swarm and focal acute pseudomembranous inflammation. Not neoplastic features. Etiopathogenetic, pathophisiologic ipoteses and clinical implication of Idiopathic ischaemic infarction of the stomach are discussed.

Ultrastructural observations on the microvasculature in advanced gastric carcinomas.

The ultrastructural features associated with vascular permeability in 9 cases of advanced gastric carcinomas were studied, and compared with that of control non-neoplastic mucosa. Tumour microvasculature showed features in common with those of control mucosa, including complete basal lamina, well-developed interendothelial junctions, fenestrations and caveolae. Some tumour blood vessels showed endothelial cell swelling accompained by luminal narrowing and perivascular fibrosis. In 2 out of 9 cases, there were endothelial attenuation with numerous fenestrations and vesiculo-vacuolar organelles. The vesiculo-vacuolar organelle is a recently described cytoplasmic structure found in the endothelial cells lining tumour microvessels and normal venules and which provides an important pathway for extravasation of circulating macromolecules. Our ultrastructural data suggest that advanced gastric carcinomas share with experimental tumour models in vivo only some morphologic features associated with hyperpermeability including fenestration, endothelial attenuation and vesiculo-vacuolar organelles. The implications of perivascular fibrosis on the delivery of immune cells to gastric carcinomas are discussed.

[Combined diagnosis in breast carcinoma: preoperative role of mammoscintigraphy with Tc99m-sestamibi. Our Experience]. / Diagnostica integrata nel carcinoma della mammella: il ruolo prechirurgico della mammoscintigrafia con Tc 99m-sestamibi. Nostra esperienza.

The Authors, taking recent literature on tumoral pathology breast studies in to consideration, studied a group of patients with a node or a suspect adenous zone by clinical and instrumental examination with mammoscintigraphy. 22 patients were selected by clinical examination, mammography and ultrasonography. A mammoscintigraphy (Tc 99m Sestamibi) was performed before the surgical operation. The histologic examination revealed 14 cases of breast cancer; 12 of these (86%) resulted positive after scintigraphy, while 2 were false negative. In this study, the scintigraphic exam and its diagnostic accuracy were analyzed, both in relation to anatomical structure of the mammary gland (thick breast, fibrocystic mastopathy, postsurgical scars, etc.) and also in relation to characteristics of the suspected node, the nature of which was not possible to determine from other exams carried out. In conclusion, after comparison between our experience and those reported in literature, we conclude that because of its high specificity and sensibility the mammoscintigraphy exam assumes an important comparative index in obtaining elements for an additional evaluation when other instrumental examinations are dubious.

[Myogenic stromal tumors of the stomach: personal experience]. / I tumori stromali dello stomaco di derivazione muscolare: esperienza personale.

Myogenic gastric tumours are a rare pathology and present difficulties in terms of nosographic classification, which in most cases can be overcome thanks to improvements in imaging and immunohistochemical techniques. Over the period 1995-1999 we observed 5 patients with aspecific dyspeptic symptoms and occasional epigastric pain, suffering from non-epithelial gastric tumours, associated, in one case, with a carcinoma of the stomach. Histological examination of endoscopic biopsies was inconclusive for a definite histopathological diagnosis, while intraoperative biopsies showed the myogenic origin and the absence of morphostructural abnormalities. In the light of these data, we performed three wedge resections, one distal gastric resection and, in the patient with advanced gastric cancer, a D3 total gastrectomy. Histological examination, immunohistochemistry and cytofluorometry enabled us to diagnose stromal tumours with a low risk of malignancy in all cases. At follow-up after 9-54 months all patients are still alive and free of disease. Though the preoperative diagnosis of stromal tumours is possible with endosonography and CT, only histology, immunohistochemistry and cytofluorometry enable us to define the condition nosographically and establish a prognosis with sufficient accuracy to allow correct surgical treatment. A prolonged follow-up is always necessary to identify eventual relapses and/or metastases, which are particularly frequent in the borderline group or in cases with a high risk of malignancy.

[Unusual case of calcified renal fibroma]. / Un raro caso di fibroma renale calcifico.

The renal fibroma is an extremely rare event that takes its origin from parenchima, from the peri-renal tissues or from the renal capsule. A case of renal fibroma of a rarely met medullary origin is described.

[Primary echinococcosis of the thyroid gland: apropos of a case]. / L'echinococcosi primitiva della tiroide: a proposito di un caso.

The Authors report a case of primary hydatid cyst of the thyroid. After a review of the literature, they underline the rarity of the case and discuss pathogenesis, clinical and diagnostic related problems. The Authors conclude that, although modern imaging techniques have allowed diagnostic improvements, preoperative diagnosis is still difficult.

Differences in AgNOR quantity between colorectal cancer and corresponding metastases: are they useful for prognostic purposes?

In order to evaluate the relationship between primary colorectal adenocarcinomas and their metastases with regard to AgNOR proteins expression, we have performed a morphometric analysis of AgNOR silver precipitates (AgNORs) in advanced colorectal carcinomas (stage III-IV) as well as in corresponding lymph node and distant metastases. Surgical specimens studied consisted of 64 primary tumours, 56 lymph node and 43 hepatic or omental metastases; for each formalin-fixed paraffin-embedded specimen, silver staining according Ploton et al. (1986) was performed and the AgNOR area (NORA) relative to primary site, lymph node and/or distant metastases was calculated. A significant difference (P < 0.001) among the non-neoplastic colonic control mucosae and primary or metastatic neoplastic lesions was found, but no statistically significant differences were encountered among the categories of primary colorectal carcinomas and their lymph node or distant metastases. Moreover, on the basis of NORA data case per case, three groups of patients were selected. In particular, in the group 1 NORA values of metastases were higher than those of the corresponding primary carcinomas, while in the group 2, NORA values of metastases were lower than those of the corresponding primary neoplasms; no differences of NORA values were encountered in group 3. The cumulative patient survival estimated by the Kaplan-Meier method showed a worse prognosis for patients belonging to group 1, where higher AgNOR values, not only in primary carcinomas but also in lymph node and distant metastases, were found.

Neutrophil interaction with tumour cells in small early gastric cancer: ultrastructural observations.

The authors studied the neutrophil inflammatory reaction by light and electron microscopy in 4 small early gastric cancers (three tubular adenocarcinomas and one adenocarcinoma with signet-ring cell component), selected for the absence of coagulative necrosis and ulceration. Neutrophils showed ultrastructural signs of activation such as aggregation, adhesion and lipid bodies. Some neutrophils were found to be in intimate contact with the intact tumour cells and with those that displayed a varying degree of damage. In particular, relatively early damage, such as disorganization of the intermediate filaments and dilatation of the rough endoplasmic reticulum, occurred at the contact regions. In spite of the severe damage to the tumour cells, the neutrophils themselves were intact. These findings are discussed in relationship to a number of recent studies of the neutrophil-mediated tumour cell injury, in man and animals.

Unexpected cytological diagnosis of two cases of echinococcosis.

The Authors report two cases of hydatid cysts localized in the soft tissues of the thigh and in para-renal region respectively. In both cases the cystic nature of the lesion was revealed by echography while the common serologic and hematologic preoperative tests did not show pathologic values. The working diagnosis was traumatic or developmental lesion and the patients were undergone to fine needle aspiration (FNA) cytology which permitted to make the unexpected diagnosis of hydatid cysts. The enzyme linked immunosorbent assay for echinococcus, done at the time in monitoring the disease, was positive only in one case. Although the routine use of FNA cytology for the diagnosis of echinococcosis should be discouraged, this procedure may represent a real aid in the definitive diagnose of clinically unsuspected hydatid cysts.

[The prognostic value of the ejection fraction at rest and under stress assessed by nuclear angiography in myocardial infarct patients]. / Valore prognostico della frazione di eiezione a riposo e da sforzo valutata mediante angiografia nucleare in pazienti con infarto del miocardio.

BACKGROUND: The aim of this study was to assess the utility of ejection fraction at rest (rEF) and its change during stress (delta EF) as a predictor of cardiac events during the follow-up of patients (pts) with myocardial infarction. METHODS: 74 pts (44 treated with thrombolytic therapy (TR), and 30 not (noTR)), were studied with 99mTcPYP angiography within 2 +/- 1 months, after AMI. By 20 +/- 10 months, 41 pts had no events (Group A) while 33 pts experienced cardiac events (3 deaths, 16 angina, 12 CABG, and 2 PTCA). RESULTS: rEF was similar in both Groups A and B (A 47 +/- 8 vs B 45 +/- 10 p. ns), 44 +/- 15 vs B-noTR 46 +/- 12 p. ns). delta EF was different between Groups A and B. Group A showed a positive delta EF (3.2 +/- 6), and this result was more evident in thrombolyzed AMI (A-TR 4.4 +/- 4.5 vs A-noTR 1.16 +/- 3.9 p. < 0.01). Group B showed a negative delta EF (-4.4 +/- 5.3), and this result was more evident in non thrombolyzed AMI (B-TR -2 +/- 6.4 vs B-noTR -5.8 +/- 8 p. < 0.01). CONCLUSIONS: A decrease in EF during exercise radionuclide angiography is useful in identifying pts with high risk of cardiac events after AMI. Thrombolytic therapy improves stress EF in both Groups A and B.

Ventricular cross stimulation in a dual chamber pacing system: phenomenon analysis.

Seven cases of ventricular cross stimulation from a group of 23 patients implanted with DDD devices are presented. In two patients the phenomenon was observed at the moment of DDD programming at nominal values, and in five other patients it was reproduced by increasing the atrial output voltage up to ten volts. In all 23 patients cross stimulation disappeared permanently within 24 hours after implantation. From the onset of cross stimulation to its end, atrial and ventricular threshold voltages were unchanged, while the atrial and ventricular impedances significantly decreased. These results suggest that an important role in the phenomenon occurs by impedance variation at the interface between the pulse generator and body tissue.

[Epithelial neoplasms of Vater's ampulla: anatomico-clinical and immunohistochemical study]. / Neoplasie epiteliali dell'ampolla di Vater: studio anatomo-clinico ed immunoistochimico.

3 adenomas and 5 carcinomas of the ampulla of Vater are studied to evaluate their histogenesis and diagnostic significance of the antigen defined by the monoclonal antibody CA 19/9. In the adenomas, some dysplastic glands show a faint positivity for CA 19/9 antigen, whereas in the ampullomas this antigen is present in adenomatous residue and in well differentiated adenocarcinomatous areas. The present observations indicate that the endoscopical and macro-microscopical examinations are fundamental to evaluate the location of the ampullary neoplasia. Moreover, the immunohistochemical finding of the CA 19/9 antigen in adenomas and carcinomas suggests their histogenetic relationship, but it is not useful in their differential diagnosis.

[A case of vascular leiomyosarcoma of the superficial soft tissues]. / Su di un caso di leiomiosarcoma vascolare dei tessuti molli superficiali.

The authors report a case of vascular leiomyosarcoma of the superficial soft tissues, and point out its epidemiologic (rareness of the report), biologic (high degree of malignancy, trend to local relapse and remote conversion into metastases), histopathologic aspects. They consider significant as to prognostic value the appraisal of the "mitotic index" and the opportunity of a radical intervention, followed by radiotherapy. They, moreover, think it useful, in consideration of the frequency of the relapses, to perform a periodic checking of the patient.