[Fetoscopic laser coagulation in 100 consecutive monochorionic pregnancies with severe twin-to-twin transfusion syndrome]. / Coagulation laser en fœtoscopie des anastomoses vasculaires placentaires: étude observationnelle de 100 grossesses gémellaires monochoriales consécutives compliquées de syndrome transfuseur-transfusé sévère.

OBJECTIVES: To report pre- and post-surgical datas of large series of severe twin-to-twin transfusion syndrome (TTTS) managed with laser ablation surgery in our centre, to evaluate the incidence of complications, perinatal outcome and to compare with other cohorts. PATIENTS AND METHODS: Observational study of 100 cases of TTTS consecutively treated with fetoscopic laser coagulation between January 2004 and April 2010 in CMCO-SIHCUS of Schiltigheim. RESULTS: There are nine stage I, 49 stage II, 38 stage III and four stage 4. Median gestation at time of laser is 20.6 weeks (14-29) whereas median gestation at delivery is 32.6 weeks (16.3-39). Overall perinatal survival rate is 68.5% (137 children over 200). Eighty-five percent have one or more surviving twins. The survival rate is the same for donors and for recipients. Preterm premature rupture of the membranes are observed in 17% of cases and the median gestational age for this complication is 30 weeks (20-34). Cerebral abnormalities are present in 7% of newborns. CONCLUSION: Our results for the management of severe TTTS are comparable to the other reported series. There are still many questions remaining concerning the optimal management of TTTS.

In-hospital mortality and morbidity of elderly medical patients can be predicted at admission by the Modified Early Warning Score: a prospective study.

OBJECTIVE: Although early warning scores were originally derived as bedside tools for alerting the medical staff, they may serve as decision rules for the admission of medical patients. We conducted this study to investigate the ability of the Modified Early Warning Score (MEWS) to identify a subset of patients at risk of deterioration, who might benefit from an increased level of attention. DESIGN: Prospective, single centre, cohort study. SETTING: A 64-bedded medical ward in a public, non-teaching Hospital in Italy. PATIENTS: All patients consecutively admitted from 15th November 2005 to 9th June 2006. INTERVENTIONS: On admission, the attending physician measured five physiological parameters (systolic blood pressure, pulse rate, respiratory rate, body temperature and level of consciousness) and calculated the MEWS. The main outcome measures were in-hospital mortality and a composite of mortality and transfer to a higher level of care. A secondary end-point was the length of stay for discharged patients. MEASUREMENTS AND RESULTS: In all, 1107 patients were admitted; 621 (56.1%) were women and 486 were men. Patients of female gender were also older (mean age 80.6 years) than men (mean age 77.1; p < 0.05). Of 1107, 995 patients (89.9%) were older than 64 years. A total of 966 patients were discharged, 102 deceased and 39 were transferred. In comparison with the lowest score, the risk of death was incremental among all the MEWS categories, as well as the risk of the combined outcome of death and transfer, and highly significant (risk of death, chi(2) for trend 136.307; risk of death or transfer, chi(2) for trend 105.762; p < 0.00001 for both). Patients with MEWS < or = 4 were discharged after a mean stay of 8.3 days, and alive patients with MEWS of five or more were discharged after a mean stay of 9.4 days (p = ns). A patient with a MEWS of zero at admission has a very low probability to die or to be transferred because of clinical instability (OR 0.14, 95% CI: 0.08-0.24). CONCLUSIONS: We have confirmed that the MEWS, even when calculated once on admission, is a simple but highly useful tool to predict a worse in-hospital outcome.

[An unusual case of pulmonary infiltrates with hepatic involvement in a woman with eosinophilia]. / Un caso inusuale di infiltrati polmonari con interessamento epatico in una donna con eosinofilia.

The literature reports many cases of eosinophilic pulmonary infiltrations, with different etiology. In our case clinical pictures were not very clear and specific at first and the clinical course was altered by an ex adjuvantibus steroid treatment before admission to hospital. It was new and unusual because it presented some characteristics of chronic eosinophilic pneumonia and idiopathic hypereosinophilic syndrome, with hepatic involvement as in the former, but without serious heart disease as in the latter. This confirms the difficulties in making a classification of the different clinical pictures because of their indistinct margins, which might appear as different forms of a single disease. In our case the patient refused transbronchial lung biopsy which is commonly considered a minimum diagnostic requirement. Some authors are not in agreement and think it is sufficient to find eosinophils in BAL to start steroid treatment, avoiding biopsy risks. Another interesting finding is the need for a long-term low-dose steroid treatment, to avoid relapses.

[Pheochromocytoma and autoimmune hypothyroidism]. / Feocromocitoma ed ipotiroidismo autoimmune.

The association of multiple endocrine diseases is frequent and the coincidental involvement of the thyroid and adrenal glands is well recognized. On the contrary, two cases of hypo or hyperthyroidism have only been reported in literature: one concerning adrenal pheochromocytoma with simultaneous autoimmune hypothyroidism and another of a diffuse toxic goiter associated with pheochromocytoma. The purpose of the present report is to point out a new case of a pheochromocytoma associated with an autoimmune hypothyroidism in which the latter is florid and not biochemical.

Lithium-induced sinus node dysfunction.

A 74-year-old woman, on lithium carbonate treatment, developed symptomatic sinus node dysfunction and central nervous toxicity, which disappeared after discontinuation of the drug and when serum lithium fell from 2 to 1.27 mEq/L. Our review of the literature demonstrates that sinus node abnormalities can occur both in presence of therapeutic and toxic serum lithium levels and are frequently asymptomatic and completely reversible. All patients receiving lithium should have their pulse regularly recorded and the drug should be promptly discontinued if severe bradycardia or other rhythm disturbances appeared during the treatment.

Free-cortisol assay by immunoextraction: comparison with an equilibrium dialysis procedure.

We describe a new method for directly determining the apparent free cortisol concentration in plasma samples by use of an antibody-coated test-tube RIA. Buffer-diluted plasma or standard serum is added to antibody-coated test tubes, incubated at 4 degrees C for 4 h, and the solutions are aspirated. 125I-labeled cortisol is added to each tube and incubated for 3 h at 4 degrees C. Then the insides of the tubes are washed and their radioactivities counted. The standard curve is in terms of free cortisol, the standard serum solutions having been measured with an equilibrium dialysis procedure. Plasma samples (n = 155) from normal subjects and from various patients, measured with the new immunoextraction method and the equilibrium dialysis technique, gave results that correlated well (r = 0.847, p less than 0.001). Results by this direct RIA also correlate well with the clinical adrenocortical status of patients for whom data on total plasma cortisol may be misleading. This simple, easy RIA is suited to be the routine method for free cortisol in plasma.

Prenylamine-induced ventricular arrhythmias and syncopal attacks with Q-T prolongation. Report of a case and comment on therapeutic use of lignocaine.

A 70-year-old man, on prenylamine for exertional angina, complained of syncopal attacks which seemed to be caused by bursts of ventricular tachycardia associated with Q-T prolongation. These symptoms disappeared after treatment with lignocaine, and the Q-T interval gradually returned to normal when prenylamine was stopped. This communication emphasizes the possibility of the occurrence of Q-T prolongation with associated ventricular arrhythmias in patients treated with prenylamine and the usefulness of a cautious trial with lignocaine in ventricular arrhythmias linked to Q-T prolongation.