Purpura fulminans in meningococcal septicaemia in an adult: a case report.

Purpura fulminans is a rare and severe complication of meningococcal septicaemia. It presents as a petechial rash spreading rapidly in extent and depth, evolving into full-thickness skin necrosis. The condition is extremely uncommon in the adult population. We report the case of a 28-yr-old man with extensive meningococcal-related skin necrosis. The initial diagnosis was made and first treatment given in the emergency department of a local hospital, from where after 12 days he was transferred to our hospital. Our approach was based on the continuation of intensive treatment and on staged aggressive debridement. Temporary alloplastic skin grafts were used to prepare the wound bed and the wounds were closed with autologous skin grafts. The patient survived but subsequently, owing to chronic skin ulceration and scar instability, he underwent late bilateral below-the-knee amputation.The patient returned to normal deambulation with an orthopaedic prosthesis 18 months after the onset of meningococcal septicaemia.

[Treatment of traumatic injuries of the spleen. Retrospective analysis of 164 cases]. / Trattamento delle lesioni traumatiche della milza. Analisi retrospettiva su 164 casi.

Increased awareness of the spleen's immunologic function and the risk of overwhelming post-splenectomy sepsis has aroused interest in methods of splenic preservation in patients with abdominal trauma. During an 8-year period, 164 patients with documented blunt splenic injuries were treated in accordance with an evolving therapeutic program. Definitive treatment included nonoperative management in 19 patients (group I, 11.6%), repair in 50 (group II, 30.5%) and splenectomy in 95 (group III, 57.9%). Mortality and morbidity were higher in group III (6.3% and 34.3% respectively) according to the Injury Severity Score (ISS 33.3 +/- 13). In group II one patient died from severe head injuries. Only one patient failed nonoperative management and required laparotomy with resultant splenectomy on hospital day 10. Observation without surgery has proved to be safe and effective in children (failure incidence less than 10%); success rates in adults would not parallel the experience reported in children because of differences in anatomy and mechanism of injury. Selective criteria, including hemodynamic stability after initial fluid challenge, normal level of consciousness, lack of peritoneal signs, transfusion requirements of less than 4 units of blood, CT demonstration of minor splenic lesion and exclusion of associated abdominal injuries requiring surgery, make eligible for nonoperative management 12 to 18% of adults with anticipated success in over 75%. Operative repair or partial splenectomy can be employed in many patients, both adults and children, with a 1% incidence of rebleeding necessitating reoperation.

[Artificial nutrition in the injured patient]. / La nutrizione artificiale nel paziente traumatizzato.

Current knowledge of physiopathology allows better understanding of the metabolic and immunological alterations that occur after trauma, thus allowing more adequate treatment. Nutritional support is recognized as an important therapeutic intervention to promote wound healing, reduce the risk of infection and improve survival. The patient with severe trauma needs nutritional support from the beginning of treatment. The early administration of enteral nutrition is an important factor in the reduction of gut bacterial translocation and thus of septic complications. In the early phase, the parenteral route is capable of providing a sufficient calorific and protein support, whilst awaiting the recovery of the enteral route.

[Indications for the surgical treatment of esophageal varices hemorrhage]. / Indicazioni al trattamento chirurgico dell'emorragia da varici esofagee.

The authors present their experience in the treatment of acute bleeding from oesophageal varices. From 1983 to 1991, 596 patients underwent sclerotherapy during diagnostic endoscopy; a stop to bleeding was achieved in 512 cases (86%). Twenty-seven surgical emergency decompressive shunts were performed, 14 total portal-systemic and 13 selective; operative mortality was 64% and 54% respectively. One patient was submitted to oesophageal-gastric devascularization. Hundred-sixty elective shunts were performed, 99 total portal-systemic and 61 selective; operative mortality was 8% and 11% respectively. Since 1990 3 patients received liver transplantation. The 5-year survival rate of patients submitted to selective shunts was 46%; the 5-year survival rate of nonalcoholic cirrhotics submitted to shunt SRD was 73%.

A study of 3H-PK 11,195 binding to "peripheral-type" benzodiazepine receptors on human lymphocytes. Evidence of decreased binding in hepatic encephalopathy.

In an attempt to assess the involvement of the "peripheral-type" benzodiazepine receptors (pBDZR) in hepatic encephalopathy (HE), we examined the binding of the isoquinoline carboxamide derivative 3H-PK 11,195 to lymphocyte membranes from a group of patients with liver cirrhosis with or without clinical signs of HE and normal controls. Lymphocyte 3H-PK 11,195 binding is saturable, with high affinity and presents the pharmacological specificity corresponding to pBDZR. A significant 40% decrease in the number of 3H-PK 11,195 binding sites, without a concomitant change in the apparent affinity, is observed in the group with HE as compared to the controls, but not in that with liver diseases without HE. The decrease in binding capacity correlates significantly with the clinical grading of HE, but not with age, sex, aetiology of cirrhosis or presence of surgical shunt. In contrast to the reduction of pBDZR, 3H-N-methylscopolamine binding to lymphocyte muscarinic receptors is not affected in HE. These findings are consistent with a role for pBDZR in HE and may stimulate studies of endogenous modulators and pharmacological agents for these receptors in the disease.

Imipenem-cilastatin in the treatment of hospital infections.

Imipenem was tested on 65 gram-negative bacterial strains consecutively isolated in patients affected by hospital infection and used as empiric therapy in 52 patients presenting a hospital infection suspected of gram-negative origin. More than 96% of the tested strains resulted sensitive to imipenem. This antibiotic showed a good clinical result in more than 80% of the cases when used as therapy. Therefore imipenem could be considered the drug of first choice in patients with a severe prognosis and a nosocomial infection suspected to be due to a gram-negative microorganism.

[Traumatic perforation of the duodenum. Diagnostic and therapeutic problems]. / Perforazioni traumatiche del duodeno. Problemi diagnostici e terapeutici.

The treatment of traumatic ruptures of the duodenum is one of the greatest controversies in surgery. The injury mechanisms, diagnostic criteria and factors underlying the prognosis are analysed and indications suggested for the various types of intervention. The problem relating to the operating technique are specified.

[Traumatic perforation of the duodenum: report of 5 cases]. / Perforazioni traumatiche del duodeno: a proposito di 5 casi.

The results of surgery in 5 cases of traumatic rupture of the duodenum are presented. The site of the laceration, the time between trauma and operation, associated lesions, diagnostic routine and type of operation are specified. The mortality encountered (40%) should be related to the seriousness of the lesions.

[A rare case of Merkel's tumor with intestinal metastases]. / Raro caso di tumore di Merkel con metastasi intestinali.

A rare case of intestinal metastasis of a neuroendocrine carcinoma of the skin (Merkel Cell Tumor) is reported. The primary tumor was excised from the left arm two years earlier and followed an aggressive course with lymph-nodes, tonsillar and intestinal spread. Histologically, the intestinal lesion was similar to the primary tumor with small, undifferentiated cells. Undifferentiated small cell carcinoma and lymphomas of the gastrointestinal tract are to be considered in the differential diagnosis. Merkel Cells Tumor usually affects head and neck (44%) and extremities (48%), and is a highly malignant neoplasia, with early recurrence and distant metastases. Wide surgical excision of the primary lesion is the treatment of choice, while controversial is the role of prophylactic regional lymphadenectomy. Adjuvant radio- and chemo-therapy is frequently associated.

Beneficial effect of enhanced macrophage function in the trauma patient.

Host immunosuppression after trauma contributes to septic morbidity. The macrophage is a key element in the host immune response. This study evaluated glucan, a macrophage stimulant, in a prospective, randomized, double-blind study of 38 trauma patients undergoing surgery. Glucan (21 patients), 50 mg/m2, or placebo (17 patients) was given intravenously daily for 7 days. Delayed hypersensitivity skin testing was performed on days 1 and 7 after trauma. Serum interleukin-1 (IL-1) and tumor necrosis factor (TNF) were assayed after trauma. While the total mortality rate was significantly less in the glucan group (0% versus 29%) (p less than 0.05), the mortality rate from sepsis was not statistically different (0% versus 17.6%). Glucan therapy significantly decreased septic morbidity (9.5% versus 49%; p less than 0.05). Serum IL-1 had a greater increase in glucan patients on day 3 after trauma (143.4 +/- 19.3% versus 78.6 +/- 11.7%; p less than 0.05), but there was no difference thereafter. Serum TNF did not vary between groups. Early increase in IL-1 correlated with subsequent skin test conversion to positive. Neither serum IL-1 nor TNF was a reliable indicator of future sepsis. Further clinical trials are indicated to evaluate biologic response modifiers that activate macrophages in the trauma patient.

[Segmental portal hypertension caused by splenic vein thrombosis]. / Ipertensione portale distrettuale da trombosi della vena splenica.

Seventeen cases of segmental portal hypertension due to splenic vein thrombosis are reported. This syndrome may be asymptomatic for a long time and then present suddenly in the form of a serious picture of high digestive haemorrhage due to rupture of gastric fundus varices as a result of hypertrophied submucous collateral drainage circulation. Useful for diagnosis are oesophagogastroduodenoscopy, which points to stomach varices, and splenoportography or splenic artery angiography with venous phase, which highlight pathognomonic dilatation and tortuosity of the gastroepiploic veins. Surgical exploration typically shows: presence of large epiploic vessels, splenomegaly, absence of changes in the liver and in the portal and mesenteric circulation. Curative treatment of choice is splenectomy.

Estrogen receptors in colorectal adenocarcinomas and in other large bowel diseases.

Seventy-two patients with tumor and ten with non-neoplastic colon disease were studied for the presence of estrogen receptors (ER) by three different methods. Only seven specimens (six primary adenocarcinomas and one recurrent cancer) had an ER concentration above 3 fm/mg of cytosolic protein, with no sex, age and tumor stage correlation. Our results suggest that the large bowel does not contain a cytosolic receptor for estradiol.

[Distal pancreatectomy with conservation of the spleen. Apropos of 3 consecutive cases]. / Pancreatectomia distale con conservazione della milza. A proposito di tre casi consecutivi.

Three distal pancreatectomies with preservation of the spleen are described. The indications were infiltration of the pancreatic tail by a gastric adenocarcinoma in the first patient; acute and chronic inflammation of the pancreas in the second and third. This type of operation takes very little longer than classic distal pancreatectomy with splenectomy, does not increase the incidence of postoperative complications and above all prevents the onset of sometimes lethal sepsis especially in young patients.

[Retrospective analysis of 1354 autopsies in cases of death caused by trauma]. / Analisi retrospettiva di 1354 autopsie in casi di decesso per trauma.

1,354 deaths due to traumatic causes arising in 1976-1985 among patients admitted to the Molinette Hospital, Turin were analysed. The causes were divided into 5 major groups with to monitoring the course of the pathologies concerned over time. The results confirm an increase in deaths from septic shock that reflects increased recourse to surgery and the application of resuscitation manoeuvres and equipment, but a decrease in death due to haemorrhagic shock. These two pathologies represent the major lines for future research aimed at improving the prognosis in traumatic lesions.

A modified technique of orthotopic transplant of the kidney in rabbits.

In this study kidneys were harvested from bred-for-research cats weighing 4 to 5 kg. General principles of donor bilateral nephrectomy en bloc with aorta, vena cava, renal vessels, and ureters were followed. After the harvest the grafts were placed in lactated Ringer slush. A cuff was prepared on the renal vein over a 10 French plastic tube. The aorta was divided and left in connection with the renal artery at each side. Twenty female checkered Flemish giant rabbits weighing 4.0-6.0 kg served as recipients. After premedication with 40 mg/kg of ketamine, anesthesia was maintained with repeated doses (every 10-15 min) of a 0.1-mL mixture of 5 parts ketamine and 1 part acepromazine diluted 50% in a normal saline. Arterial pressure, CVP, blood gases, and temperature were monitored. Through a limited midline incision a native left nephrectomy was performed. The venous anastomosis was performed with a cuff technique without clamping the vena cava (which causes severe hemodynamic instability); the anastomotic time was 2-3 min. The arterial anastomosis was performed with an end-to-side aorta-to-aorta anastomosis; the anastomotic time was 5 to 7 min. There were no episodes of venous or arterial thrombosis. The donor procedure took approximately 40 min, and the backtable preparation of the graft an additional 45 to 60 min. Preparation of the recipient for the anastomosis took 15 min and the anastomotic time (warm ischemia) was 13 +/- 5 min. In this model suitable for xenograft research the duration of the surgery in the recipient has been greatly reduced because of (1) the previous backtable preparation of the graft, and (2) the cuff technique used for venous anastomosis. The present anesthesia regimen and careful hemodynamic monitoring were also important in the success of this model.

[Colorectal tumors and hormonal receptors. A critical review of the literature]. / Tumori del colon retto e recettori ormonali. Una revisione critica della letteratura.

The importance of sexual hormones in the development of cancers of the large bowel is strongly supported experimentally and epidemiologically. The clinical search for the presence of hormonal receptors in the cells of patients operated for tumours of the colon and rectum has been common since 1975. This investigation ought to have opened up new diagnostic and therapeutic prospects for these tumours which have given such a little curative satisfaction. The present review considered reported data. Unfortunately the emerging picture is irregular in cases and results. It is personally considered that these studies are not for the moment likely to produce important novelties for the treatment of tumours of the large bowel tract.