Low-Energy Traumatic Obturator Hip Dislocation with Ipsilateral Femoral Shaft Fracture in a Patient with Omolateral Knee Arthroplasty.

Ipsilateral obturator hip dislocation and femoral shaft fracture are rare. We report such a case in an older woman after a low-energy injury. She had a knee prostheses in the same limb. The patient was treated by open manipulative reduction of the luxation without opening joint and open reduction and internal fixation of the femur with angular stability plate and screws. We could not find a similar case in the literature. An early diagnosis of the dislocation is crucial in order to obtain good results. Great awareness and radiologic examination are fundamental to achieve precocious diagnosis of both these rare combined injuries, as treatment in these cases is considered an emergency. The first step was an attempt to reduce the dislocation by closed means but it failed. Then we performed a short approach at the trochanteric region and used Lambotte forceps to manoeuvre the proximal femur without opening the joint achieving reduction. Thereafter the femoral shaft fracture underwent open reduction and internal fixation with an angular stable plate. After a 2-year follow-up the outcome was very good.

Hemiarthroplasty versus reverse shoulder arthroplasty: comparative study of functional and radiological outcomes in the treatment of acute proximal humerus fracture.

PURPOSE: To compare functional and radiographic results of reverse prosthesis versus hemiarthroplasty after complex displaced proximal humeral fractures in elderly patients when adequate ORIF cannot be achieved and prosthetic shoulder replacement is required. METHODS: From 2008 to 2012, 67 patients were treated with hemiarthroplasty or reverse arthroplasty. We evaluated 53 cases with an average follow-up of 27.5 months (range 12-64). Twenty-eight patients with an average age of 71.4 years were treated with a hemiarthroplasty and 25 patients with an average age of 77.3 years with a reverse prosthesis. All patients were assessed before and after surgery by Constant-ASES-DASH score, strength in abduction, ER1, ER2, and X-rays. RESULTS: In hemiarthroplasty group, we observed a mean Constant score of 42.3 pt, ASES score 51.3 pt, and DASH score 46.1, with an average strength of 1.3 lb in abduction and of 3.7 lb in ER1 and 1.8 lb in ER2. In reverse arthroplasty group, we measured a mean Constant of 56.2 pt, ASES 69.3 pt, and DASH score 40.4, with an average strength of 4.3 lb in abduction and of 3.3 lb in ER1 and 3.2 lb in ER2. Radiographically, it is interesting to observe that greater tuberosity healing rate was 37 % in hemiarthroplasty group compared to 84 % in reverse arthroplasty group. About complications, the highest rate was recorded in the hemiarthroplasty group. CONCLUSION: Reverse shoulder arthroplasty indication is steadily increasing in acute displaced proximal humeral fracture. Pain and articular movement results appear better than those with hemiarthroplasty. Our data are similar to the international literature.

Anastomosis biliodigestivas laparoscópicas: nuestra experiencia / Laparoscopic biliary anastomosis: our experience

Antecedentes: Actualmente, para la resolución de la obstrucción de la vía biliar ûbenigna o maligna-, se incluyen varias opciones terapéuticas; quirúrgicas, endoscópicas, percutáneas y combinadas.Objetivo: Analizar los resultados en el manejo laparoscópico de la patología biliar que requiera una derivación biliodigestiva.Lugar de aplicación: Centro médico de alta complejidad.Diseño: retrospectivo y descriptivo.Población: 102 pacientes con indicación quirúrgica de derivación biliodigestiva.Material y Método: Revisión de historias clínicas, bases de datos y videos de las anastomosis biliodigestivas, realizadas entre Octubre de 1993 y Agosto de 2005. 102 pacientes con obstrucción de la vía biliar, el 51.6% por patología benigna y 48.4% maligna. Tres procedimientos terapéuticos coledocoduodenoanastomosis (83 casos), hepaticoyeyunoanastomosis (9casos), y colecistoyeyunoanastomosis (1 caso). Fueron incluídos 7 pacientes(29%) con cirugías biliares previas.Resultados: 93 anastomosis biliodigestivas laparoscópicas, debiendo convertir 8.8% (9 casos), 2 por sangrado de arteria hepática propia, 5 por dificultad técnica, 1 por sospecha de cáncer de vesícula y 1 por sospecha de apertura duodenal, El tiempo operatorio promedio fue de 110 minutos (rango 45 a 300). Morbilidad del 21.5% y mortalidad a los 30 días del 5.3%. Estadía hospitalaria promedio 6 días (rango 2 a 36).Conclusión: Todos los indicadores (tiempo quirúrgico, internación, conversión, y tasa de complicaciones) mejoraron con la progresión de la experiencia en el equipo quirúrgico.

[Recurrent acute myocardial infarction in a patient with nocturnal paroxysmal hemoglobinuria]. / Infarto miocardico acuto recidivato in un paziente con emoglobinuria parossistica notturna.

Paroxysmal nocturnal hemoglobinuria is a form of acquired hemolytic anemia with a high incidence of thrombotic complications, generally in the venous district; arterial thrombosis is rare, and exceptional in the coronary tree. We describe the case of a man who had two episodes of myocardial infarction, both during a hemoglobinuric crisis; this patient was free from cardiovascular risk factors and angiography revealed that there was no coronary stenosis. The clinical course was favorable and the patient's response to thrombolytic and dicumarol therapy was satisfactory. To our knowledge, this is the second case of coronary involvement in paroxysmal nocturnal hemoglobinuria described in the literature.

[Limits of cardiac functional adaptation in "top level" resistance athletes]. / Limiti dell'adattamento funzionale cardiaco in atleti "top level" di resistenza.

BACKGROUND: Sports activity, particularly when performed at high level, provokes cardiovascular adjustments depending on the type of sport and on the level of the load. METHODS: We evaluated 15 athletes from the Italian national team during a non-agonistic period of cross country skiing, with non-invasive tests including exercise test, color Doppler echocardiography, Holter monitoring, physical examination and standard rest electrocardiogram. RESULTS: Physical examination, rest electrocardiogram, exercise testing and echocardiography were all within the range of the expected values for this type of subjects. Holter monitoring recorded during the periods of agonistic activity revealed significant hypokinetic arrhythmias such as severe bradycardia, pauses, I and II degree atrioventricular blocks, and complete atrioventricular block in 2 cases; these features were not observed on Holter monitoring recorded during the non-agonistic period. CONCLUSIONS: The perfect health status of subjects and their racing results may bring about physiological functional adjustments, but these observations suggest the need for a follow-up to evaluate possible pathologic outcomes.

[Possibility of evaluation of chest pain at the time of hospitalization]. / Possibilità di valutazione del dolore toracico al momento del ricovero in ospedale.

A series of 140 patients admitted to an Internal Medicine or a Cardiology Department for an acute chest pain is examined in order to evaluate the possibility of reaching a quick diagnosis, particularly for coronaric heart diseases, according with history, physical examination, electrocardiogram. In most of cases it was possible an immediate, correct evaluation of the patients, but in some cases a right diagnosis was achieved only after a period of observation and different investigations.

New trends in ganglioside chemistry.

New methods have been developed for the preparation of highly purified gangliosides, homogeneous in the saccharide, long chain base, and fatty acid moieties and gangliosides carrying different kinds of labelled probes. Gangliosides, homogeneous in the oligosaccharide portion, were prepared by preparative normal phase HPLC on a Lichrosorb-NH-2 column, using a gradient of acetonitrile-phosphate buffer, pH 5.6, as solvent system. Each class of ganglioside (from monosialo- to tetrasialogangliosides) was then submitted to reversed phase HPLC on a preparative RP-8 column, using acetonitrile-5 mM phosphate buffer, pH 7, as solvent system, to obtain gangliosides homogeneous in the long chain base moiety. Gangliosides containing C18 and C20 sphinganine were prepared by catalytic hydrogenation of the corresponding unsaturated gangliosides. GM1 with homogeneous acyl chain was prepared by alkaline hydrolysis in the presence of tetramethylammonium hydroxide (which forms a GM1 deacetylated at the level of sialic acid, and a GM1 deacetylated at the level of sialic acid and deacylated at the level ceramide), followed by re-N-acylation, carried out in the presence of dimethylaminopropyl, ethylcarbodiimide and natural fatty acids, or of mixed anhydride of ethylchloroformate and 14C-stearic acid, and re-N-acetylation performed with acetic anhydride or labelled acetic anhydride. The GM1 derivative, de-acetylated at the level of sialic acid, also produced by alkaline treatment of GM1, was submitted to re-N-acetylation with 14C-acetic anhydride to produce specifically 14C-labelled GM1. Re-N-acylation was carried out a) in the presence of dimethylaminopropyl, ethylcarbodiimide and natural fatty acids, b) with mixed anhydride of ethylchloroformate and 14C-stearic acid. After re-N-acylations, re-N-acetylation was performed with acetic anhydride or labelled acetic anhydride. Gangliosides tritium labelled in the oligosaccharide moiety were prepared by the galactose oxidase/3H NaBH4 method, and gangliosides tritium labelled at carbon-3 of unsaturated long chain bases by the dicyano-dichlorobenzoquinone (DDQ)/3H NaBH4 method.

[Bone metastasis as a sign of the existence of latent neoplasia]. / Metastasi ossee come segno di esordio di neoplasia latente.

A series of 65 patients in whom bone metastasis was the earliest sign of tumour is examined. The diagnostic aspects of the bone metastasis from laboratory examination to radiology, from scintigraphy to bone marrow biopsy are analysed as is the problem of locating the primary tumours that remain of unknown site. The prognosis is poor for all such patients. The possibility of altering the course of the disease and the quality of the patient's life depends on the site and type of the primary neoplasm concerned. Effective systemic palliative treatment is currently only available for plasmacytomas and lymphomas in general, for cancers of the prostate, breast, thyroid and gonads and for a certain number of small cell lung cancers. In the light of the present study and data from the literature it is concluded that the approach to early bone metastasis patients should concentrate on the search for tumours responsive to treatment using simple clinical and instrumental examination techniques.

Normal-phase high-performance liquid chromatographic separation of non-derivatized ganglioside mixtures.

A new analytical and semi-preparative high-performance liquid chromatographic method for the separation of a brain ganglioside mixture into individual components is described. Gangliosides were applied to a LiChrosorb-NH2 column and eluted with the solvent system acetonitrile-phosphate buffer at different volume ratios and ionic strengths. The elution profile was monitored by flow-through detection of UV absorbance at 215 nm. The separation of mono- to polysialogangliosides was performed in one step in a total elution time lower than 90 min and with high reproducibility.

High performance liquid chromatography preparation of the molecular species of GM1 and GD1a gangliosides with homogeneous long chain base composition.

A semi-preparative, analytical high performance liquid chromatographic (HPLC) procedure is described for the isolation of molecular species of GM1 and GD1a gangliosides containing a single long chain base, C18 or C20 sphingosine, C18 or C20 sphinganine, each in its natural erythro or unnatural threo form. The threo forms were obtained from 2,3-dichloro-5,6-dicyanobenzoquinone/NaBH4 -treated gangliosides. The ganglioside molecular species separated by HPLC were analyzed for carbohydrate, fatty acid, and long chain base composition. In particular, long chain bases were submitted to gas-liquid chromatographic-mass spectrometric analyses as their trimethylsilyl (TMS) or N-acetyl-TMS derivatives, and chain length, presence or absence of C4-C5 double bond, and C-3 steric configuration were ascertained. The final preparations of individual molecular species of GM1 and GD1a gangliosides were more than 99% homogeneous in their saccharide moiety, contained a single long chain base (homogeneity higher than 99%), and had a fatty acid composition primarily of stearic acid (92 to 97%). All the individual molecular species of GM1 and GD1a gangliosides were also prepared in radioactive form by selective tritiation at C-3 of the long chain base. Their specific radioactivity ranged from 1.3 to 1.45 Ci/mmol. The availability of these molecular species of gangliosides is expected to facilitate studies aimed at ascertaining the role played by the hydrophobic portion in the functional behavior of gangliosides.

Analytical and preparative high-performance liquid chromatography of gangliosides.

Analytical and preparative procedures are described for high-performance liquid chromatography (HPLC) fractionation of gangliosides without previous derivatization. These procedures make use of a reversed-phase Lichrosorb RB-8 or mu Bondapak RP-18 column, and of a mixture of acetonitrile and 5 mM phosphate buffer, at fixed or varying volume ratios, as solvent system. Peak elution from the column is monitored by flow through reading of absorbance at 195 nm. Under all the described conditions HPLC is capable of resolving all common gangliosides and of separating each of them into four molecular species containing C18-sphingosine, C18-sphinganine, C20-sphingosine, or C20-sphinganine. The analytical method has been successfully applied to fractionation of ganglioside mixtures from calf brain and to verification of homogeneity of single-ganglioside preparations. It is suitable for quantitative purposes, with high sensitivity (detection limit, 0.1 nmole) and precision (SD less than 10% of mean values in the concentration range 0.1-50 nmoles). The semipreparative method, which provides successive cycles of analysis in a fully automated way, enables the preparation in 2-4 days of 100-mg amounts of each molecular species starting from single gangliosides, like GM1 and GD1a. The preparative method makes use of acetonitrile-phosphate buffer-tetrahydrofuran as eluting solvent, and requires the addition to the starting ganglioside of the corresponding radioactive compound as tracer. This procedure, applied to GM1 ganglioside, is devised for processing up to 50 mg of ganglioside per analysis.

Perinatal development of styrene monooxygenase and epoxide hydrolase in rat liver microsomes and nuclei.

Nuclear enzymes were found to develop earlier than the corresponding microsomal activities. In fact styrene monooxygenase enzymatic activity at 18 days gestational age reached about half the values of adult animals, whereas fetal microsomal activity was only about 1/20 the adult level at the same age. In microsomes and nuclei the ontogenic development of epoxide hydrolase is slightly slower than styrene monooxygenase. This suggests that fetuses and newborn animals are exposed to higher risk of accumulation of styrene-7,8-oxide, a toxic and possibly teratogenic product of styrene monooxygenase.

Opiate tolerance and dependence is associated with a decreased activity of GTPase in rat striatal membranes.

In vitro addition of opiates to rat striatal membranes significantly stimulated a low Km GTPase activity. The opioid peptide (D-Ala2, Met5) enkephalinamide was ten folds more active than morphine to elicit the effect while the kappa agonist ethylketocyclazocine was almost inactive. Opiate stimulation was antagonized by naloxone, indicating that specific opiate receptors were involved. Moreover, the effect was stereospecific since levorphanol significantly increased the GTPase activity while its enantiomer dextrorphan was completely inactive, even at concentrations as high as 100 microM. On the other hand, opiates have been reported to inhibit striatal adenylate cyclase whose activity is dependent on GTP. Our data suggest therefore that stimulation of GTPase can be the mechanism by which opiates lower adenylate cyclase activity. This view is supported by the finding that in striatal membranes of rats made tolerant-dependent to morphine, GTPase activity was significantly decreased. Narcotic tolerance and dependence is in fact associated to hyperactivity of adenylate cyclase. It is concluded that GTPase could be the primary site on which opiates act to produce the acute or chronic effects on adenylate cyclase activity.

Nuclear metabolism. II. Further studies on epoxide hydrolase activity.

Apparent Km- and Vmax-values of nuclear styrene 7,8-oxide hydrolase were determined at different protein concentrations. In the protein concentrations range used no significant differences in the apparent Km-values were observed. The influence of the incubation with different modifiers (i.e. SKF-525A, metyrapone, 1,2-epoxy-3,3,3 trichloropropane, cyclohexene oxide) at two different concentrations on this enzyme activity was also determined. Cyclohexene oxide and 1,2-epoxy-3,3,3-trichloropropane, two well known inhibitors of the microsomal epoxide hydrolase(s) caused a marked inhibition, metyrapone had a strong activating effect whereas SKF-525A had no effect. In vivo pretreatment with phenobarbital significantly induced the nuclear epoxide hydrolase whereas beta-naphthoflavone caused a lower degree of induction. This pattern is quantitatively different but qualitatively very similar to the microsomal one. Moreover a toxifying to detoxifying enzymatic activity balance is attempted for the metabolization of the alkenic double bond of styrene, taking into account the ratio between the styrene monooxygenase (toxifying enzyme) and the styrene, 7,8-oxide hydrolase (detoxifying enzyme) after the above mentioned pretreatments, both in the microsomal and nuclear fractions.

Induction of nuclear styrene monooxygenase and epoxide hydrolase in rat liver.

The apparent Km and Vmax of styrene monooxygenase and styrene epoxide hydrolase were determined in intact nuclear preparations from male rat liver after in vivo treatment with phenobarbital and beta-naphthoflavone, which are known to induce microsomal cytochrome P-450 and cytochrome P-448 respectively. Treatment with phenobarbital does not alter the apparent Km, but greatly increases the Vmax of both nuclear styrene monooxygenase and styrene epoxide hydrolase. Almost the same pattern is observed for styrene monooxygenase after treatment with beta-naphthoflavone, whereas the same treatment slightly increases both the Vmax and Km value of styrene epoxide hydrolase.

Is nuclear styrene monooxygenase activity a microsomal artifact?

Microsomal contamination in nuclear preparations could represent one of the main sources of bias in the evaluation of the real metabolic capacity of the nuclear envelope. In this paper we present a quantitative study of the level of nuclear styrene monooxygenase enzymatic activity after artificially increasing the native microsomes to nuclei ratio. In one experimental conditions no significant elevation of the nuclear monooxygenase was observed. These data indicate that, if any microsomal contamination is present, it cannot account for more than 30% of the total enzymatic activity found in nuclear preparations.

Nuclear metabolism. I. Determination of styrene monooxygenase activity in rat liver nuclei.

Styrene monooxygenase activity was measured in intact nuclear preparations from rat liver by means of a gas chromatographic method. Styrene epoxide formation is NADPH-dependent although it is enhanced when NADH is added with NADPH. This activity is inhibited by microsomal monooxygenase inhibitors SKF 525A and metyrapone and by microsomal epoxide hydrase inhibitors 1,2-epoxy-3,3,3-trichloropropene oxide and cyclohexene oxide. The percentage of inhibition is quantitatively different for the four compounds. Known inducers of liver microsomal monooxygenase show different patterns of induction on nuclear preparations. Phenobarbital induces nuclear monooxygenase activity more than the respective microsomal activity, whereas the contrary holds true for beta-naphthoflavone.