Complications of unintentional dural puncture during labour epidural analgesia: a 10-year retrospective observational study.

INTRODUCTION: Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS: This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS: Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION: Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.

Management of posterior reversible syndrome in preeclamptic women.

Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome associated with a number of conditions including preeclampsia. It is characterized by seizures, alteration of consciousness, visual disturbances, and symmetric white matter abnormalities, typically in the posterior parietooccipital regions of the cerebral hemispheres, at computed tomography (CT) and magnetic resonance (MRI). We report three new cases of PRES in preeclamptic patients and describe the management of these patients. We present a brief review of other cases in the literature, with particular attention to the anesthetic management.

Life span history of non-fatal suicidal behaviours in a large sample of general practitioners' patients: data from Rovigo, Northern Italy.

A survey about history of non-fatal suicidal behaviour was performed on 1,171 subjects in the waiting room of general practitioners' practices in the territory of Rovigo (Northern Italy). The mean age of interviewed subjects was 52.9 ± 17.0, with a majority of female individuals. Two and two percent admitted previous experience of non-suicidal self-injury, 4.7 % admitted having had serious suicidal thoughts/plans, and 1.8 % reported at least one suicide attempt. Compared to the rest of the sample, people with history of suicidal behaviours resulted to be of younger age (p < .05), whilst their level of well-being was poorer (p < .001). When compared to the results of the Italian arm of the European Study of the Epidemiology of Mental Disorders, carried out on general population samples, the present study produces higher rates of suicidality, despite the much higher mean age of the interviewed subjects compared to the general population.

The clinician's role in the diagnosis of breast disease.

Until 20 or 30 years ago, the diagnosis and treatment of breast disease was managed exclusively by the surgeon. This situation has changed to some extent as a result of recent technological advances, and clinicians' contributions to the diagnostic work-up and/or treatment of these cases can begin at any time. If they are the first physician to see the patient after the examination and formulation of a diagnostic hypothesis, they will almost always have to order a panel of imaging/instrumental examinations that is appropriate for the type of lesion suspected, the patient's age, and other factors; if they intervene at the end of the diagnostic work-up, it will be their job to arrive at a conclusion based on all of the data collected. The clinical examination includes various steps - history taking and inspection and palpation of the breasts - each of which is essential and requires the use of appropriate methods and techniques. The diagnostic capacity of the examination will depend largely on the consistency of the breasts, but it is influenced even more strongly by the doctor-patient relationship. Physicians must know their patient well, listen to and understand what she is saying, explain their own findings and verify that the explanations have been understood, and they must be convincing. Clinicians must also be able to assess the results of imaging studies (rather than relying solely on the radiologist's report), and this requires interaction with other specialists. The days are over when a clinician or radiologist or sonographer worked alone, certain that his/her examination method was sufficient in itself: today, teamwork is essential. But this also means that each member of the team must be extremely competent in his/her own sector and be aware of the other team members' limitations and expectations. The clinical examination remains central to the process since it is the basis for selecting appropriate treatment. SOMMARIO: Da quando si conosce la patologia mammaria la diagnosi e la terapia di tale patologia sono state a totale appannaggio del chirurgo, situazione che è proseguita fino a qualche decennio fa. Il recente progresso tecnologico ha modificato, in parte, questa situazione e il clinico può entrare nel percorso diagnostico o terapeutico in qualsiasi momento. Se è il primo coinvolto, dopo l'esame e dopo un'ipotesi diagnostica, dovrà, quasi sempre, orientarsi verso indagini strumentali in relazione al sospetto, all'età della paziente ecc., se è l'ultimo anello deve arrivare a una conclusione mettendo insieme tutte le informazioni. L'esame clinico è composto di varie fasi: anamnesi, ispezione, palpazione, ognuna essenziale. Ogni singola fase va affrontata con metodo e tecnica appropriata. La capacità diagnostica dell'esame clinico è influenzata dalla costituzione della mammella, ma ancor di più è condizionata da uno stretto rapporto tra paziente e medico che deve conoscere molto la paziente che gli sta davanti e che non solo deve "visitare", ma capire, spiegare, accertarsi che si abbia capito, convincere. È inoltre indispensabile che il clinico sia in grado di esaminare le indagini strumentali e non limitarsi a leggere i referti, quindi interagire con gli altri specialisti. L'epoca del clinico o del radiologo o dell'ecografista che lavora da solo credendo che il proprio esame sia sufficiente o sganciato da altri contesti è finita da tempo, tutti hanno bisogno di tutti. È però vero che ciascuno deve essere estremamente competente nel suo settore e deve conoscere i limiti e le aspettative di chi collabora in altre specialità, come rimane valida la regola che la clinica resta comunque il momento centrale, non fosse altro perché poi deve affrontare la terapia.

Parasuicide in Rovigo (North of Italy) during the period 2000-2005.

INTRODUCTION: The greatest predictor of eventual suicide is parasuicide, which includes both suicide attempts and deliberate self-harm with no intent to die. The rate of parasuicide is reckoned to be at least ten times the suicide rate. METHODS: An observational study of the population of Rovigo Public Health Unit has been carried out to investigate parasuicide cases that presented to a general hospital in the six-year period from 1st January 2000 to 31st December 2005. RESULTS: An incidence of 36.39 parasuicides/100,000/year referred to a general hospital has been estimated, with a majority of female and young subjects. The principal method used was drug poisoning (59.1%); the more frequent diagnoses are mood and personality disorders. Method of attempt distribution is different for age and gender (p < 0.001), while diagnosis distribution is different only for age (p < 0.001). Comparison between method of attempt and diagnosis distribution indicates a significant difference (p < 0.01). In 36.4% of cases there was no contact with the Mental Health Service after parasuicide. DISCUSSION: The present study confirms that parasuicide is more common in females and younger people and that the more probable diagnoses are mood and personality disorders. The finding of a high number of subjects without any previous contact with the Mental Health Service and, especially, after parasuicide, claims attention on primary and secondary prevention of suicidal behaviour. CONCLUSIONS: The results appear to be in line with those from literature on parasuicide in Western populations.

[Territorial emergency: physician or nurse?]. / Emergenza territoriale: medico o infermiere?

This study was conceived to assess a pattern of Italian prehospital critical care team, especially referring to the advanced life support (ALS) rescue team. Function and management of ALS rescue team and its relationship with other members of the emergency medical system (intra hospital physician, basic life support team, general practitioner) are analysed; stress is laidon the knowledge, the background and the complexity of the emergency procedures. The benefit of 2 major prehospital options of the ALS team, composed by 1 physician and 1 nurse staffing or by 2 trained nurse staffing, is discussed; the importance of educational programs for ambulance teams, a comparison of cost-effectiveness and the number of emergency teams availability is underlined. The authors, finally emphasize the advantages of a territorial coverage with an integrated system of ambulances staffed with specially trained rescuers or technicians, ambulances with rescuers and nurses, and ALS teams staffed with emergency physician and 1 nurse (integrated or not with ambulances with 2 trained nurses), being perfectly capable to face up any background in pre-hospital emergency medicine setting.

[Non-palpable lesions of the breast. Preoperative location techniques with vegetable charcoal]. / Lesioni non palpabili della mammella. Tecnica di localizzazione preoperatoria con carbone vegetale.

PURPOSE: Mammography and US increase the rate of early breast cancer diagnoses. The difficult intraoperative location of nonpalpable lesions has led to the development of various techniques suitable to this purpose. We investigated the effectiveness of free-hand vegetable charcoal lesion marking during both mammography and US and compared this technique with other more commonly used methods. MATERIAL AND METHODS: Our series consisted of 485 consecutive charcoal markings of nonpalpable breast lesions submitted to histologic examination. Marking was carried out free-hand under mammographic guidance in 392 cases and under US guidance in 93 cases. The technique, presented in the paper with schematic drawings, was successful because the surgeon correctly identified the charcoal tracing in all 485 cases. There were no complications, neither during charcoal introduction nor during surgery. RESULTS: The comparison with other marking techniques showed the following advantages of our method: 1) it is rapid and easy to perform; 2) patient discomfort is minimal and no local anesthesia is needed; 3) it is accurate and there are no risks of charcoal displacement or spread; 4) the tracing charcoal is easy to find; 5) the most appropriate surgical route can be followed, with consequently better cosmetic results in the patients not undergoing quadrantectomy; 6) surgery can be performed on an outpatient basis under local anesthesia; 7) a minimal amount of glandular tissue is removed; 8) there are absolutely no side-effects; 9) cost is low; 10) surgery can be planned over time; 11) there is no risk of cutting the wire with an electrotome; 12) no particular equipment or instruments are needed; 13) there are no problems in very superficial lesions. CONCLUSIONS: To conclude, on account of our results and of so many advantages, we believe that free-hand vegetable charcoal marking during mammography and US is now the best possible solution to the problem of surgical identification of nonpalpable breast lesions.

[The phantom breast syndrome]. / Síndrome del seno fantasma.

BACKGROUND: The phantom breast syndrome (PBS) is a complication of mastectomy which consists of a sensation of breast persistence after mastectomy. MATERIALS, PATIENTS AND METHODS: The incidence, clinical course and location of PBS in 97 operated women were studied for a 15-year period. All women were interviewed in postoperative follow-up controls after mastectomy. RESULTS: The incidence of PBS was 29 patients out of the 97 total. The syndrome was present for more than 48 months in eleven of these patients. In most cases the location of "phantom sensations" was the nipple (15 cases) and the entire breast in five patients. In only three patients was phantom breast pain (PBP) reported whereas some discomfort was reported by the other patients. CONCLUSIONS: The incidence of PBS in our series was similar to that reported by other authors, but PBP was less common. Neither postoperative sequelae nor the antitumoral specific therapy seemed to have influence on the emergence of PBS.

[Color Doppler ultrasonography in the diagnosis of solid breast lesions]. / L'eco-color-Doppler nella diagnosi delle lesioni solide mammarie.

The color-Doppler signals in 50 patients with breast lumps were assessed subjectively. Number and location of vessels within the masses were recorded and compared with histologic diagnosis and lesion size. All the malignancies were vascularized but only 16/37 of the benign ones showed vessels. All malignancies but one displayed > or = 2 vessels, which on the other hand occurred in only 4/16 vascularized benignancies. There was a relation between size of the lesion and number of the observed vessels, and color-Doppler proved more reliable in the differential diagnosis of breast masses when lesions less than 2 cm were considered.

Plasma steroid transport in subjects with tumors of hormonal target organs: a review.

Tumors derived from a hormonal target organ are assumed to be stimulated by the same hormone that stimulates the normal target tissue. In spite of attempts to acquire direct indications of a correlation between hormones and cancer, none have been definitive because studies of total and free hormone levels have given contradictory results. For this reason, attention has shifted to the study of plasma binding and transport of hormones, that is, of the proteins responsible for modulation of the hormone effect and thus of hormone bioavailability. The data reviewed indicate that in-depth study of the transport and binding system of sex steroids would give new information about the endocrine characteristics of cancer patients.

Breast carcinoma and skeletal formation.

We have studied skeletal structure in 67 women with breast carcinoma and in 59 women without breast carcinoma, looking for differences of development that might be correlated with hormonal, metabolic or genetic abnormalities. We have measured the lengths of the limbs and of their segments (upper arm, forearm, thigh, leg), of the bisacromial and bitrochanteric transverse diameters and total height and height divided into the parts from vertex to pubis and from pubis to the ground. The analysis showed statistically significant coefficients of regression with presence of mammary carcinoma for height (0.0904262, S.D. 0.0461), length of thigh (0.12989, S.D. 0.03981) and length of lower leg (-0.68475, S.D. 0.1390). This skeletal type might be the expression of a genetic condition that is associated with the existence of mechanisms that permit development of mammary cancer.

Breast carcinoma and plasma 17-beta-estradiol binding.

The data relating to plasma steroid binding and transport (usually measured with dehydrotestosterone) are controversial. The plasma E2 binding of 79 breast carcinoma patients, 19 premenopausal and 60 postmenopausal, were compared to 46 controls, 21 premenopausal and 25 postmenopausal. In this study the authors removed the endogenous steroids with charcoal, incubated the plasma with 17-beta-E2 in non-saturation conditions, and used ammonium sulfate to precipitate the complex. The authors chose 17-beta-E2 as ligand because the plasma steroid binding system has not been shown to be homogeneous and because this binding function may vary independently for the different steroids. In these patients, the E2 binding was significantly (P less than 0.01) increased (85 +/- 11 pg/ml and 73 +/- 13 pg/ml in premenopausal and postmenopausal) compared to the normal controls (59 +/- 7 pg/ml and 58 +/- 5 pg/ml in premenopausal and postmenopausal women. It is still unclear whether this is a primary increase of the binding capacity or a reaction of the host for sequestering excess circulating E2. However, the small percentage of false-positives and false-negatives suggests that E2 binding could be used as a tumor marker in breast carcinoma.

Current status of hormone receptor measurements in cancer patients.

Despite increasingly sophisticated techniques, improvements in the correlation between laboratory findings and tumor response to endocrine therapy have not been obtained by hormone receptor studies. A possible explanation is that present knowledge of the mechanisms of the endocrine stimulus is incomplete. Some aspects of the present model, (elevated conjugated steroid levels, multiplicity of the plasma proteins capable of binding hormones, pulsatility of the plasma protein bond and of the receptor system for steroids), are still unclear and thus are not used in diagnosis. By evaluating these factors it will probably be possible to correlate better laboratory data with clinical findings.

Development of laboratory hormone tests and their application in the monitoring of cancer patients.

In the endocrinologic study of dysplastic and neoplastic pathologies of hormone-dependent organs we propose the determination not only of the plasma levels of the "total" hormone but also those of the free hormone as well as the plasma/hormone binding capacity and the kinetics of the plasma/steroid interaction.

[Barium peritonitis: experimental study using barium sulfate and radioactive barium]. / Le peritoniti da bario: studio sperimentale con solfato di bario e con bario radioattivo.

Barium peritonites are known to be a serious complication of barium enema examinations, being accompanied by a high mortality rate. The authors made their study injecting barium and radioactive 133Ba in the peritoneum of 68 rats without causing damages to the colon, in order to verify the toxicity of barium if injected in the peritoneum, and to evaluate the various extraperitoneal locations. Moreover, they compared the alterations caused by this agent with those consequent to a similar agent, such as talcum. The results show that barium is not toxic on its own: it gives in fact origin to granulomas similar to those caused by talcum; a particular tropism for the lymphatic tissues is present as well.

Isoelectric focusing studies on human pancreatic secretion.

Pure bile, pancreatic and duodenal human juices have been analyzed by isoelectric focusing, either at rest or upon stimulation with caerulein. In rats, stimulation has also been performed by secretin. Twenty bands have been resolved and quantified in the pancreatic secretion. By developing zymograms, a number of isozymes have been identified: 6 iso-amylases [pl's 7.2, 7.1 and 6.6 (major) and pl's 7.4, 6.7 and 5.8 (minor)], 3 lipases [pl's 7.0 and 6.8 (major) and 6.4 (minor)], two major alkaline proteases (pl's 9.8 and 8.4) and one major acidic protease (pl 4.3) and one band of RNAase activity (pl 8.6). The stimulation kinetics follow a mechanism according to Palade, indicating uniform response to secretogogues, parallel intracellular transport and parallel discharge of pancreatic exocrine proteins.

[Use of a new selective stain for demonstrating the vagal fibers in gastric surgery. Experimental study]. / L'impiego di un nuovo colorante selettivo per evidenziare le fibre vagali nella chirurgia gastrica. Studio sperimentale.

Scalar concentrations (0.4%-0.2%-0.1%-0.05%) of methylene blue in a 7.02% ascorbic acid solution have been used in animals and humans for visualizing vagal branches at gastric level. These solutions constitute a simplified variation of Lee's test and the most effective for determining vagal fibres proved to be the 0.1% concentration.