Management of acute dyarrhea: current and future trends.

Acute diarrhea is a very common symptom, which may recognize different causes and is basically the expression of an altered homeostasis of the bowel, which overcame current classifications. When approaching patients with acute diarrhea, we should firstly check body temperature and vital parameters and secondly provide a general medical examination mainly focused on the abdomen, in order to exclude surgical causes of diarrhea, such as acute appendicitis, diverticulitis, intestinal occlusion and others. Another important aspect is the assessment of the level of hydration in order to provide the right amount of fluids. There is no current indication for the administration of loperamide in infectious diarrhea, but there is a strong rationale for new class of drugs, which may be defined as "mucous regenerators", such as gelatin tannate. Further studies are needed on this matter in order to test the effect of gelatin tannate in adult patients with acute diarrhea.

Incidence, clinical features and management of acute allergic reactions: the experience of a single, Italian Emergency Department.

OBJECTIVES: Few data on the incidence, aetiology, clinical features and management of patients with acute allergic reactions presenting to the Emergency Department are currently available. The aim of the study was to report the annual experience of a single Italian adult Emergency Department about anaphylaxis. PATIENTS AND METHODS: This is a retrospective, case-based study of adult patients attending the Emergency Department in Alessandria, Italy, during the years 2009-2010. We evaluated the medical records of patients satisfying diagnostic codes involving acute allergic reactions. Incidence, demographic data, causative agents, clinical features, management and outcome were reported. RESULTS: 390 patients with acute allergic reactions were evaluated during the year, corresponding to 0.7% of all Emergency Department visits. Causative agents were recognized in 55.1% of patients and more commonly included drugs (26.9%), insects (14.8%) and foods (8.9%). Cutaneous features were the single most common clinical presentation although two or more clinical features were frequently reported (17.7%). Anaphylaxis was diagnosed in 4.6% of patients. After therapy and a period of monitoring, 92.8% of patients were discharged directly from the Emergency Department, 7.0% were admitted and one patient died, corresponding to a fatality rate of 0.2%. CONCLUSIONS: Acute allergic reactions are common diseases referring to our Emergency Department. In the half of cases a precipitant agent was identified and cutaneous and/or mucosal changes were often the first feature. Most patients were definitely treated and discharged but about 7.0% of patients required hospitalisation. Observation Unit and Intermediate Care Unit were essential for clinical management of these patients.

Assessing water-electrolyte changes of hyperglycaemic hyperosmolar coma.

AIM: We reported new methods to accurately estimate salt and water deficits during hyperglycaemic hyperosmolar coma (HC), valid under restricted boundary conditions. The accuracy of these estimates is herein verified over the unrestricted spectrum of abnormalities, to correctly evaluate any patient with just one algorithm that recognizes the boundary conditions pertaining to each abnormality, choosing the appropriate calculations. METHODS: A large number of cases of HC was simulated on computer by subtracting an exhaustive combination of water, sodium and chloride losses coupled to a large variety of gains in glucose. Altered solute concentrations were generated. From these true plasma concentrations generated by the computer, the losses of water and electrolytes were back-calculated with our new computational algorithm, by knowing in addition only the normal total body water and extra-cellular volume. The accuracy of the method was tested by comparing true to calculated values over the entire range of deranged values. In 100 patients admitted to hospital for HC these same computations were performed, where calculated data were validated by comparing them to true data obtained by balance studies performed during correction of the abnormality. RESULTS: Both in simulated and real cases of HC true and calculated data for the changes in Na and volume were significantly correlated (R (2)=0.76 and 0.50, respectively, P<0.01), while their mean values were not significantly different by paired "t" tests (P>0.05 for all). CONCLUSION: Our new computation algorithm, applicable to the bed-side, useful in accurately assessing the average water-electrolyte deficits of HC, can be used to guide correct re-infusion strategies.

Diagnostic and prognostic significance of high sensitive troponin in chest pain.

BACKGROUND AND OBJECTIVES: Chest pain is one of the most frequent presenting complaints among patients arriving to the Emergency Department. In this population, the prevalence of acute coronary syndrome is about 25% instead that of acute myocardial infarction ranges from 5 to 15%. The diagnostic challenge for the emergency physician is the early rule-in or rule out of acute myocardial infarction within first few hours after chest pain presentation, particularly in those patients with normal or not significant electrocardiogram. EVIDENCE AND INFORMATION SOURCES: The current review is based on an analysis of most important clinical trials on this topic. STATE OF THE ART: The universal current guidelines established that the term "myocardial infarction" should be used when there is evidence of myocardial necrosis of ischemic origin, as documented by an increase of myocardial necrosis markers. Actually, cardiac troponins are considered the standard biomarkers for acute myocardial infarction diagnosis, because are more superior in sensitivity and specificity to the other available markers. PERSPECTIVES: More recently, high sensitive troponin assays have been developed, permitting the early measurement of very low concentrations. CONCLUSION: In this review, we analyzed the diagnostic and prognostic significance of these new high sensitive troponins in Emergency Department chest pain management.

Chest pain unit and decentralized testing of cardiac markers.

Chest pain is one of the most important reasons of Emergency Department arrivals (5% of total). As it is not possible to rule-in all patients claiming chest pain, it has been proposed to create new departments to monitor these patients during some hours, in order to exclude or confirm an acute coronary syndrome. These departments are named Chest Pain Units (CPUs). The Chest Pain Unit has been created since June 1998 in Alessandria Hospital "SS. Antonio e Biagio e C. Arrigo". Chest Pain Unit patients presenting in Emergency Department with an unclear defined chest pain are submitted to a continuous ECG monitoring of S-T trend for 24 h. Moreover, cardiac markers such as myoglobin, mass CK-MB and Troponin-I are tested at arrival and Troponin-I is tested again serially 3, 6, 9, 18 h after the first sampling. It is really important to be able to measure these markers of myocardial damage with robust and quick methods. A point-of-care analyzer is available in our chest pain unit and enables our department to obtain results in a very short time at low cost and with quality similar to that of clinical chemistry laboratories' instruments. This easy-to-use analyzer can be run by nurses without interfering in their normal activities. The presentation of our experience will be completed by describing all patients admitted in our Chest Pain Units from January to June 1998.

Emergency medicine: the Italian experience.

The Italian health care system is largely socialized, with priorities and policies established both nationally and regionally. Currently emergency medicine in Italy is practiced mainly by traditional specialists, such as internists and surgeons, and the scope of emergency medicine practice is not as broad as that seen in the United States. However, dedicated training programs in emergency medicine have recently been developed, and it appears that in the future, specially trained emergency physicians will be increasingly available. Emergency medicine is currently viewed as a sub-specialty of internal medicine, and it is unclear whether emergency medicine will be recognized as an independent specialty.

Low doses of alpha 2B interferon in the treatment of hairy cell leukemia: results of treatment and mean follow-up at 18 months in 13 patients.

We treated 13 Hairy Cell Leukemia patients with rIFN a 2b. In case of complete/partial response, the patients were submitted to maintenance treatment, while, in case of minimal/no response, a second induction cycle was administered, followed by a maintenance one. The patients were followed, on an outpatients basis, for 18 months at least, obtaining a 100% overall response rate; one patient had complete response, 7 had partial response, and 5 only minimal response. Six patients (46%) relapsed an average of 13 months after the end of the treatment. The utility of a maintenance therapy is discussed.

A cultural study on corneal explants and clinic assessment of the effectiveness of treating corneal ulcers induced by alkal test with topic aprotinin and fibronectin.

The A.A. studied the effectiveness of colliriums containing fibronectins aprotinin, and fibronectin associated with aprotinin compared to a placebo using 12 rabbits in which a deep corneal ulcer was induced by alkal. The results showed the same effectiveness of the three collyrium versus the placebo there was clinical recovery in all cases and restoration of corneal trasparency for 13 out of 15 treated eyes. Cellular cultures obtained from primary explants of treated corneal cells, compared with non treated groups, gave the same outcome of the clinical's ones.

[The diagnostic difficulties in a case of Behçet's disease]. / Difficoltà diagnostiche in un caso di malattia di Behçet.

Behçet's disease is a chronic, heterogeneous, multisystem disorder caused by a vasculitis involving arterial and venous vessels of all sized. In 1990, a new set of diagnostic criteria has been proposed as a guide to diagnosis of Behçet's disease, requiring the presence of oral ulcerations plus two of the following symptoms or signs: genital ulcerations, characteristics eye lesions, typical skin lesions, and a positive pathergy test. Nevertheless, both clinic and pathologic diagnosis of Behçet's disease remains sometimes very difficult. Diagnostic procedures and therapeutic implications in a case of Behçet's disease are reported and discussed.

Folinic acid does improve 5-fluorouracil activity in vivo. Results of a phase III study comparing 5-fluorouracil to 5-fluorouracil and folinic acid in advanced colon cancer patients.

We report the results of a phase III trial in which we compared 5-fluorouracil (5-FU) to 5-FU and folinic acid (FA) in 150 previously untreated metastatic colon cancer patients. Patients were randomized in the ratio of 1:2 to receive 5-FU (370 mg/m2, i.v., for 5 days) in arm A or equidose 5-FU plus FA (200 mg/m2, i.v., for 5 days) for arm B, each cycle being repeated every 4 weeks. Five of 49 evaluable arm A patients (10.2%) and 31 of 97 arm B (31.9%) achieved a complete or partial response (p < or = 0.01). Median survival time of arm A patients was 6 months (mean: 6.18), while it was 8 months (mean: 9.01) for arm B cases (p < or = 0.05). In conclusion, our data indicate that FA can enhance 5-FU activity and that this combination is an effective palliative treatment for metastatic colon cancer patients.

[Correlation between the grade of histological malignancy and nuclear positivity using the AgNOR technique in 6 cases of isolated bone NHL]. / Correlación entre el grado de malignidad histológica y la positividad nuclear con la técnica de AgNOR en 6 casos de LNH óseos monolocalizados.

Several reports have shown that the degree of positivity for the AgNOR count can be used to evaluate the aggressiveness of malignancies since it express an increased protein-synthesis activity. This technique was applied to six cases of stage I osseous non-Hodgkin's lymphoma--4 intermediate grade (2 diffuse small, non-cleaved cell and 2 diffuse large, non-cleaved cell lymphomas) and 2 high-grade immunoblastic lymphomas--in order to assess the histologic grade and the number of AgNOR-positive regions. It was noted that survival together with the trend to invade the surrounding soft tissues (i.e., the tumour aggressiveness) correlated with the AgNOR granule count. Both factors were also related with Ki-67 cell-proliferation antibody positivity. Such correlations were even higher than those found with the histologic features conventionally evaluated in the Working Formulation, so they seem to convey more reliable indices of neoplastic growth potential.

[The infusion of high-dose immunoglobulins in a case of idiopathic thrombocytopenic purpura]. / Infusione di immunoglobuline ad alte dosi in un caso di porpora trombocitopenica idiopatica.

Idiopathic thrombocytopenic purpura (ITP) is a disease characterized by the presence of circulating antiplatelet antibodies, which can cause platelet destruction, through the mediation of the reticuloendothelial system (RES). We report on a patient affected with ITP insensible to first line steroid therapy, who achieved a complete response following the administration of high-dose immunoglobulins (HDIgG, 400 mg/kg/die for 5 days), in association with decreasing doses of steroids. At the end of the treatment with immunoglobulins, the patient presented a normal platelet count and, up to date, 5 moths from the end of therapy, he is in good shape and presents normal platelets values.

Anti-HCV antibodies and hepatocellular carcinoma. Relationship in a medium-risk population.

By means of an accurate immunoenzymatic assay, the prevalence was studied of antibodies to hepatitis C virus (HCV) in three different populations: 74 patients affected with hepatocellular carcinoma (HCC) on preexisting cirrhosis, 82 patients with liver cirrhosis but with no apparent neoplasm, and 70 control subjects, hospitalized for various conditions, of internal medicine or geriatric interest. 70.2% of HCC patients exhibited anti-HBC antibodies, versus 47.5% of cirrhotic subjects with no tumor and 7.1% of controls. Such results suggest the possible role of HCV in the etiopathogenesis of HCC, and its possible synergy with other agents-e.g., hepatitis B virus, alcohol--in causing chronically injured hepatocytes to become neoplastic.

Rearrangements on chromosomes 7 and 14 with breakpoints at 7q35 and 14q11 in angioimmunoblastic lymphadenopathy and IBL-like T-cell lymphoma.

In this report we discuss some cases of AILD and IBL-like T-cell lymphomas and attempt to clarify the cytogenetic relationship between these complex disease states. During the period 1980-1987 we have studied No. 6 patients affected with AILD, three of which showed final evolution into Immunoblastic T-cell lymphoma. Cytogenetic studies, carried out on surgical lymphonodal material with histological diagnosis of AILD and leukemic cells obtained from the peripheral blood at the time of diagnosis, were analysed with IBAS 2000 for a computerized analysis, according to ISCA 1978 criteria. We have found similar translocations in three of our patients with AILD and terminal T-cell immunoblastic lymphoma, occurring between chromosomes 7 and 14 with breakpoints at 7q35 and 14q11. The arising of T-cell lymphoma in patients with AILD seems to be related to the presence of clonal cells with abnormal 7:14 translocation, which represent a very sensible marker of clonality desides of T-cell maturational lineage. In our opinion, the forms of AILD with these cytogenetic aberrations are pre-lymphomatous lesions. On the contrary, the lack of such rearrangements is indicative of non-neoplastic patterns.

Cytologic diagnosis and chromosome analysis: sensitivity, specificity, accuracy and predictive value in malignant and benign pleural effusions.

It is often difficult to determine the origin a pleural effusion even if it is very important for prognosis of a patient. We have studied No. 200 patients, affected with nontraumatic effusions, using cytogenetic technics and cytologic examination. Cytologic diagnosis of pleural effusions allows to detect correctly its malignant nature in a percentage of cases ranging, according to various Authors, between 45 and 80%. The main parameters we have considered in our study, in order to value chromosomal analysis as a useful test for malignity in pleural effusions, can be, at least, placed upon those obtained with cytologic diagnosis. Therefore, we think we can consider chromosomal analysis in neoplastic effusions as a useful completion in terms of diagnostic advantage of cytologic diagnosis.