Very early nutrition supplementation in burned patients.

We studied some metabolic and hormonal effects of a very early nutrition supplementation in burned patients. The patients were divided into two groups of 10 patients each. Supplementation in the first group, the very early nutritionally supplemented (VENS) group, was started immediately after admission, ie, after 4.4 +/- 0.5 h (mean +/- SEM) from the injury; it was started after 57.7 +/- 2.6 h from the injury in the second group (control group). Hormonal and metabolic indices were recorded every 4 d up to 28 d. In the VENS group, the nitrogen balance became positive in 8.8 +/- 4.1 d whereas it took 24.1 +/- 6.9 d in the control group (p less than 0.05). Urinary catecholamine excretion and plasma glucagon concentrations were lower during the first 2 wk of observation in the VENS group compared with the control group. Insulin concentrations were significantly higher on the fourth and eighth days in VENS patients and plasma cortisol concentrations were similar in both groups.

T-Cell immune activation in children with vertically transmitted hepatitis C virus infection.

Little is known concerning the clinical features, the histological outcome, and the effects on the maturation of immune system of children with vertically-transmitted hepatitis C virus (HCV) infection. Specifically, no data are available on the peripheral distribution of T-cell subsets. The frequency of naive and memory cells, activated T cells, and cytokine-producing T cells was analyzed in nine HCV-infected children born to HCV-positive mothers. In HCV-infected children, the distribution of naive and memory cells was not significantly altered in the CD4 subset whereas within the CD8 subset, an increase of memory and a decrease of naive cells was observed. The frequency of HLA-DR-positive and Fas-positive T cells was increased in HCV-infected children in both CD4 and CD8 subsets. The distribution of Fas-expressing T cells was directly related to that of HLA-DR cells and inversely related to the frequency of naive T cells. In regard with cytokine production we found increased levels of both CD4 and CD8 interferon-gamma (IFN-gamma)-producing cells whereas no difference in the percentage of interleukin-2 (IL-2)-producing T cells was observed. No meaningful correlation was observed between individual T cell subsets and ALT levels or HCV viral load. In conclusion, our results indicate an increased T-cell activation and a shift to a T(H)1 pattern of cytokine production in children with vertically transmitted HCV infection. The cause of this kind of immune response could reside in the persistent antigenic stimulation by chronic HCV infection.

Aminotransferase changes in burned patients.

The time course of serum transaminases (alanine aminotransferase and aspartate aminotransferase) has been followed in 30 selected consecutive patients presenting burn sizes ranging from 10% to 95% of the total body surface (mean 43.13) and a survival index from 0.99 to 0.00 (mean 0.59). The results show that in all the patients both transaminases change in parallel, increasing in 18 patients (60%). In nearly all patients both enzymes increase during the second week after injury and aspartate aminotransferase increases later than alanine aminotransferase. The higher transaminase levels are noted in moderately ill patients. No clear correlation between the overall increase of transaminases and the extent of burned surface area has been found. We conclude that functional liver alterations mostly contribute to the increase of serum transaminases in burns.

Heart rate and metabolic response to burn injury in humans.

BACKGROUND: Although frequently done, estimating the energy requirements of individual burn patients without measuring their resting metabolic rate is a less than satisfactory method of evaluation. METHODS: We tested whether heart rate, which relates to the energy expenditure during physical activity, is also associated with postburn hypermetabolism (calculated as percentage increase of resting metabolic rate above the predicted normal fasting resting metabolic rate). Twenty-three patients [12 men and 11 women, aged 38 +/- 13 years (mean +/- SD); weight, 71.6 +/- 14.8 kg; body mass index, 25.4 +/- 3.6; total burn surface area, 35.3 +/- 17.8% (percentage of body surface)] were studied weekly for 3 weeks after an overnight fast. RESULTS: Measured resting metabolic rates and heart rates were 2016 +/- 497 kcal/d, 101 +/- 13 bpm (n = 19); 2231 +/- 485 kcal/d, 107 +/- 13 bpm (n = 18); and 1903 +/- 598 kcal/d, 99 +/- 14 bpm (n = 11) for weeks 1, 2, and 3, respectively. Postburn hypermetabolism was +36% +/- 19%, +55% +/- 27%, and +36% +/- 35% in the first, second, and third week, respectively. In each week postburn hypermetabolism correlated with heart rate (r = 0.65, p = .003; r = 0.69, p = .001; and r = 0.80, p = .002, respectively). Only in the second week did postburn hypermetabolism correlate with total burn surface area (r = 0.52, p = .02); there was no correlation with body temperature. In a multiple regression analysis, predicted resting metabolic rate, heart rate, and total burn surface area together explained 77% of all of the variance observed in the 48 fasting resting metabolic rates that were measured in the study (r2 = 0.77, p < .0001), and each of these variables also had a significant partial correlation with fasting resting metabolic rates (r2 = 0.45, p < .0001; r2 = 0.29, p < .0001; and r2 = 0.03, p < .03, respectively). CONCLUSIONS: In burn patients, variability in heart rate is associated with a significant part of postburn hypermetabolism variability. Therefore, heart rate may be considered a useful variable to be used for the evaluation of the energy requirements of severely burned patients.

[Peripheral arterial disease in a population of type 2 diabetic patients: its correlation with diabetic microangiopathy and laboratory parameters]. / L'arteriopatia obliterante periferica in una popolazione di diabetici di tipo 2: correlazione con la microangiopatia diabetica e parametri laboratoristici.

BACKGROUND: The aim of this study was to evaluate the incidence of peripheral arterial disease (PAD) in a population of type 2 diabetic patients (NIDDM) and its possible correlation with diabetic nephropathy (DN), diabetic retinopathy (DR) and also with some biochemical parameters of glomerular and tubular renal function. METHODS: The study included a total of 150 NIDDM patients, randomly selected, who have been followed-up at the Metabolic Center of our Division. All patients underwent assessment of the ankle/brachial pressure index (ABI) and Doppler ultrasound of the lower extremities. They were then divided into 2 groups: Group 0 without PAD and Group 1 with PAD. They also underwent a echo color-Doppler study of the renal interlobar arteries in order to evaluate the resistive index (RI), while the retinal vessels were assessed by biomicroscopy and fluorangiography. RESULTS: The incidence of PAD in this study was 30.6%, occurring on average 14 years from the onset of diabetes, and affecting particularly patients with nephropathy. The presence of both albuminuria and retinopathy in the same patient increases by 8.9 times the risk of cardiovascular disease. CONCLUSIONS: The RI, measured at the level of the intrarenal arteries, is of great interest as a marker not only of renal vascular damage in NIDDM patients, but also of a generalized vascular involvement.

[Renal Doppler color ultrasonography in the study of diabetic nephropathy]. / Eco-color Doppler renale nello studio della nefropatia diabetica.

The traditional ultrasound approach in the field of diabetic nephropathy provides only partial clinical information; moreover, the data obtained are merely descriptive, in particular regarding the involvement of the intrarenal arteries, which is however the area mainly involved. The aim of our study was to assess the data provided by Doppler ultrasound and in particular the role of the Resistive Index (RI) in a population of 160 type 2 diabetics (NIDDM), divided into 4 groups according to the severity of diabetic nephropathy. The assessment of RI has enabled us to detect among patients in the early stages of diabetic nephropathy (64 patients of group 1), a subgroup of 28 subjects (43.8%) showing RI values equal to or above the threshold value of 0.7. The determination of renal size and of renal parenchyma echogenicity proved to be of little value. The most relevant clinical information is provided by the RI, a parameter that will allow the early detection of patients affected by NIDDM, who show renal vascular involvement without however any other alterations of the traditional ultrasound parameters.

[Prevalence of Chlamydia pneumoniae in respiratory infections in children: an ambulatory diagnostic problem]. / Prevalenza di Chlamydia pneumoniae nelle infezioni respiratorie del bambino: un problema diagnostico ambulatoriale.

It has been recently suggested that Chlamydia Pneumoniae infection is a common finding among children with acute respiratory diseases. Chlamydia cell culture is difficult and time-consuming to perform. Polymerase chain reaction (PCR) is a more rapid but also more expensive technique used to identify Chlamydia in pharyngeal swab, but it can be performed only in few specialized laboratories. We tested a rapid enzyme immuno-assay to detect Chlamydia in 20 children with respiratory infections (mean age 3.29 years; male:female ratio = 12:8) and in 21 healthy children (mean age 4.70 years male:female ratio = 15:6). Prevalence of Chlamydia isolation from pharyngeal swab was very high in both patients and healthy children without a significative difference in the two considered groups (45% vs 42%, p = 0.8). Specific Chlamydia IgG antibodies were undetectable in all patients and healthy children. Nine out of 20 patients affected by acute respiratory disease were Chlamydia-positive and 11 out 20 were Chlamydia-negative: these two groups didn't differ in regard to clinical and laboratory features, whereas duration of symptoms was significantly longer in Chlamydia-positive patients (9.3 vs 5.5 days, p = 0.014). Our study suggests a high prevalence of Chlamydia pharyngeal swab positivity in both healthy and sick children. Diagnosis of Chlamydia infection was not feasible on the basis of the considered clinical and laboratory findings.

Sonographic characteristics of carotid artery plaques: Implications for follow-up planning?

UNLABELLED: The aim of our study was to analyze the ultrasound characteristics of carotid plaques in an outpatient population and to determine their implications for planning the ultrasound follow-up. MATERIALS AND METHODS: We studied 747 consecutive outpatients (397 [53%] of whom were women) who underwent color Doppler sonography of the carotid arteries. Most of the patients presented multiple cardiovascular risk factors or were being followed-up for carotid artery stenosis. RESULTS: Stenosis ranging from 1% to 69% was observed at the level of the right internal carotid arteries (ICA) in 419 (56.1%) of the 747 patients and in the left ICA in 408 of 747 (54.5%). One hundred twenty-four (29.5%) of the 419 RICA plaques and 77 (18.8%) of the 408 LICA plaques were classified as type 1 or type 2 according to the modified Gray-Weale classification. CONCLUSIONS: Type 1 and type 2 plaques, which are referred to as "vulnerable plaques," were found in 160 (21.4%) of the 747 patients we examined. These patients should be subjected to closer ultrasound follow-up, even if they have only moderate carotid artery stenosis.

Role of ultrasound and color Doppler imaging in the detection of carotid paragangliomas.

INTRODUCTION: Carotid body paragangliomas (PGLs) are highly vascularized lesions that arise from the paraganglia located at the carotid bifurcation. PURPOSE: To evaluate the usefulness of gray-scale ultrasound (US) and color Doppler ultrasound (CDUS) in the detection and follow-up of carotid PGLs of the neck. MATERIALS AND METHODS: The authors retrospectively reviewed US and CDUS examinations of the neck performed in 40 patients with PGL syndrome type 1 and single or bilateral neck PGLs confirmed by CT or MRI; the patients had a total of 60 PGLs of the neck. US and CDUS outcome was compared to the outcome of second-line imaging techniques such as magnetic resonance imaging (MRI) or computed tomography (CT). The following findings were considered: presence/absence of focal lesions at US imaging and difference in maximum diameter of the lesion measured at US and MRI/CT. Results were compared using the Student's t-test. RESULTS: Of the 60 PGLs of the neck only 5 (8.3%) were not visualized at US or CDUS examination. The difference in maximum diameter of these lesions measured at CT/MRI and US/CDUS ranged between -5 mm and +16 mm (mean difference 2.2 ± 6.0). This difference was statistically significant (p = 0.008). CONCLUSIONS: US and CDUS are useful methods for identifying carotid PGLs also measuring less than 10 mm in diameter. However, diagnostic accuracy of US and CDUS is reduced in the measurement of the exact dimensions of the lesions.

Challenge in differential diagnosis of a liver mass histologically defined as a metastatic lesion from an occult primary intestinal tumour. The importance of clinical findings and the limitations of histology and molecular profiles. A case report.

Differential diagnosis of liver lesion in the absence of proven primary tumor is still a challenge. We experienced a case of an asymptomatic 14 cm lesion of right hemiliver in a 67 year-old man submitted to right hepatectomy in December 2010. One year before the patient underwent to endoscopic removal of a tubular adenoma of the right colon. Preoperative diagnosis was supported by ultrasound, CT scan, PET and liver biopsy. The patient received 6 cycles of preoperative chemotherapy (FOLFOX) with down-staging of the lesion diameter. Immunohistochemistry on the surgical specimen showed positivity for cytokeratins 19 and 20, CEA, MUC-2, negativity for cytokeratin 7 and a-fetoprotein. Moreover, the neoplastic cells showed a focal positivity with lower intensity for MUC-1 and MUC-5AC. The immunohistochemical profile suggested the possibility of a metastatic tumour from the large bowel, without excluding a primitive mucinous cholangiocarcinoma with intestinal phenotype. At 6 months after intervention, the patient was submitted to chemotherapy (FOLFOX). At present he is in good condition, without radiological signs of recurrence. Oncologists must evaluate the possible benefits of further adjuvant treatments based on the differential diagnosis between a primitive or metastatic liver tumour. In conclusion, correct diagnosis of liver masses is mandatory and remains a challenge that can differentiate either follow-up or surgical and adjuvant treatment. Histology and immunohistochemistry must be related to clinical findings as they may not always be sufficient to reach a correct final diagnosis, and can even be confusing. At present, molecular biology cannot be considered a helpful for diagnosis in these cases.

Síndrome del cíclope: hallazgo sin el antecedente quirúrgico de ligamento cruzado anterior / Cyclops syndrome: finding no surgical history ACL

La presencia de un nódulo fibrovascular llamado cíclope, a nivel del espacio intercondíleo anterior, es un hallazgo ampliamente descrito en la literatura médica como una complicación en casos con antecedente de reconstrucción del ligamento cruzado anterior (LCA). Sin embargo, como sucedió en nuestro paciente, en la actualidad se han comunicado algunos pocos casos con injuria del LCA y lesión cíclope, pero sin el antecedente quirúrgico. Nuestro paciente tuvo un trauma directo en su rodilla seis meses antes de la consulta médica y una injuria del LCA, que podrían haber estado vinculados con la etiopatogenia de la formación de un nódulo fibroso. En el examen físico se observó una limitación en la extensión de la rodilla y en la resonancia magnética (RM), una formación redondeada bien definida, en íntimo contacto con el LCA desgarrado, correspondiente a síndrome cíclope.

The presence of a fibrovascular nodule called Cyclops at the level of anterior intercondylar space, is a finding widely described in the literature as a complication in patients with previous anterior cruciate ligament reconstruction (ACL). However, at present, it has been described some patients with ACL injury and cyclops lesión but without surgical history, as in our case. Our patient had a history of direct trauma in his knee six months before medical consultaron, which could be linked to the pathogenesis of fibrous nodule formation. On physical examination, there was a limitation on the extensión of the knee and a well defined rounded neoformation, closed to the torn ACL corresponding to Cyclops syndrome was observed with magnetic resonance imaging (MRI).

[Arthritis and infections]. / Artriti e infezioni.

Arthritis caused by infectious agents can be secondary to direct invasion of the joint space or to immune mechanisms (subsequent to or concomitant to an infection). Septic arthritis refers to a situation when bacteria can be cultured in synovial fluid. Arthritis can complicate for example meningococcemia or infection by Neisseria gonorrhoeae or Haemophilus influenzae. Reactive (postinfectious) arthritides are an important diagnostic category within a pediatric rheumatology practice. Yersinia and, less frequently, Salmonella, play an important role in postdiarrheal disorders. The arthritis that can ensue is usually oligoarticular and occurs 1-2 weeks after the enteric infection. Reiter's syndrome, rare in the pediatric age, is characterized by the triad urethritis-conjunctivitis-arthritis. Postviral arthritides can occur after a variety of viral infections, including Parvovirus B19, rubella, and others (e.g. hepatitis B, Epstein-Barr virus, chickenpox, mumps). Especially in patients with acute arthritis, the presence of preceding infections should always be investigated. Although the majority of postinfectious arthritides are self-limiting in nature and do not require specific treatment, conditions such as Lyme borreliosis and rheumatic fever can be associated with significant morbidity, and sometimes can be even lethal.

[Sentinel lymph nodes in early gastric cancer: preliminary feasibility study]. / Il linfonodo sentinella nell'early gastric cancer studio preliminare di fattibilità.

From January to December 2004, 8 patients with pre-operative diagnosis of early gastric cancer (EGC) and no nodal involvement were submitted to sentinel node biopsy using the dual mapping procedure with endoscopic blue dye and 99mTc radio-colloid injection. All the patients underwent standard radical gastrectomy and D2 lymphadenectomy. The resected nodes were evaluated by routine (hematoxylin-eosin) histopathological examination; the sentinel (blue or hot) nodes in addition were evaluated with immunohistochemistry for cytokeratin. The preliminary results and perspectives for feasibility of sentinel node biopsy and its accuracy in predicting the nodal status in EGC are discussed.

Lactoferrin serum levels in burned patients.

Twenty burned patients were studied (with mean body surface area burned 46.5%, mean age 25.4 years, and mean survival probability 78%), and lactoferrin, white-cells count and blood cultures were determined. Lactoferrin was detected more frequently (P less than 0.01) in the samples of patients with positive blood cultures. The role of lactoferrin in host defense mechanism and its possible function in sepsis is considered.

Alanine and aspartate aminotransferase serum levels in burned patients: a long-term study.

Increased alanine and aspartate aminotransferase (ALT and AST) serum levels are usually considered expressions of cellular necrosis, especially in hepatocytes. They represent cellular damage due to burn which, according to many authors, becomes normal before discharge of patients. We studied 43 consecutive burned patients, both during and after recovery, from a minimum of 120 to a maximum of 640 days, and an average of 18.62 blood samples were taken from each patient. Hepatitis A and B markers were tested. Results showed a 67.44% increase in aminotransferases in patients during recovery and a 25.58% increase after discharge. No neopositivity was observed for hepatitis A and B markers. We therefore conclude that the increase of enzymes during recovery expresses a toxic-infective phase and this increase, contrary to what was believed, does not always drop to normal values at time of discharge. Instead, after discharge, higher values can be a manifestation of a Non-A Non-B hepatitis.

Accidental high voltage electrocution: a rare neurosurgical problem.

The authors describe a case of accidental electrocution from a high voltage current in a young worker, who was struck by the electric shock in the mid-occipital region. The case is especially interesting due to the improbability of anyone surviving after receiving a shock of more than 1000 V., and to the development of bilateral parieto-occipital haemorrhagic infarction with spastic paraparesis, directly caused by the high voltage current and not indirectly by heat generation or secondary head trauma.