Massive pneumomediastinum following orbital fracture.

Pneumomediastinum is a rare complication of facial fractures, always persuading the physicians to search for other and potentially more serious injuries such as esophageal or tracheal rupture. A 75-year old man presented to the Emergency Department (ED) reporting an accidental fall while walking on the road. He did not report loss of consciousness (LOS), was not taking anticoagulant drugs, did not report chest, abdomen or limb trauma. On physical examination he only showed swelling of nose and right orbit. The patient underwent a Computed Tomography (CT) scan of head and facial bones, showing a complex fracture involving right nasal bone, ethmoid, right orbital lateral wall, and right maxillary sinus lateral wall. No intracranial lesions were found. Due to the finding of subcutaneous emphysema in the right cheek, the scan was extended to the whole neck and chest. The exam showed a massive pneumomediastinum, extending till the diaphragmatic hiatus. The patient thus underwent bronchoscopy and esophagogastroscopy, but no further lesions could be found. Antibiotics therapy was then administered, and was discharged in good conditions after a five-days observation. In our patient, air had probably escaped into the pharyngo-maxillary space from the right maxillary sinus and tracked into both the retropharyngeal space and, for contiguity, into the pre-tracheal space. As our case report shows, if the airway is secure, the pneumomediastinum does not necessarily require treatment other than clinical observation and management of the fracture. If no other injuries are present, resolution of the pneumomediastinum may be expected without further medical interventions.

Mechanisms of oxygenation responses to proning and recruitment in COVID-19 pneumonia.

PURPOSE: This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia. METHODS: Twenty-five patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmH2O and during recruiting maneuver (supine, 35 cmH2O). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmH2O of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO2/FiO2. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction. RESULTS: The average values of venous admixture and PaO2/FiO2 ratio were similar in supine-5 and prone-5. However, the PaO2/FiO2 changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (p = 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (p = 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (p = 0.004) while PaO2/FiO2 ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (p = 0.04). Consolidated tissue, PaCO2 and respiratory system elastance were higher in patients assessed late (all p < 0.05), suggesting, all together, "fibrotic-like" changes of the lung over time. CONCLUSION: The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers.

MRI and correlation between TNM and CEA, CA19.9, AFP in rectal cancer Experience of a single academic surgical center.

In our study we examined 75 patients treated for rectal cancer in the period between 01/01/2011 and 31/12/2014. Out of these 75 patients, we considered those 36 staged through MRI. We then compared the TNM stage obtained through MRI with the one emerged from histological examination. The correlation between the two TNM stages was assessed considering all patients staged through MRI and dividing the cases according to the submission or not to a neoadjuvant treatment. Finally, we analyzed serum levels of tumor markers CEA, CA 19.9 and AFP, relating them with the final disease stage. Data analysis showed a statistically significant correlation in the T stages, especially in the population not subjected to neoadjuvant treatment. Instead, for N, we found no statistically significant correlation. Similarly, none of the tumor markers presented a statistically significant correlation with disease stage. However, according to the positivity of tumor markers, we associated the following score: 0, (no positive marker)1 (only one marker positive) 2 (two markers positive) 3 (three markers positive). In presence of three markers positive, meaning the highest score, we found a statistically significant correlation with N + staging of the disease, obtained by postoperative pathologic examination. The conclusion is that MRI is certainly effective in T stage evaluation. Probably, for limph node involvement evaluation, more reliable parameters for establishing possible lymph node malignancy need to be found. The role of the tumor markers CEA, CA 19.9, AFP during preoperative evaluation of rectal tumors remains undefined. KEY WORDS: MRI, Rectal cancer, Tumor markes, Tumor regression, T stage.

Intestinal duplications: incidentally ileum duplication cyst in young female.

Gastrointestinal tract duplication is a rare congenital malformation in young patients and in adults, that occur anywhere from the mouth to the anus and their macroscopic structure may be cystic or tubular. Intestinal duplication does not show specific symptoms, indeed they can present with a variety of symptoms including abdominal distension and pain, sickness, hemorrhage, chronic respiratory disorders, as well as non-painful abdominal mass. Nonetheless, intestinal duplication can remain completely asymptomatic and be diagnosed as an incidental finding. Presentation with acute complications such as intestinal invagination or mechanical occlusion is quite rare. We present a case of asymptomatic ileum duplication cyst in young female who referred to the emergency department for trauma and was screened by eco-Focus Assessment Sonography for Trauma (eco-FAST), followed by MR and CT. The patient underwent ileal resection and prophylactic appendicectomy with ileo-cecal termino-lateral anastomosis. In this case, the intestinal duplication cyst was an asymptomatic incidental finding.

Defecography: a still needful exam for evaluation of pelvic floor diseases.

The aim of this discussion is to describe what is a defecography, how we have to perform it, what can we see and to present the main physio-pathological illnesses of pelvic floor and anorectal region that can be studied with this method and its advantages over other screening techniques. Defecography is a contrastographic radiological examination that highlights structural and functional pelvic floor diseases. Upon preliminary ileum-colic opacification giving to patient radiopaque contrast, are first acquired static images (at rest, in maximum voluntary contraction of the pelvic muscles, while straining) and secondarily dynamic sequences (during evacuation), allowing a complete evaluation of the functionality of the anorectal region and the pelvic floor. Defecography is an easy procedure to perform widely available, and economic, carried out in conditions where the patient experiences symptoms, the most realistic possible. It can be still considered reliable technology and first choice in many patients in whom the clinic alone is not sufficient and it is not possible or necessary to perform a study with MRI.

Clinical usefulness of computed tomography study without contrast injection in the evaluation of acute pulmonary embolism.

OBJECTIVE: To evaluate the percentage of cases in which emboli can be detected in unenhanced scans and to identify the cases in which they appear hyperattenuating or hypoattenuating in comparison to the circulating blood. METHOD: An angio-computed tomography (CT) scan was performed before and after contrast injection in 140 consecutive patients after clinical suspicion of pulmonary embolism. A radiologist analyzed the examination results thus obtained. The enhanced scan was analyzed first, and after detecting the thrombus, the unenhanced scan was evaluated. RESULTS: Fifty-one examinations were positive for a pulmonary embolism; in 21 cases, it was possible to identify the embolus even in the unenhanced scans. In 10 cases, the clots were hyperattenuating in comparison to the circulating blood; in 5 cases, they were hypoattenuating; and in 6 cases, they were mixed hyper-hypoattenuating. CONCLUSION: In a relatively high percentage of cases, particularly those of central thromboembolism, it is possible to identify and characterize the clots even in unenhanced scans.

Percutaneous renal artery embolisation of non-functioning allograft. Preliminary experience.

PURPOSE: Percutaneous renal artery embolisation has been introduced as an alternative to nephrectomy in patients with non-functioning allograft and Graft Intolerance Syndrome (GIS). The symptoms resulting from GIS include fever, local pain, hypertension and haematuria. MATERIALS AND METHODS: From April to October 2003, five patients were treated using this technique. The intraparenchymal renal arteries were embolized by injection of calibrated tris-acryl gelatin microspheres of increasing size (from 100-300 to 700-900 microns) and occlusion was completed by the insertion of 5mm to 8mm steel coils into the renal artery. RESULTS: The procedure was well tolerated in all cases and no major complications occurred. In 3 patients GIS-related symptoms disappeared immediately. One patient required a second embolisation due to collateral circulation arising from a lumbar artery with resolution of symptoms. In the last case, the patient underwent nephrectomy because of septic fever. CONCLUSIONS: On the basis of our preliminary experience we believe that, in selected patients, percutaneous renal artery embolisation is an effective, repeatable and minimally invasive alternative to nephrectomy with no significant serious complications.