Venous thrombosis in emergency department: diagnosis, treatment, and disposition.

AIM: The Authors describe diagnosis, treatment and therapy of deep venous thrombosis in Emergency Department following the last guidelines indications. DISCUSSION: Deep venous thrombosis of the legs, ranges from asymptomatic, incidentally discovered emboli to massive embolism causing immediate death. Chronic sequelae of venous thromboembolism (deep venous thrombosis and pulmonary embolism) include the post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension. Acute pulmonary embolism may occur rapidly and unpredictably and may be difficult to diagnose. Diagnosis and treatment can reduce the risk of death, and appropriate primary prophylaxis is usually effective. Patients treated for acute pulmonary embolism appear to be more times as likely to die of recurrent thromboembolism in the next year.

Treatment with icatibant in the management of drug induced angioedema.

Acute, drug-induced angioedema may not respond to standard therapies, because the pathogenetic mechanism that induces the pathology is not always mediated by histamine but, in certain instances, by bradykinin. A case of angioedema is reported here, in which allergic etiology was excluded by the non-response to antihistamines. Considering the clinical history (repeated use of drugs) and the ineffectiveness of standard therapy, it was decided to administer a beta2 receptor antagonist, icatibant. After 20 minutes, the patient reported a subjective improvement. The only form of angioedema for which this type of medication is licensed is the hereditary deficiency of C1 inhibitor. The use of icatibant for the treatment of other types of angioedema (which can also be life-saving if the airway is involved) is off label. The off-label use of a drug is allowed in the absence of a viable alternative therapy, if there is scientific evidence in the literature and if the prescriber takes responsibility. The case here reported draws attention to this therapeutic problem and underlines the fact that a life-threatening emergency can justify the use of icatibant.

Erythrocyte uroporphyrinogen decarboxylase activity: diagnostic value and relationship with clinical features in hereditary porphyria cutanea tarda.

A marked discrepancy between mild and late clinical features and a nearly complete absence of erythrocyte uroporphyrinogen decarboxylase activity (Ery-UROD activity) was observed in a case of inherited porphyria cutanea tarda. The entity and time of appearance of clinical features, the onset of clinical symptoms after exposure to contributing factors, the effectiveness of phlebotomies and heterozygosity of the mother alone for uroporphyrinogen decarboxylase (UROD) deficiency were typical for familial porphyria cutanea tarda (F-PCT), whereas the extremely low UROD activity was peculiar to hepatoerythropoietic porphyria (HEP). These observations indicate that: 1) Ery-UROD activity may not always be useful to discriminate between F-PCT and HEP; 2) Ery-UROD activity does not always correlate with clinical symptoms; 3) in inherited UROD deficiency, the genetic defect may be heterogeneous. Finally, the observed discrepancy may provide additional evidence for the existence of tissue-specific isozymes.

The synergistic effect of simultaneous addition of retinoic acid and vitamin D3 on the in-vitro differentiation of human promyelocytic leukemia cell lines could be efficiently transposed in vivo.

Both human cell lines HL-60 and AML-193 exhibit a myeloblastic and promyelocytic morphology, respectively, but may be regarded as bipotent leukemic precursors. They can be triggered to differentiate to either granulocytes or monocytes upon retinoic acid (RA) or 1,25-dihydroxyvitamin D (D3) addition, respectively. We have investigated the effect of combined addition of these chemical inducers on the in-vitro differentiation of both cell lines. RA and D3 added together exert synergistic effects on the in-vitro maturation of these myeloid cell lines. Interestingly, the additive effects were lost if the cells were incubated with the inducers added at sequential times. The synergistic effect could be transposed in vivo and could be clinically significant in the treatment of the promyelocytic leukemia. This clinical strategy may help to prevent retinoic acid resistance or to overcome it in patients relapsed after RA therapy and usually unresponsive to a reinduction therapy with RA alone.

[Non-traumatic rhabdomyolysis: clinical and laboratory diagnosis, assessment of renal complications]. / La rabdomiolisi non traumatica: riconoscimento clinico e di laboratorio, valutazione delle complicanze renali.

PURPOSE: Non traumatic rhabdomyolysis (RML) is an infrequent and sometimes clinically silent syndrome. RML incidence is increasing in the last few years. A prospective study was performed: 1) to value the non traumatic RML incidence in patients admitted to Emergency Room; 2) to reevaluate the clinical and laboratory criteria of diagnosis; 3) to establish complications' incidence and prognosis during the recovery. PATIENTS AND METHODS: In Emergency Medical First Aid 15.301 patients were examined. To the study were admitted only patients having CK level grater than fivefold the upper normal limits and without trauma, recent surgery, heart and cerebral disease. RESULTS: During the six months study, non traumatic RML incidence was 0.1% (16 patients of 15.301). Drugs, alcohol and substance abuse acute intoxication were the commonest causes. The Acute Renal Failure (ARF) was the more frequent complication (9 patients of 16). Four patients of nine was treated only by fluid administration, the other five by dialysis. Oligoanuric-ARF appeared only in patients affected by toxic RML. These patients had no-return to normal renal functional values at the time of hospital discharge. CONCLUSIONS: Non traumatic RML should be take into account by emergency doctor in cases of acute intoxication. To prevent the complications it's necessary the right interpretation of clinical and laboratory datas and an early and adequate therapy.