A case of spontaneous gastric rupture in a 5 years girl.

We describe a case of spontaneous gastric rupture in a child of 5 years old. The patient reached us in a serious condition; the anamnesis was negative for traumatic events or gastrointestinal disorders. An abdominal X-ray and CT scan revealed free air and fluid in the abdominal cavity, leading to the diagnosis of gastro-intestinal perforation. Submitted to urgent surgery, a rupture of the posterior wall of the stomach was found that was treated with gastrectomy "à la demande". The surgery follow-up was regular. Morphological and immunohistochemical study showed some muscular abnormalities of the muscular gastric wall.

Experimental observation of microtearing modes in a toroidal fusion plasma.

Experimental evidences of short wavelength electromagnetic modes are found in the reversed-field-pinch configuration device RFX-mod by means of in-vessel magnetic probes. The modes are revealed during the helical states of the plasma. Their amplitude is well correlated to the electron temperature gradient strength in the core. On the basis of linear gyrokinetic calculations we interpret these instabilities as microtearing modes.

[Bithalamic infarct: is there an evocative aspect? Radioclinical study]. / Accident vasculaire ischémique bithalamique: existe-t-il un tableau évocateur ? Etude radioclinique.

INTRODUCTION: Bithalamic paramedian infarcts are uncommon. This stroke results in a complex clinical syndrome. CASE REPORT: We report four cases of bithalamic paramedian infarcts with a presumed mechanism of occlusion of a single thalamic paramedian artery. DISCUSSION: This normal anatomic variant corresponds to an asymmetrical common trunk for the two thalamosubthalamic paramedian arteries arising from a P1 segment (type IIb in the G. Percheron classification dating from 1977). A literature analysis (from 1985 to 2006) allowed us to identify the most widely reported clinical signs. Four main clinical findings are described: vertical gaze palsy (65%), memory impairment (58%), confusion (53%) and coma (42%). We also found these symptoms in our patients but rarely associated; however, all four patients had exhibited episodes of drowsiness. In this article, we discuss the anatomy-function correlation responsible for such clinical variability. CONCLUSION: Clinicians should be aware of this diagnosis to better understand the imaging results which provide confirmation. Although the literature describes frequently severe consciousness disorders such as coma, this diagnosis must also be considered in patients presenting a simple fluctuation of consciousness, e.g. hypersomnia.

Preliminary design of electrostatic sensors for MITICA beam line components.

Megavolt ITER Injector and Concept Advancement, the full-scale prototype of ITER neutral beam injector, is under construction in Italy. The device will generate deuterium negative ions, then accelerated and neutralized. The emerging beam, after removal of residual ions, will be dumped onto a calorimeter. The presence of plasma and its parameters will be monitored in the components of the beam-line, by means of specific electrostatic probes. Double probes, with the possibility to be configured as Langmuir probes and provide local ion density and electron temperature measurements, will be employed in the neutralizer and in the residual ion dump. Biased electrodes collecting secondary emission electrons will be installed in the calorimeter with the aim to provide a horizontal profile of the beam.

In-vacuum sensors for the beamline components of the ITER neutral beam test facility.

Embedded sensors have been designed for installation on the components of the MITICA beamline, the prototype ITER neutral beam injector (Megavolt ITER Injector and Concept Advancement), to derive characteristics of the particle beam and to monitor the component conditions during operation for protection and thermal control. Along the beamline, the components interacting with the particle beam are the neutralizer, the residual ion dump, and the calorimeter. The design and the positioning of sensors on each component have been developed considering the expected beam-surface interaction including non-ideal and off-normal conditions. The arrangement of the following instrumentation is presented: thermal sensors, strain gages, electrostatic probes including secondary emission detectors, grounding shunt for electrical currents, and accelerometers.

Safety and efficacy of continuous intravenous morphine for severe cancer pain.

To study the efficacy and safety of continuously administered intravenous morphine for cancer pain unrelieved by standard narcotic therapy, bolus intravenous injections of 2 to 5 mg of morphine were given every 10 minutes until pain relief was achieved. Within the next hour, continuous intravenous morphine infusion was begun with the hourly dose equal to the cumulative bolus dose. Respiratory rate, pulse, blood pressure, arterial blood gas values, mental status, and pain relief were recorded at baseline and during the study period. A reduction in arterial oxygen pressure (PaO2) and/or increase in arterial carbon dioxide pressure PaCO2 of more than 20 percent of baseline values occurred, during the first 24 hours of infusion, in a minority of patients. This did not require changes in hourly morphine dose. Despite subsequent increases in morphine dose, blood gas values tended to remain at or return toward baseline values. Severe toxicity occurred during one trial and was heralded by bradypnea and marked somnolence. Major pain relief was achieved in 11 of 15 trials. Therefore, continuous intravenous morphine is effective and safe therapy. Bradypnea associated with marked somnolence is a cause for dose reduction.

Hemoptysis as the sole presentation of thyroid carcinoma.

A 23-year-old man experienced hemoptysis in 1968, secondary to papillary carcinoma of the thyroid with metastasis to the lungs. The patient was treated initially with thyroidectomy and Iodine- 131 (131I), and subsequently with radical neck dissection. Following a period of fifteen years in which the patient was well clinically, he experienced recurrent hemoptysis. No other source of bleeding was identified, and the hemoptysis was attributed to the lung metastases of the thyroid carcinoma.

Pneumocystis carinii pneumonitis in patients with lung cancer.

Pneumocystis carinii pneumonia was histologically documented in five patients with bronchogenic carcinoma. All patients had been treated with combination antineoplastic chemotherapy. Two patients received no corticosteroids, two received no chest radiotherapy, and one received neither radiotherapy nor corticosteroids. This suggests that as more patients with lung cancer are treated with intensive chemotherapy, pulmonary infection with P carinii may become an important differential diagnostic consideration in the presence of pulmonary infiltrates.

Laser therapy in patients with primary lung cancer.

Twenty-eight therapeutic bronchoscopic procedures with laser were carried out on 20 patients with primary lung cancer. Indications for laser bronchoscopic study were nonresectable, endoscopically visible tumor in patients who had any of the following complications after chemotherapy and/or radiation therapy: increasing dyspnea, postobstructive pneumonia, atelectasis, or hemoptysis from an endoscopically visible site. Symptomatic benefit was noted by 15 of 20 patients after laser therapy. There were two procedure-related deaths. Our conclusions regarding selection of patients for laser therapy of endotracheal and endobronchial lesions are given.

Mediastinal compression due to tension hydrothorax.

We describe a patient in whom a malignant pleural effusion accumulated with sufficient pressure to cause mediastinal compression resulting in acute respiratory distress, dysphagia, and massive edema of the lower extremities. Emergency thoracocentesis produced immediate relief to respiratory symptoms and dysphagia, with gradual disappearance of the edema and a weight loss of 6.8 kg (15 lb) without adjunctive medications. It is suggested that thoracocentesis is a life-saving measure in this circumstance and should be done immediately in patients with similar initial clinical findings, as further diagnostic evaluation or other therapy directed to the mediastinum will not releive the tension and will only delay removal of the fluid.

Pneumothorax with fine-needle aspiration of thoracic lesions. Is spirometry a predictor?

To assess the value of spirometry for predicting the risk of pneumothorax (PTX) following percutaneous fine needle aspiration (FNA) of thoracic lesions, we examined retrospectively the incidence of PTX in 89 FNA and associated spirometry. Spirometry results were classified as normal, obstructed, or restrictive. Overall, the PTX rate was 20 percent. When the PTX occurrence was analyzed based on our spirometry classification, no significant difference was found between the groups. A PTX occurred in 27.8 percent of the FNA performed in patients with normal spirometry. On further analysis of specific spirometry measurements (FEV1, FVC, FEV1 percent predicted, and FEV1/FVC) and incidence of PTX, no significant correlation in PTX rates was found. These data suggest that the FNA pneumothorax is not correlated with lung function as measured by routine spirometry.

Legionella pneumonia presenting as a bulging fissure on chest roentgenogram.

We report a case of Legionella pneumonia presenting as a bulging interlobar fissure on the lateral chest roentgenogram. This microorganism should be added to the list of etiologic agents producing a bulging fissure on chest roentgenogram.

Aortic valve reconstruction associated to ascending aorta tubular graft replacement in aortic incompetence by annuloaortic ectasia.

OBJECTIVE: Aortic valve incompetence associated with severe aortic ectasia is usually treated by aortic valve and ascending aorta replacement. In cases of isolated aortic ectasia or in Type A aortic dissection the valve is often normal and the incompetence is just due to annular dilatation. Such conditions lead to the application of various valve-sparing surgical techniques, as described by Senning et al., showing the advantages of preservation of the native valve, but the disadvantage of a high technical complexity and a high incidence of recidivation. METHODS: We describe a valve-sparing surgical procedure, which has the advantage of a direct and simple approach together with satisfying mid-term results. After the aortic bulb has been fully transected, the excessive wall tissue is resected by two or three triangular excisions just above the valve commissures. Wall excision was indicated in those patients with an aortic diameter exceeding 65 mm at the sino-tubular junction. Tissue excision should not exert tension on to the coronary ostia or excessively reduce aortic diameter. Three external Teflon strips, overriding each other, are placed around the aortic bulb and are included in the direct suture of the edges of the triangular excisions. They are fixed by a running suture over the free border of the bulb. Aortic valve commissures are resuspended when needed. In this way, the aortic bulb, with a competent valve, is wrapped in a prosthetic and inextensible graft. The aortic continuity is then re-established with the interposition of a tubular dacron graft. RESULTS: From April 1990 to December 1995, 21 patients (mean age 48 years, range 32-70) scheduled for surgery for aortic valve incompetence associated with annuloaortic ectasia were treated with this technique. In one patient the procedure failed to achieve a satisfying valve competence and the valve was replaced. In another case a prolapse of the non-coronary cusp required reoperation with aortic valve replacement, without further complications. At follow-up time (mean 42 months, range 18-78), all patients were well and healthy, with control echoes showing no residual valve incompetence and with invariate bulb diameters at every successive examination. CONCLUSIONS: Our experience shows that this new valve-sparing approach allows safe and persistent correction of aortic valve incompetence and annuloaortic ectasia although longer term follow up is needed.

The association between rhabdomyolysis and acute renal failure in patients undergoing cardiopulmonary bypass.

OBJECTIVE: The authors describe 9 cases of rhabdomyolytic acute renal failure (ARF) as a complication of cardiopulmonary bypass. EXPERIMENTAL DESIGN: Retrospective research between June 1992 and March 1994. SETTING: Department of Cardiac Surgery. PATIENTS: 931 consecutive patients undergoing major cardiac surgery. INTERVENTIONS: Patients affected by rhabdomyolytic ARF were treated with pharmacological therapy and/or plasmapheresis/continuous arteriovenous hemofiltration. In seven patients indirect cannulation of the femoral artery was used. MEASURES: Incidence, risk factors of syndrome results obtained with pharmacological treatment, CAVH and plasmapheresis were evaluated. Statistical analysis was performed with ANOVA, Tukey Kramer test and chi2 test (p<0.05 as significant). RESULTS: The syndrome occurred in 0.96% (9/931 patients) of the total cases; 11.3% (6/53 -p<0.0000) in patients undergoing a direct femoral artery cannulation for cardiopulmonary bypass and 9.5% (2/21, p<0.01) in patients in which the aortic balloon pump was used. Six patients develop acute anuric renal failure and underwent plasma exchange and hemodialysis (1 case) or CAVH (5 cases); 3 patients underwent early medical treatment and developed developed acute renal failure (ARF) with preserved diuresis. Early medical therapy appeared to prevent the evolution towards anuric ARF. The indirect cannulation of the femoral artery does not seem to produce a rhabdomyolytic ARF syndrome. In patients with direct femoral artery cannulation risk factors appear to be: arteriopathy (p<0.001), prolonged extra corporeal circulation (p<0.001), low cardiac output syndrome (p<0.001), continuous i.v. infusion of epinephrine (p<0.0001). CONCLUSIONS: Rhabdomyolytic acute renal failure is a severe complication, early identification of patients ¿at risk¿ is most important. The preventive measures and the therapy adopted proved efficient.

A new technique for hemodilution, preparation of autologous platelet-rich plasma and intraoperative blood salvage in cardiac surgery.

We have developed a new system for the production of autologous platelet-rich plasma and red blood cell concentrates to be used in autologous transfusion support of cardiac surgery patients. In 15 operations no homologous blood products were required. Costs were diminished since with the same harness it was possible to carry out the intraoperative blood salvage and concentrate the erythrocytes contained in the oxygenator and its lines. Indirect costs were also reduced since no infective complication was observed due to homologous blood products.

The "fully no-touch" technique for the internal thoracic-coronary artery anastomosis.

Extreme technical accuracy is crucial in coronary artery surgery. Although late graft patency depends mostly upon the patient's own biochemical status in chronic ischemic patients who have undergone elective surgery, graft disease is certainly promoted by an inaccurate technique or by careless arterial harvesting, which may cause both intimal lesions and anastomotic strictures. We describe a technique of internal thoracic-coronary artery anastomosis that fully prevents contact between vessels and surgical instruments. In order to enable the suturing of a fully dilated vessel, intracoronary papaverine is injected into the clamped aortic root while the heart is still beating and before systemic cooling begins. The suturing technique applies some microvascular principles, the chief being a high number of stitches incorporating the least amount of tissue, to avoid bulk.

Ten years of surgery of aortic dissections and aneurysms. Clinical experience and original contributions.

From January '82 to April '91, 117 patients with aortic disease were operated upon at our University Hospital in Genoa, Italy. Thirty-seven had arch dissections or aneurysms; 66 had acute aortic dissection type A and 14 had aortic dissections or aneurysms type B, acute and chronic. Patients with arch or type B aortic pathology but without surgical indication and cases of post-traumatic aortic transections are not included. There were 84 male and 33 female patients with a mean age of 52 (6 min and 74 max). In the acute patients, the mean interval between clinical onset and surgery was 34 hours (6 min-72 max). All patients with primary arch disease had surgical repair with the aid of deep hypothermia and circulatory arrest (17-96 min). Type A dissections were treated with standard CPBP at 28 degrees C. Surgical techniques included direct suture of intimal tear alone, direct suturing of the two aortic stumps; interposition of Dacron tubular prosthesis; Bentall repair; separated valve and aortic replacement; an original aortic bulb aortoplasty with valve repair; arch replacement with resuturing of one or more aortic trunks. Human fibrin glue (Tissucol) was employed either as haemostatic agent, widely spread over the suture lines or as tissue adhesion agent between dissected aortic layers. Human fibrin glue is adopted because it gathers high glueing capacity and maintenance of the elastic property of the vessel wall. Hospital mortality (30 days) has been 25% in ascending aortic dissections (16/66 patients) and 50% in patients with arch disease (18/37 patients) who needed circulatory arrest. Late mortality 5/83 (6%). Reoperations for aortic valve insufficiency or re-dissection have been 7 (8.4%). Early diagnosis (increasing reliability of 2D-Echo and CT scans), aggressive surgery, meticulous myocardial and cerebral protection and introduction in clinical use of biological glues seem to be the milestones of present and further improvements in surgical results.

Aortic valve repair for traumatic aortic insufficiency.

Prolapse of a commissural portion of the aortic valve due to partial intimal tear following a blunt chest trauma is a rare condition. Aortic valve repair is a technically demanding operation and the presence of aortic incompetence due to leaflet prolapse often leads to aortic valve replacement. We report the case of a patient with aortic insufficiency due to commissural disruption following a road traffic accident, and in whom aortic valve repair was performed.

[General criteria for the organization of an intrahospital emergency plan in Italy]. / Criteri generali per l'organizzazione di un piano intraospedaliero per l'emergenza sul territorio.

The purpose of this work is to provide general criteria to draw up a hospital organization plans for emergencies, in order to efficiently manage the consequences of a massive flow of casualties from a major accident or natural disaster.