Visual lung ultrasound protocol (VLUP) in acute respiratory failure: description and application in clinical cases.

Lung ultrasound (LUS) is widely used as a diagnostic and monitoring tool in critically ill patients. Lung ultrasound score (LUSS) based on the examination of twelve thoracic regions has been extensively validated for pulmonary assessment. However, it has revealed significant limitations: when applied to heterogeneous lung diseases with intermediate LUSS pattern (LUSS 1 and 2), for instance, intra-observer consistency is relatively low. In addition, LUSS is time-consuming and a more rapid overview of the extent of lung pathology and residual lung aeration is often required, especially in emergency setting. We propose a Visual Lung Ultrasound Protocol (VLUP) as a rapid monitoring tool for patients with acute respiratory failure. It consists of a probe sliding along the mid-clavicular, mid-axillary and scapular lines in transversal scan. VLUP allows a visualization of a large portion of the antero-lateral and/or posterior pleural surface. Serial assessments of two clinical cases are recorded and visually compared, enabling rapid understanding of lung damage and its evolution over time. VLUP allows a semi-quantitative and qualitative point-of-care assessment of lung injury. Through this standardized approach it is possible to accurately compare subsequent scans and to monitor the evolution of regional parenchymal damage. VLUP enables a quick estimation of the quantitative-LUSS (qLUSS) as the percentage of pleura occupied by artifacts, more suitable than LUSS in inhomogeneous diseases. VLUP is designed as a standardized, point-of-care lung aeration assessment and monitoring tool. The purpose of the paper is to illustrate this new technique and to describe its applications.

Medullary sponge kidney: unusual finding in kidney transplant recipient.

BACKGROUND: Medullary sponge kidney is generally considered a benign condition, gold standard for the diagnosis is urography but it has almost been replaced by UroCT that did not present the same sensibility. Although it is really rare, our sonography's findings were consistent with medullary sponge kidney in the transplanted kidneys. CASE PRESENTATION: A 45-year-old woman with a long history of double-kidney transplantation complained of frequent urinary tract infections, a history of vague loin pain and came to our attention for sonography follow-up. Her kidney function was normal, we did not find signs of infections in the transplanted kidneys and urinary findings were normal. Curiously, the transplanted kidneys came from a newborn and the patient received a double-kidney transplantation in order to guarantee a satisfactory renal function. CONCLUSIONS: Despite a long history of kidney transplantation, genetic disease should not be forgotten when symptoms and images recall to specific inherited alterations. Sonography has to be considered in diagnostic path of kidney cystic disease.

Use of macrogol 4000 in chronic constipation.

BACKGROUND: Chronic constipation is a common functional disorder of the gastrointestinal tract, affecting up to 35% of the general population, and especially the elderly. However, its definition as perceived by the patient can vary, making it difficult to understand the problem and find appropriate therapeutic measures. The approach to chronic constipation, thus, needs a thorough understanding of the patient's complaint and the main pathophysiological mechanism requiring treatment. Lifestyle changes do not usually meet with complete patient satisfaction. Other treatments include different types of laxatives. Of these, osmotic laxatives appear one of the most effective and are, therefore, frequently prescribed. DESIGN: This review will cover the topic of osmotic laxatives, specifically focusing on polyethylene glycol (PEG/macrogol 4000) in chronic constipation and as a key agent for bowel cleansing prior to colonoscopy. PEG formulations, including macrogol 4000, are safe, effective treatments for constipation, even in children and elderly patients. Macrogol 4000 may well be more palatable than combined formulations (macrogol 3350 with electrolytes), which could help improve adherence to the long-term treatment required for chronic constipation. CONCLUSIONS: PEG/macrogol is also recommended as an effective option for bowel cleansing prior to colonoscopy. The improved cost-effectiveness of macrogol over other commonly prescribed laxatives, such as lactulose, should be taken into consideration.

Thrombotic thrombocytopenic purpura mimicking an acute meningoencephalitis.

Thrombotic thrombocytopenic purpura is a rare, threatening disease characterized by thrombocytopenia, microangiopathic haemolytic anaemia and organ dysfunction, e.g., neurological impairment and renal insufficiency. We describe a patient with neurological impairment mimicking a meningoencephalitis in whom a thorough clinical evaluation along with appropriate laboratory tests led us to identify an underlying thrombotic thrombocytopenic purpura. The successful outcome of this patient was based on plasma exchange and immunosuppressive treatment. Thrombotic thrombocytopenic purpura should be considered in the differential diagnosis of patients presenting with any neurological abnormalities, anaemia and unexplained thrombocytopenia.

Chronic intestinal pseudo-obstruction related to viral infections.

Chronic intestinal pseudo-obstruction (CIPO), one of the most severe gastrointestinal motility disorders, is a condition characterized by a clinical picture mimicking small bowel occlusion with related symptoms and signs in the absence of demonstrable mechanical obstruction. Analysis of full-thickness biopsy samples may unravel structural changes of the neuromuscular layer involving the whole gut, although the midgut is usually worst affected. Intestinal pseudo-obstruction can occur in association with systemic neurological, endocrine, and connective tissue diseases or malignancy but, when no recognizable etiology is found, CIPO is referred to as idiopathic (CIIPO). The latter form can be diagnosed early in life due to a genetic etiology or in adulthood when a viral origin may be considered. This review addresses the hypothesis that some systemic neurotrophic viral infections can affect the enteric nervous system thereby altering normal peristaltic activity. Available data are reviewed, focusing specifically on herpesviruses or polyomaviruses (JC virus). These suggest that in comparison to a proportion of CIIPO patients, healthy controls rarely harbor viral DNA in the myenteric plexus, leaving open the possibility that a viral infection might have an etiologic role in the development of CIIPO. The review thus provides some new perspectives in the pathophysiology and perhaps targeted treatment of CIIPO.

[Gastroesophageal reflux disease: therapeutic features (Part II)]. / La malattia da reflusso gastro-esofageo: aspetti terapeutici (Parte II).

Gastroesophageal reflux disease (GERD) can be defined as a condition resulting from the reflux of stomach contents into the esophagus. Its pharmacological treatment is aimed at symptom relief, healing of erosions and ulcerations and prevention of relapses. Based on the pathophysiology, the ideal treatment is directed to enhance basal sphincter pressure or decrease the frequency of TLESR, restore esophageal "clearance", accelerate gastric emptying and highten mucosal resistance as well as reduce or inhibit gastric acid secretion. Most of these targets are currently achievable because the availability of different types of drugs, however the "ideal" pharmacologic treatment of GERD does not exist. Current remedies for GERD include life style changes along with a wide array of antisecretory drugs, such as antacids, H2-antagonists and proton pump inhibitors (PPI). Surgery, based on anti-reflux procedures, and endoscopic approaches may have a role in the management of patients with GERD.

[Gastroesophageal reflux disease: clinical and pathophysiological features (part I)]. / La malattia da reflusso gastro-esofageo: aspetti clinici e fisio- patologici (Parte I).

Gastroesophageal reflux disease (GERD) can be described as a clinical picture resulting from the reflux of stomach contents into the esophagus. The actual prevalence of GERD remains unestablished, although this disorder is generally common in old patients, male sex and in subsets of patients with pulmonary manifestations such as asthma. From a pathophysiological stand-point, GERD is thought to have a multifactorial etiology which involves genetics, anatomical, functional, environmental, hormonal and pharmacological factors. GERD has different clinical presentations which may be divided in three main classes: typical symptoms (heartburn and regurgitation); atypical or extraesophageal symptoms (angina-like chest pain, asthma, chronic cough and laryngitis); and complications (ulcers, strictures and Barrett's esophagus). In GERD diagnosis a key role is played by: accurate symptom evaluation, response to proton pump inhibitors and, finally, at least one in a life-time endoscopy. Moreover, barium swallow X-ray, 24-h esophageal pH monitoring and gastro-esophageal manometry can be useful to support diagnosis in some unusual cases or in cases partially or unresponsive to standard pharmacologic treatment.