Role of post mortem CT (PMCT) in high energy traumatic deaths.

BACKGROUND: Post Mortem Computed Tomography (PMCT) is being increasingly implemented in forensic field and could be an adjuvant to classic autopsies. In this study we evaluated the feasibility of complementation of conventional autopsy in trauma victims with PMCT. MATERIALS AND METHODS: A total of 21 subjects, who had sustained various types of blunt high-energy trauma, were selected from the casuistry of the Section of Legal Medicine at University of Pisa: before autopsy, a PMCT examination (Toshiba Aquilion 16 CT scanner) was performed, and after the acquisition of the raw images, MPR and VR reconstructions were performed with dedicated software. RESULTS: PMCT is more sensitive than conventional autopsy in detecting skeletal injuries, whilst autopsy constitutes the method of choice for the detection of thoracic and abdominal visceral injuries. CONCLUSIONS: PMCT should be considered a useful tool in addition to conventional autopsy in evaluating trauma victims: it detects further bone fractures in body parts difficult to investigate during autopsy (i.e. posterior regions), facilitating the pathologist in the reconstruction of events and in determining the cause of death.

Influence of liver transplantation in the nutritional profile of severe cirrhotic patients

OBJECTIVE: The aim of this study was to analyze the influence of liver transplantation in food intake and nutritional status of severe cirrhotic patients. METHODS: The sample consisted of 23 patients who underwent liver transplantation. Three 24-hour dietary recall were applied and anthropometric measurements were collected before and three months after transplantation. The consumption of macronutrients and fat soluble vitamins were also evaluated. The anthropometric data evaluated were body mass index, abdominal circumference, percentage of adequacy of arm circumference, triceps skinfold thickness and arm muscle circumference. Related mean comparison tests, comparison of changes in the proportions of categorical variables and correlation of quantitative variables were used in the statistical analysis. Data were considered to be significant when p < 0.05. RESULTS: Most patients were female and aged between 40 and 65 years. The average consumption of calories, proteins, lipids, cholesterol and monounsaturated fatty acids was significantly higher after liver transplantation (p < 0.05). The average of anthropometric parameters did not differ significantly between the evaluated times. There was no significant change in nutrient intake or anthropometric classification after transplantation. Most patients were classified as malnourished or overweight after transplantation, according to some anthropometric parameters. CONCLUSION: Food consumption changed after transplantation. There was no change in the nutritional status from pre- to post-transplant but, in general, most patients had altered nutritional status in both evaluation moments.

VNS in drug resistant epilepsy: preliminary report on a small group of patients.

BACKGROUND: In 1997 Vagus Nerve Stimulation (VNS) received approval from the US Food and Drug Administration (FDA) as an adjunctive therapy in the treatment of medically intractable partial epilepsy in people aged 12 years and older who are ineligible for resective epilepsy surgery. Although the exact mechanisms of action are unknown, the use of VNS with children has increased, including those younger than 12 years of age, or those with generalized epilepsy. METHODS: We describe the outcome for the first group of nine patients, aged 8-28 years, who had pharmaco-resistant epilepsy and were treated with VNS. During the follow up, we gradually and slowly increased the parameters of the stimulation in order to assess the efficacy of VNS even at parameters which would usually be considered "non-therapeutic", along with possible side effects and changes in quality of life. RESULTS: At the last follow, up 1 patient was "seizures free", 3 were "very good responders", 3 were "good responders" and 2 were "non responders". We obtained an initial seizure reduction with low stimulation parameters, the highest current reached being 2.00 mA. This observation supports the possibility that, for younger patients, lower stimulation intensities than those commonly used in clinical practice for adults can be therapeutic. We also wanted to underline the reduction in seizure frequency (approximately 91.7%) and the reduction in seizure duration (> 50%) in the patients affected by drug-resistant absence epilepsy. Adverse effects were mild, tolerable and, in most of cases, easily resolved by adjusting the stimulation parameters. Hoarseness of voice was the most frequent side effect. The improvements in the quality of life are relevant and seem to be independent of the VNS effect in controlling seizures. CONCLUSIONS: Our small experience seems to confirm the efficacy and safety of VNS in drug resistant partial and generalized epilepsy in developing age groups.

Severe persistent pulmonary hypertension of the newborn in a setting where limited resources exclude the use of inhaled nitric oxide: successful treatment with sildenafil.

UNLABELLED: We present the case of a full term neonate with severe persistent pulmonary hypertension of the newborn (PPHN) after birth asphyxia cared for at the St. Elizabeth Hospital in Curacao, Netherlands Antilles. Although the child was ventilated with high pressures and was given high doses of cardiovascular pressors, the arterial oxygen levels remained low with an alveolar-arterial O2 gradient of 651 mmHg. As a last resort, sildenafil (1.5 mg/kg) was given via a nasogastric tube. This resulted in an immediate and sustained elevation of arterial oxygenation and subsequent complete recovery. After administration of sildenafil there was a transient hypotension which was corrected by a single bolus of saline. CONCLUSION: We discuss the current treatment modalities of persistent pulmonary hypertension of the newborn and the potential use of phosphodiesterase 5 inhibitors such as sildenafil in a situation where the standard of practice with inhaled nitric oxide and extracorporeal membrane oxygenation is not available.

Fine-needle biopsy: prospective comparison of aspiration versus nonaspiration techniques in the abdomen.

A prospective study was designed to compare the aspiration (suction method) and nonaspiration (nonsuction method) techniques of fine-needle biopsy (FNB) in 50 consecutive patients with abdominal pathologic conditions. Sites of biopsy included liver (n = 24), retroperitoneum (n = 9), adrenal gland (n = 5), pancreas (n = 4), omentum (n = 4), and miscellaneous sites (n = 4). Aspiration and nonaspiration FNBs were performed in each lesion with 22-gauge needles, and results were interpreted by a single cytopathologist. Cytologic specimens obtained with each technique were analyzed for diagnostic accuracy, total number of cell clusters per biopsy (graded 0-10, 10-20, 20-30, and > 30), presence of crush artifact, and amount of blood present (graded from 0 to +3). No significant differences were seen between the aspiration and nonaspiration techniques with regard to number of cell clusters per biopsy (44 of 50 specimens vs 42 of 50) (P < .0003), amount of blood present (grade 2.3 vs 2.2) (P < .0003), and amount of crush artifact. The positive predictive value for the aspiration technique was 91.5% versus 74% for the nonaspiration technique. The aspiration technique of FNB appears superior to the nonaspiration technique in the abdomen.

Evaluation of serum immunoglobulins by protein electrophoresis and rate nephelometry before and after therapeutic plasma exchange.

One hundred fourteen pre- and postplasma exchange (PE) serum protein electrophoretograms and serum IgG, IgA, and IgM levels obtained during a 4-month period from 23 patients were evaluated. The interval between PE sessions varied from once daily to approximately once monthly. Typically, post-PE patterns had decreased alpha-1, decreased alpha-2, decreased beta, and decreased gamma fractions. The average percentage decreases of the immunoglobulins subsequent to PE were as follows: IgG, 52%; IgA, 55%; and IgM, 51%. There was a high linear correlation between the pre- and post-PE concentrations of IgG and IgA, whereas correlation of pre- and post-PE IgM concentrations was much lower. All IgG, IgA, and IgM levels (100%) returned to their respective reference intervals before subsequent PE when procedures were scheduled at least 2 weeks apart. When procedures occurred 1 week apart or less, only 1 IgG level (1%) returned to its reference interval, whereas 68 IgA (73%) and 74 IgM levels (80%) returned to their respective reference intervals. During this study, a faint monoclonal band was discovered in each of two patients. One had a normal baseline serum protein electrophoretogram before initiation of PE therapy, and the gammopathy was of uncertain significance. In the other patient, a vertebral plasmacytoma was discovered. It is concluded that PE reduces IgG, IgA, and IgM by approximately the same percentages; however, reference interval levels of IgA and IgM are restored more rapidly than IgG levels. Because monoclonal proteins may be present before or may appear during PE therapy, patients should be monitored by baseline and subsequent periodic serum protein electrophoresis.

Needle aspiration cytology of the irradiated breast.

During a 3-year period (1987-1989), 60 fine-needle aspiration biopsies (FNAs) were obtained from new breast lesions in patients previously treated by radiation and surgery for breast carcinoma. The lesions occurred at or near the site of previous excision, 3-117 months after initiation of radiotherapy. FNAs were classified as follows: acellular (11); negative (29); atypical (13); suspicious (4); and positive (3). For statistical analysis, acellular, negative, and atypical diagnoses were considered negative findings, and suspicious and positive diagnoses were considered positive findings. On the basis of subsequent biopsy and/or patient follow-up, FNA yielded a sensitivity of 86%, a specificity of 98%, a positive predictive value of 86%, a negative predictive value of 98%, and an efficiency of 97%. Excluding cystic lesions, the most reliable criterion for distinguishing malignant from benign lesions was the abundance of epithelial cells, both singly and in large clusters. Cellular characteristics were less helpful, since nuclear atypia was seen in both benign and malignant lesions. It is concluded that (1) FNA is a reliable technique in the evaluation of the irradiated breast; (2) when performed by an experienced operator, an acellular aspirate may be interpreted as evidence against recurrent carcinoma; and (3) epithelial atypia must be interpreted with caution to avoid a false-positive diagnosis.

Oligoclonal banding detected by urinary protein electrophoresis and immunofixation in two patients with the acquired immune deficiency syndrome and proteinuria.

Monoclonal and oligoclonal banding has been observed in electrophoretograms of serum, cerebrospinal fluid, and urinary protein from patients infected with the human immunodeficiency virus (HIV). This is the first report of kappa oligoclonal banding in the protein electrophoretograms for urine but not for serum of two patients with the acquired immune deficiency syndrome (AIDS). Both patients had proteinuria, but only one had the nephrotic syndrome and renal failure. Serum oligoclonal banding in HIV-infected patients occurs much more frequently than in age-matched controls and may be detected before AIDS or lymphadenopathy syndrome evolves. The use of oligoclonal banding as a marker for HIV infection is currently under investigation. Urine as well as serum samples should be included in this research.

Translocation (X;19) with involvement of the inactive X chromosome in oligoblastic granulocytic leukemia.

A 72-year-old female with metastatic breast cancer developed oligoblastic granulocytic leukemia 6 months after initiation of chemotherapy. Cytogenetic examination of the bone marrow cells revealed a balanced t(X;19)(q12;q13.3) as the sole abnormality in 50% of the metaphases. The remaining cells showed a normal female karyotype. The der(19) chromosome displayed consistent folding in the Xq13-q23 region in all metaphases, indicating involvement of the inactive X chromosome in translocation.