Primary hyperparathyroidism related to a parathyroid adenoma: the dramatic clinical evolution of a misdiagnosed patient and its surgical solution.

Primary hyperparathyroidism is a clinical condition related to an excessive and abnormally regulated secretion of parathyroid hormone (PTH) from the parathyroid glands which is responsible for an alteration of the calcium and phosphorus metabolism. Parathyroid adenomas are the most important cause of primary hyperparathyroidism (80-85%). A case of parathyroid adenoma observed in a patient aged 47, admitted to the Emergency Medicine Department of our Hospital with a diagnosis of hypertensive crisis, cephalea, vomiting, and a clinical history of recurrent episodes of severe abdominal and renal pain, is presented. Lab data showed severe hypercalcemia and a progressive worsening of the renal function. A severe neurological involvement with stupor, derangement of mind, the arising of acute respiratory depression, lethargy compelled the colleagues to transfer him to the Intensive Care Unit; a neck ultrasonography showed a poor-echogenous area under the right thyroid inferior pole, with signs of vascularization. The suspect of a primary hyperparathyroidism related to a single adenoma of the parathyroid gland suggested a surgical treatment. A ''concise parathyroidectomy'' was performed. Our surgical approach was confirmed by the comparison of the preintervention and the post-intervention iPTH values: 2080 pg/mL (normal range: 12-65 pg/mL) before excision vs 101 pg/mL after the removal. The histologycal exam reported a parathyroid adenoma with large areas with haemorrage. Three days after surgery the patient was in good general conditions. Patients affected by primary hyperparathyroidism are often misdiagnosed because their clinical conditions can create differential diagnosis problems with other diseases. However the surgical option remains the gold standard treatment.

Arteriovenous fistulas for hemodialysis created using a long-term absorbable suture: a safe solution and a measure to minimize myointimal hyperplasia.

BACKGROUND/AIMS: The goal of the therapeutic management of patients affected by end-stage renal disease (ESRD) is to maintain the vascular access (VA) as long as possible. Myointimal hyperplasia development in the vascular walls of arteriovenous fistulas (AVFs) is considered one of the most important factors responsible for procedure failure. These alterations could be linked to hemodynamic changes in the anastomosis and to the presence of the surgical suture itself. We report our preliminary experience, discussing the use and the possible benefits of an absorbable suture in polyglycolide trimethylene carbonate (PTC) in AVF creation. METHODS: Seventy-four AVFs were created as primary access for hemodialysis (HD), using PTC, over 4 years. Age, gender, ESRD etiology, artery and vein preoperative diameters, AVF survival outcome, and the number of AVFs created per year were recorded. The Kaplan-Meier method was used to analyze AVF survival rates. RESULTS: No dehiscences, pseudoaneurysms, or failures in the 'critical' period related to PTC absorption were recorded. Kaplan-Meier analysis was used to evaluate AVF survival; 12-month primary AVF survival (74.33%) and AVF failure (25.67%) rates, 9 'early' (8.22%) and 10 'late' failures (13.51%), and a 360-day mean survival were found. CONCLUSIONS: Our data indicate that PTC, a well known and widely used material for sutures in vascular surgery, is safe and effective in AVF creation. Potential advantages of PTC sutures are represented by a reduced myointimal hyperplasia formation in the AVF vascular walls, prolonging the AVF lifespan and avoiding re-interventions.

[Arterial hypertension in pregnancy. Concise review]. / L'ipertensione arteriosa in gravidanza. Rassegna sintetica.

The diagnostic principles and current therapy employed in cases of arterial hypertension during pregnancy are summarised. Apresoline is recommended in all forms of hypertension. Salt free diets and diuretics are usually not recommended in pre-eclampsia-eclampsia. In all other hypertensive forms they are, but in association with apresoline and/or beta-blocking agents.

[Electrocardiographic changes in acute abdomen]. / Alterazioni elettrocardiografiche in corso di addome acuto.

We have examined the electrocardiograms of 516 patients hospitalized for acute abdomen. We have excluded from this research the younger patients than 14 years, those with shock, those with clinical signs of cardiopathy, those with electrolytic alterations and those executing anti-arythmic or anti-depressing therapy. We have found changes of repolarization and of rhythm. The changes of regularization consisted in flottening-inversion of T wave in the precordial and/or limb leads associated sometimes at negative deflection of the ST tract in the same leads. The changes of rhythm consisted in atrial or ventricular extrasystoles, paroxismal atrial tachycardia, paroxysmal atrial fibrillation. Sometimes the changes of repolarization and rhythm were associated. We have discussed the possible pathogenetic mechanisms answerable for these changes; sympathetic adrenergic activation mediate or no from a parasympathetic reflex, reduction of intra-cellular potassium, activation of enzymatic systems, reabsorption of toxic substaces. The Authors have underlined the benignity of these ECG changes, disappearing after resolution of abdominal disease, and the necessity of a correct interpretation of those, to avoid the arising of a iatrogenic disease.

[Effects of ticlopidine on platelet function at rest and after exercise in patients with previous myocardial infarct. An acute crossover double-blind study]. / Effetti della ticlopidina sulla funzione piastrinica a riposo e dopo sforzo in pazienti con pregresso infarto del miocardio. Studio acuto cross-over e doppio cieco.

The effects of Ticlopidine on platelet function at rest and after exercise test in 12 patients with a history of myocardial infarction but no risk factors and/or residual angina, were investigated. The patients were treated with 500 mg per diem Ticlopidine or placebo for 15 days in a crossover double-blind study. Blood samples were taken before and 3 minutes after maximum effort exercise cycle tests. Blood samples from 25 healthy volunteers of comparable age and sex were used for control purposes. The parameters examined were: platelet aggregation induced by ADP (1 and 3 mumol/l), Arachidonic Acid (AA) (1.3 mmol/l) and collagen (2 micrograms/ml); the presence of circulating platelet aggregates and plasmatic fibrinogen levels. When compared with the controls, the patients showed higher levels of aggregation caused by ADP, AA and collagen as well as circulating aggregates. Exercise produced a statistically significant increase in platelet activation, while Ticlopidine significantly inhibited the platelet aggregation induced by ADP, AA and collagen as well as circulating aggregates both at rest and after the exercise test. Fibrinogen levels were higher in the heart attack patients than the controls especially after exercise, but not to a statistically significant degree. Treatment with Ticlopidine did not influence plasma fibrinogen levels. It is not known whether the patients with signs of effort-induced platelet aggregation run a higher risk of ischaemic cardiopathy or whether drug treatment could prevent this eventuality.

[Electro-vectorcardiographic diagnosis of left ventricular hypertrophy in the presence of anterior fascicular block]. / Diagnosi elettro-vettorcardiografica di ipertrofia ventricolare sinistra in presenza di blocco fascicolare anteriore.

The aim of this study is to value the utility of the electro-vectorcardiographic criteria of left ventricular hypertrophy (LVH) in presence of the anterior fascicular block (LAFB) utilizing as "gold-standard" the left ventricular mass (LVM) determined by bidimensional echocardiogram (Eco2D). Fifty-four patients with LAFB type IV (S3 greater than 1.5 mV) (age: 58 +/- 10 years) have been studied. Thirty normal subjects have been studied as case control. MVS has been estimated by the method of Reichek. Through estimated parameters, the association of two criteria RI + SIII greater than 2.5 mV and AQRS greater than--45 degrees has shown a high sensitiveness, but a low specificity; so the association of this two criteria is'not sufficient to identify the LVH. In the presence of LAFB the voltages increase in the frontal plane is a constant finding while in the precordial leads is a less constant repeat as LVH manifestation. As a matter of fact the QRS loop tend to be pushed more towards the high and posteriorly. The delay of intrinsic deflections can be observed only in the strict hypertrophy with a without LAFB. The repolarization anomalies with the LAFB presence are more frequent. The electric signs specificity is different. She is good for all except for the repolarization alterations, especially if limited to the T-wave. So in the LAFB type IV of ten increase the QRS voltage in the frontal plane and we can see therefore Lewis' index increased without necessary subtending a LVH.(ABSTRACT TRUNCATED AT 250 WORDS)

[The role of ergometric testing in the clinical evaluation of arrhythmia]. / Ruolo del test ergometrico nella valutazione clinica delle aritmie.

Ergometric stress testing seems useful in the identification of some supraventricular and ventricular arrhythmias induced by exercise, but poorly indicative for the purpose of prognosis, because the risk of sudden death seems to be linked to the extent of coronary artery disease or left ventricular failure. Ergometric stress testing, with ambulatory ECG, have an important role in the evaluation of the effects of antiarrhythmic drugs. This stress testing, favouring the importance of the efficacy of therapy, of probably worsening of arrhythmia, of congestive heart failure and/or conduction abnormalities, allows a more accurate prescription of physical activity and antiarrhythmic drugs.

[An allergic reaction due to i.v. urokinase administration]. / Reazione allergica dovuta a somministrazione di urokinasi e.v.

We notify a case of anaphylactic reaction due to urokinase which was administered to a patient with extended anterior acute myocardial infarction. He showed some allergic reaction symptoms such as: cutaneas eritema and dyspnea with bronchial spasm which disappeared with an intravenous cortisone drug. Therefore we think that urokinase too might give rise to anaphylactic reaction.

[Heart failure in the elderly. Therapeutic strategies]. / Scompenso cardiaco nell'anziano. Strategie terapeutiche.

The different types of cardiac heart failures are examined: chronic failure deriving from systolic dysfunction, diastolic dysfunction failure, refractory heart failure, acute failure. Heart failure in the elderly is not always associated with impaired ventricular contractility with decreased EF and ventricular enlargement, but frequently with diastolic dysfunction of the left ventricle (LV). The echocardiographic examination is very useful to evaluate the type of ventricular dysfunction. Since the aortic baroceptor system is less sensible, diuretics and drugs decreasing after-load must be use carefully because of orthostatic hypotension and deterioration of kidney function. The elderly are most sensible to the action of digitalis because of the pharmacokinetic changes of the drug due to age. Although the current therapy of heart failure can relieve symptoms and prolong life, prognosis is always serious. The most effective therapy is prevention as it aims at the control and, if possible, at the regression of left ventricular dysfunction in the asymptomatic or slightly symptomatic stage.

[Ventricular arrhythmia in hypertrophic cardiomyopathy. When and how to treat]. / Le aritmie ventricolari nella miocardiopatia ipertrofica. Quando e come trattarle.

Patients with apical hypertrophy have a natural favourable history. Non Specific Ventricular Tachycardia (NSVT) at ambulatory monitoring is more favourable if it is not associated with consciousness disorders. A high rate of NSVT episodes at Holter or the association with syncope can lead to a less favourable prognosis and therefore require pharmacological or electric treatment. The role of ET (electrophysiological test) has not yet been clearly described and is in progress. Recent studies of molecular genetics help to identify high-risk patients. Sustained monomorphic VT is not frequent but when it occurs it should be treated with BT. Patients with a light risk of VT should be treated with pharmacological therapy (white amiodarone and/or sotalol) and preferably with implantable defibrillator (ID) if VT cannot be eliminated. ID should be implanted also in the few patients surviving heart attack to avoid the risk of relapses.

[Hazards of thrombolysis. A clinical case]. / I pericoli della trombolisi. Caso clinico.

Thrombolytic therapy has led to a reduction in early and late mortality in myocardial infarction but it is not without its dangers. Two cases are reported in which it was adopted inadvisedly considering that later pathologies other than acute myocardial infarction were demonstrated. A less aggressive attitude is advised for emergency thrombolysis (pending the arrival of more effective, safer drugs) in the more peripheral centres where possible complications may be more difficult to handle.

[Idiopathic restrictive cardiomyopathy. Description of 4 cases]. / Cardiomiopatia restrittiva idiopatica. Descrizione di 4 casi.

The clinical and instrumental characteristics of four patients suffering from idiopathic restrictive cardiomyopathy are analysed. Patients were diagnosed following hemodynamic and histological tests. The major clinical symptom was cardiac decompensation and/or hyperkinetic or hypokinetic (3rd degree BAV) supraventricular arrhythmia (atrial fibrillation). Electrocardiographic and radiological alterations were not specific. The most typical echocardiographic symptom was the association of: biatrial dilation, dilation and hypertrophy of the right ventricle, normal left ventricular size, normal fractional shortening of the left ventricle. Septal hypertrophy was also observed in one case. Abundant pericardial effusion was present in all cases. When performed, echo-Doppler showed a relatively typical shortened deceleration time through the A-V valve. Catheterism revealed increased ventricular telediastolic pressures and a bi-plateau morphology of the ventricular pressure curve. Heart index was depressed in one patient and the ejection fraction was reduced in one case. Histological tests revealed interstitial fibrosis, cellular hypertrophy and, in one patient, myocardial amyloidosis. One patient underwent a heart transplant, two patients died while waiting for a transplant, one patient is still alive 13 years after the start of 3rd class symptoms.

[Current developments in the treatment of acute generalised peritonitis]. / Attualità nel trattamento delle peritoniti acute generalizzate.

Generalised acute peritonitis is a relatively frequently pathology which has always been extremely difficult to treat owing to the large number of complications. Considerable progress has been made over the past few years in the surgical treatment of these pathologies following the introduction of new materials accompanied by new techniques: continuous peritoneal lavage (CPL) and laparostomy are the best known. These techniques must be used in carefully selected patients. They allow a marked improvement in results: fewer cases of redo surgery; fewer local and general complications; shorter hospitalisation stay; fewer deaths. These results are possible because these techniques ensure a better cleansing of the peritoneal cavity, with easier removal of necrotic and purulent materials, the main cause of local and general complications.

Virtual endoscopy: already a feasible proposition or a future prospect in diagnostics? A review of the literature.

The aim of this article was to carry out a retrospective analysis of the feasibility of using virtual endoscopy in the field of gastrointestinal diseases. After a retrospective review of the international literature the authors analyse the most controversial aspects of virtual endoscopy such as its effective diagnostic reliability and potential clinical employment with specific reference to diagnosing colon diseases. The international literature shows that virtual endoscopy is currently poorly sensitivity in detecting lesions measuring less than 10 mm in diameter and that the radiologist's experience can negatively condition the trustworthiness of this procedure. Virtual endoscopy is likely to be the future gold standard in the field of diagnostic imaging. Furthermore, it eliminates all the compliance-related problems and any risk of iatrogenic lesions such as perforations and bleedings which are typical of traditional endoscopy. Its current sensitivity, however, is poor and it is unable to detect lesions smaller than 10 mm. Its reliability therefore needs to be improved.

[Thrombolytic therapy in acute myocardial infarct]. / La terapia trombolitica nell'infarto acuto del miocardio.

The benefits, main pharmacological characteristics, indications, side effects and time limits for use of thrombolytic agents in acute myocardial infarction are reviewed. The authors also point out the strategies to follow in patients after thrombolytic therapy.