Ischemic stroke with cardiac involvement in aortic thromboembolism.

An aortic thrombus may be detected by using transesophageal echocardiography after an embolic event. Clinical features are variable and may include cardiac and neurologic symptoms, such as the stroke. We report a case of a woman with an acute ischemic stroke, a myocardial infarction and a free floating aortic thrombus.

A summary of the Milan experience with multimodality therapies in patients with small cell lung cancer: attempts to improve long-term outcome.

From February 1985 to June 1993, 173 consecutive, previously untreated patients with small cell lung cancer received individualized treatment tailored to disease extent. Almost all patients (14 of 16) with stage I and II disease and 30 patients with operable stage III disease were submitted to surgery preceded or followed by chemotherapy. Chest irradiation and prophylactic brain radiotherapy (in complete responders) were administered at the end of treatment in 42 of 44 cases. Patients with inoperable limited disease received chemotherapy followed by radiotherapy in 67 of 71 cases, while chemotherapy alone or followed by radiotherapy in sites of either initially bulky or residual disease was administered to 58 patients with extensive disease. The overall response rate was 77% (complete response, 45%; partial response, 32%). Complete responses were documented more frequently in limited disease than in extensive disease (57% v 22%; P < .001). The 2- and 5-year freedom from progression rates (24% and 16%, respectively), as well as overall survival rates (31% and 16%, respectively) were significantly affected by disease extent. No patient with extensive disease was progression free and alive at 2 years, while more than half of stage I and II patients were disease free and alive at 5 years. This retrospective analysis performed on a large number of consecutive, nonrandomized patients suggests that, at least in patients with limited disease, it is possible to achieve favorable long-term results using treatment tailored to disease extent. Nonetheless, the disappointing results commonly achieved in the treatment of small cell lung cancer strongly support the need for either prospective, randomized studies to confirm recently reported improved results or new pilot studies with investigation of entirely innovative approaches.

Comparison of mezlocillin and carbenicillin as therapy for various infectious diseases.

The efficacy and safety of mezlocillin, a new broad-spectrum semisynthetic penicillin, were compared with those of carbenicillin in a nonblind, controlled clinical study in 89 adult patients. The infections treated were primarily those of the urinary tract, skin, and gastrointestinal or hepatobiliary tract. Escherichia coli, Proteus mirabilis, Proteus morganii, and Pseudomonas aeruginosa were the causative organisms isolated most frequently. A complete resolution of signs and symptoms was achieved in 78% of the mezlocillin patients and in 71% of the carbenicillin patients. In the mezlocillin group, causative organisms were eliminated in 80% of the courses, and in the carbenicillin group the elimination rate was 86%. Two adverse reactions, rash and diarrhea, were reported in mezlocillin-treated patients; none were reported for the carbenicillin group.

Effect of cyclosporin A on hepatocyte proliferation after partial hepatectomy in rats: comparison with standard immunosuppressive agents.

The effects of cyclosporin A on the regenerating liver were studied in rats after partial hepatectomy and were compared with those of conventional immunosuppressants such as methylprednisolone and azathioprine. In Group I, a standard hepatectomy removing two thirds of the organ was performed. In Group II, an oral dose of 10 mg/kg of cyclosporin A was given 1 day before and immediately, 24 hours, and 48 hours after the same hepatectomy. In Groups III and IV, azathioprine and methylprednisolone were administered in 8 mg/kg doses by way of the tail vein by the same protocol as in Group II. The mortality rate, liver weight restoration, and histologic and mitotic characteristics of the liver remnants, as well as serum levels of animotransferase, total bilirubin, and creatinine were examined from 24 hours to 10 days after the operation. Azathioprine and methylprednisolone substantially suppressed hepatocyte mitosis when compared with the control group; however, cyclosporin A treatment did not inhibit, but may, in fact, have stimulated liver cell proliferation. Changes in other parameters coincided with this phenomenon. The noninhibitory effect of cyclosporin A on liver regeneration has also been discussed.

Liver biopsy and percutaneous cholangiography using a posterior approach. 500 needle biopsies and 121 cholangiographies.

A technique of posterior percutaneous liver biopsy and cholangiography was used in 500 liver biopsies and 121 cholangiographic examinations of the biliary tract. It provided a successful liver biopsy in 98.6 percent of cases and was associated with a less than 2 percent complication rate. Successful cholangiography was possible in all patients with dilated ducts and in 87 percent of patients with normal undilated ducts. Percutaneous cholangiography was associated with a 5 percent complication rate. The advantages of this technique are that it can be performed by relatively inexperienced physicians with minimal risk of hemo- or choleperitoneum. It has a low failure rate and can be performed in obese patients or patients with coagulation defects. The route of entry eliminates the risk of injury to the gallbladder or colon. Due to the posterior position, this technique can be used in relatively uncooperative patients.

Chronic effects of subcutaneous interleukin-2 therapy on soluble interleukin-2 receptors in advanced small cell lung cancer.

The increase in IL-2 receptor serum levels is one of the most typical changes in immune parameters during IL-2 cancer immunotherapy. To better define the effects of prolonged IL-2 injection on SIL-2R levels, we evaluated 7 advanced small cell lung cancer patients who received IL-2 subcutaneously at a daily dose of 9 x 10(6) IU/m2/12h for two days followed by 3 x 10(6) IU/m2/12h for 18 days (5 days/week for 4 weeks). Moreover, four patients were also evaluated during the second IL-2 cycle. Venous blood samples were drawn before and at weekly intervals during IL-2 therapy. Mean SIL-2R serum levels rapidly increased with the start of IL-2 injection, and they were significantly higher than the baseline levels throughout the immunotherapy cycle. The increase in mean SIL-2R levels was higher in patients with progressive disease than in those with response or stable disease, but the difference was not significant. Finally, the increase in mean SIL-2R concentrations during the second IL-2 cycle was not significantly different from that seen during the first one. The present study confirms that IL-2 administration determines an evident increase in SIL-2R levels; moreover, it would demonstrate that re-exposure to IL-2 after a rest period does not induce a more pronounced SIL-2R release.

Clinical errors in emergency medicine: experience at the emergency department of an Italian teaching hospital.

The level of commitment in the analysis of clinical errors made in the emergency department (ED) is currently focused on organization and processes rather than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that the process of clinical decision making and the overreliance on the use of patterns during the cognitive process had a major role in causing the errors, rather than factors related to procedures or organization. It appears hard to design system changes and tactics to significantly reduce the probability of making errors associated with the cognitive process involved in clinical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clinically significant errors is tracked. A file is being created with the purpose to use it for teaching and orientation of all new staff.

Clinical trial of high doses of Bay I 7433 (Copovithane).

Bay i 7433 (Copovithane) is a biological response modifier with antitumour activity in vivo, but no cytotoxic or cytostatic effect in vitro. A clinical trial of the compound at doses of 15g/m2/week was carried out for six weeks in 10 patients with various forms of cancer. Tolerance was good: no systemic toxicity was observed but local inflammation occurred in two cases at the site of injection. No objective antitumour response was observed.

Changes in composition of platelet membranes after "in vitro" incubation.

Platelet membranes were isolated by the glycerol lysis technique and incubated in Krebs-Ringer phosphate buffer, to determine their chemical modifications occurring during "in vitro" incubation. The main changes observed at the end of the incubation consist in a significant loss of protein components and in the nearly equimolar decrease of sialic acid and galactosamine. Aminoacid analysis indicate that mainly polar aminoacids are lost. SDS-polyacrylamide gel electrophoresis indicates that high molecular weight proteins disappear after incubation, while no relevant differences in the relative ratios between PAS-stained bands were evident. The reported modifications are quite similar to those described in the membranes of in vivo and in vitro aged red cells.

Ciprofloxacin: multiple-dose pharmacokinetic and clinical results in patients with hypercrinic bronchopulmonary diseases.

Ciprofloxacin, a 4-quinolone derivative with a wider spectrum of activity as compared to classic quinolones employed in the therapy of urinary tract infections, was studied in view of its possible application in the therapy of bronchopulmonary infections. An oral dose of 500 mg every 12 h was administered and both the clinical response and the pharmacokinetic profile were investigated. A complete recovery was reached in 87.5% of patients and an improvement in 12.5%; no failure was recorded. A very good penetration in sputum was confirmed by the sputum/serum area under curve ratio, providing evidence for a high bioavailability in bronchial secretion. Lung tissue concentrations confirmed the good peripheral distribution of ciprofloxacin. A twelve-hour administration schedule allows high peripheral concentrations to be obtained superior or equal to the minimum inhibitory concentrations for many pathogens.

[Metastatic breast cancer: what are the objectives?]. / Il carcinoma metastatico della mammella: quali obiettivi?

UNLABELLED: The medical approach to the treatment of metastatic breast cancer has changed in the last decade since the introduction of new drugs that demonstrate high activity and better tolerability profiles. The hormonal treatment, usually considered the first choice therapy for ER-positive metastatic breast cancer patients, has seen several improvements with the discovery of new selective aromatase-inhibitor agents and pure antiestrogens. New aromatase-inhibitors have shown higher activity and fewer side effects compared to megestrol acetate in second line treatment. The first line treatment has unchanged so far, but in the next future is possible that different agents, with lower toxicity, will replace tamoxifen since studies comparing this agent with pure antiestrogens or selective aromatase-inhibitors are ongoing. These new drugs would provide a better palliation of metastatic breast cancer in terms of higher clinical benefit, tolerability and quality of life. Chemotherapy is often used in ER-negative patients or in aggressive hormone refractory disease. Randomized trials have demonstrated that anthracyclin-containing regimens were more effective than combinations without anthracyclines. New cytotoxic drugs with high activity, such as taxanes (paclitaxel and docetaxel), vinorelbine, gemcitabine and capecitabine, have been introduced. Compared with older therapies, improved objective response rates and/or improved duration of response have been reported with these newer agents alone or in combination with other drugs. However, no clear improvement of overall survival has been shown so far. Taxanos alone or in combination are today considered the second line treatment of choice and studies are assessing the value of a taxane-anthracycline containing regimen in first line treatment. Some new agents (vinorelbine) showed, alone or in combination, an interesting cost-effectiveness ratio with similar or higher "quality adjusted progression free survival" if compared to taxanes. Promising are also the results of agents that own low toxicity with comparable efficacy such as liposomal anthracycline. Attempts to improve overall survival with increased dose intensity or with high dose chemotherapy are disappointing. CONCLUSIONS: Since the goal of treatment of metastatic breast cancer is disease control rather than disease skill i.e. palliation of patients with complications of progressive cancer, the new agents have brought significant improvements (higher response rates, median time to progression, cost benefit and better tolerability). Future progresses for this disease, hopefully even in overall survival, will depend on the introduction of new therapies such as immunotherapy, inhibition of intracellular signaling, interference with tumor angiogenesis, gene-therapy and the development of vaccines.

[Clinical evaluation of the activity of 2 preparations with similar action in bronchopneumopathies in the aged]. / Valutazione clinica dell'attività di due preparati ad azione similare nelle broncopneumopatie in età senile.

The results obtained in a single blind controlled study using a new preparation, guacetisal, and an already available similar product based on dimethylaminophenazone guaiacolglycolate and calcium ethylcamphorate, are reported. The drugs were administered to 28 elderly patients of both sexes suffering from bronchopneumopathies for a period of 7 consecutive days with 2 suppositories/day. The results generally favoured the new product. Tolerance was very good at all levels.

[Guacetisal: a new molecule with balsamic-antiphlogistic action. Clinical study]. / Guacetisal: nuova molecola ad azione balsamico-antiflogistica. Studio clinico.

An open clinical trial was run on the therapeutic efficacy of a new balsamic-antiinflammatory molecule, guacetisal (presented as 500 mg Broncaspin capsules). The drug was given for a minimum of 7 days to 45 male and female patients with an average age of 64 yr suffering from variously serious diseases of the airways. The concomitant administration of fluidifying, balsamic, steroid, antipyretic and anti-inflammatory drugs was avoided, whereas various combinations of cardiokinetics, diuretics, theophyllines, and antibiotics were used where required. Clinical assessment of the parameters chosen pointed to the good therapeutic activity of the preparation, which is specifically indicated in inflammatory conditions of the airways, especially chronic forms subject to periodic recrudescence. Its equally good tolerability serves to make guacetisal extremely easy to use, with the results that its employment in non-specialist environments can also be recommended.

[Surgical treatment of 100 patients with perforated pyloric ulcer. Immediate and follow-up results]. / Trattamento chirurgico di 100 pazienti con ulcera pilorica perforata. Risultati immediati e a distanza.

The aim of this study was to assess the results of different surgical treatments in 100 patients admitted from 1972 to 1984 with perforated pyloric ulcer. Forty-six patients were treated with simple suture, thirty-two patients underwent high selective vagotomy with pyloroplasty, 13 patients were submitted to truncal vagotomy with pyloroplasty and 9 to gastrectomy. This study has shown that high selective vagotomy and pyloroplasty for perforated pyloric ulcer can be performed as safely as simple closure. The overall clinical results according to the Visick classification were recorded as excellent or very good in 85 per cent of patients treated with high selective vagotomy with pyloroplasty versus 38 per cent with similar results in simple closure patients. We conclude that high selective vagotomy with pyloroplasty is not less effective for treatment of pyloric perforated ulcer than for duodenal ulcer; simple closure should be reserved for patients treated long time after perforation and with advanced age or in patients with serious associated pathology.

[Heller's extramucosal cardiomyotomy under endoscopic control. The long-term results]. / Cardiomiotomia extramucosa secondo Heller sotto controllo endoscopico. Risultati a distanza.

Twenty-five patients underwent Heller cardiomyotomy with Nissen fundoplication, made through an abdominal incision under endoscopic control. Long term results were evaluated according to clinical, radiological, manometric and 24-hour esophageal pH-metric studies. Clinical results were excellent in 44% of the patients, good in 40%, fair in 4% and bad in 12%. The four unsatisfactory results are due to recurrence of dysphagia in one case and to appearance of GER in the others. Postoperative X-ray controls and manometric tests showed a significative decrease in the esophageal diameter, in resting and post swallowing LES and esophageal body pressure. The 24-hour pH test showed an abnormal percentage of time with pH less than 4 in two patients, and a direct connection with clinical and endoscopic results. Endoscopic control of myotomy allows us to define precisely the extension of the functional stenosis and to eliminate completely the dysphagia. In the postoperative evaluation the 24-hour pH monitoring allows an early identification of GER, and the prevention of possible complications even in the absence of any clinical sign.

[Epidemiology of severe thoracic trauma at a multiregional urban hospital. Analysis of 5 years]. / Epidemiologia del trauma toracico grave in un Ospedale urbano multizonale. Analisi di 5 anni.

The authors re-examined 198 cases of severe chest trauma presented in their hospital in 1983-1987. They analyse the clinical conditions, the diagnostic and therapeutic procedures, the results and complications and evaluate each patient according to the ISS code to compare them with the literature data, for the dead patients they classify the lesions according to the autoptic examinations. They confirm in this the validity of the ISS that can be well correlated with: mortality, length of survival and length of hospitalisation, they indicate important prognostic factors such as: age, association with extra thoracic lesions and number of intrathoracic lesions. Plotting the mortality in function of the time, they stress the need for an expert team in the first hours after trauma to manage such patients.

[Chest pain and acute myocardial infarction at the emergency department: diagnostic and therapeutic approaches. Experience of the San Camillo Hospital in Rome]. / Dolore toracico e infarto miocardico acuto in Pronto Soccorso: percorsi diagnostici e terapeutici. L'esperienza dell'Ospedale San Camillo di Roma.

BACKGROUND: Identification and treatment of patients with acute chest pain due to acute coronary syndrome is a common and difficult challenge for emergency physicians. The aim of this study was to establish: a) the reliability of diagnosis of acute myocardial infarction met in the emergency ward, b) the length of the patient's hospital stay with acute myocardial infarction discovered and treated in the emergency ward either with primary angioplasty or with thrombolysis. METHODS: We analyzed the data collected in the emergency ward of the San Camillo Hospital in Rome from January 1 to June 30, 2000, with patients suffering from chest pain and diagnosis after hospitalization. The reliability of diagnosis of acute myocardial infarction was calculated from the comparison of the diagnosis in the emergency ward and the diagnosis at hospital discharge. RESULTS: From January 1 to June 30, 2000, 45,810 patients have asked for help at the emergency ward; 2334 (5.1%) of these were suffering from chest pain. The diagnosis of acute myocardial infarction was done in the emergency ward in 147 cases (141 hospitalized, 4 deceased, and 2 transferred to other hospitals), equal to 65% of all those discharged with the same diagnosis in the period under examination. In 66 out of the 141 cases hospitalized (46.8%) primary angioplasty was successfully performed; in 14 (9.9%) only coronary angiography was performed (primary angioplasty unfeasible); in 22 (15.6%) thrombolysis was administered whereas in 38 cases (27.0%) other treatments were used. The average stay for the different groups turned out to be 9.8 +/- 4 days for primary angioplasty and 12.9 +/- 4 days for thrombolysis: the difference was relevant. CONCLUSIONS: The accuracy value of the diagnosis of acute myocardial infarction made in the emergency ward of our Hospital is the same as that published in the international literature and demonstrates the high level of treatment of chest pain. Furthermore, the shorter hospital stay obtained by primary angioplasty in comparison with thrombolysis seems to strengthen the already favorable cost-benefit ratio of primary angioplasty in comparison with thrombolysis.

[Surgical therapy of perforated duodenal ulcers: suture versus highly selective vagotomy. Immediate and remote results (case series from 1978 to 1990)]. / Terapia chirurgica delle ulcere duodenali perforate: rafia versus vagotomia superselettiva. Risultati immediati e a distanza (casistica dal 1978 al 1990).

The aim of this study was to compare the results of high selective vagotomy and simple suture in the treatment of perforated duodenal ulcer. Among 150 patients admitted in our institute from 1978 to 1990, 96 were treated with simple suture while 54 underwent high-selective vagotomy (42 with pyloroplasty). In our study with high-selective vagotomy we had no surgical mortality and low morbidity. The overall clinical results according to the Visick evaluation, were recorded as excellent or good, in 90.9% cases in the group of patients treated with high-selective vagotomy versus 40% in the group with simple suture, after a similar period of follow-up. The recurrence of ulcers after high-selective vagotomy was of 6%, compared with 32.6% in simple suture patients. The results of high-selective vagotomy performed for perforated duodenal ulcers were compared with those of a group of duodenal ulcers not complicated treated with high-selective vagotomy too; the better results of this last group may be due to higher technical difficulties in presence of peritonitis. High selective vagotomy is therefore a safe procedure in the management of perforated duodenal ulcer, and moreover obtains good long-term results in the control of peptic disease.

[Spontaneous pneumothorax caused by lung metastasis of sarcoma of the thigh]. / Pneumotorace spontaneo da metastasi polmonare di sarcoma della coscia.

Relapsing spontaneous pneumothorax can be the first manifestation of pulmonary metastases of soft tissues sarcomas. Standard imaging techniques and computed tomography may not be able to detect small malignant cystic lesion or to distinguish between them and benign bollous lesions. We report the case of a 33 year-old male who, in the past, underwent surgical treatment for a synovial sarcoma of the inferior limb. The patient was admitted to our hospital because of right spontaneous pneumothorax; both chest x-ray and CT scan didn't detect any metastatic pulmonary lesion. A few days after the discharge the patient was readmitted because of relapsed pneumothorax; high-definition CT of the chest revealed a pulmonary cystic lesion that was resected thoracoscopically. Histological examination revealed a pulmonary metastases of synovial sarcoma.

[Heparin and lipoprotein(a). Observations during hemodialysis]. / Eparina e lipoproteina(a). Osservazioni in corso di emodialisi.

The effect of heparin (bolus e.v. 5.000 I.U.) on blood levels of Lp(a) and other lipids (triglycerides, -HDL, -LDL and total cholesterol, apo A1, apo B100 and apo A1/apo B100) was studied in 15 patients (8 M and 7 F) with chronic renal failure during hemodialysis. Statistically significant reductions of the basal values were found for Lp(a) and the other lipids in the blood taken before the beginning of dialysis, 30 min' after the heparin bolus. The analysis of third blood sample (at the end of the hemodialysis, one hour after the end of the heparin maintenance infusion) showed a rise of HDL and LDL-lipoproteins over the basal values clearly in relation to reduced heparin and plasmatic fraction of the blood. The values of Lp(a) had not so high increase as consequence of more elevated affinity with heparin and of a possible enhanced metabolic rate via lipoprotein lipase. The authors, in agreement with similar changes of Lp(a) and other lipids previously observed in patients with coronary diseases during bypass surgery in extracorporeal circulation or angioplasty, (interventions requiring generous heparin treatment), believe to have now sufficient data for attributing heparin a causal role for the above mentioned effects. The authors stress the needing of other studies better understand the action to mechanisms of heparin and to evaluate possible future clinical applications of this new interesting Lp(a)-clearing effect.