[Incidence of alarm criteria and attitude towards patients with headache attended in emergency departments]. / Incidencia de criterios de alarma y actitud frente a los pacientes con cefalea atendidos en urgencias.

INTRODUCTION: Alarm criteria make it possible to identify persons who visit emergency services because of severe secondary headaches. AIMS: To determine the socio-demographic characteristics of the patients who visit emergency departments due to headache, the incidence of alarm criteria, treatment and the diagnosis after one year's follow-up. PATIENTS AND METHODS: We conducted a retrospective observational cross-sectional study of the persons attended in the emergency department of the Arnau de Vilanova Hospital between June 2014 and May 2015 due to headache. RESULTS: A total of 303 persons were identified, of whom 165 were finally included in the study. There was a predominance of women (66.7%). The mean age was 41.2 ± 15.9 years. Only 16.4% were referred from primary care and 52 (31.5%) presented alarm criteria. A computerised tomography head scan was performed in half of these cases, and lumbar puncture was carried out in four of them (7.7%). A serious cause of headache was found in four cases (2.4%). After one year of follow-up, three patients who did not initially visit because of alarm criteria were diagnosed with severe diseases of the central nervous system, and 23 (13.9%) returned to the emergency department for the same reason. CONCLUSIONS: Only one out of every two patients meets the alarm criteria. The proportion of severe secondary headache is really low. The multidisciplinary management of headache needs to be improved in our setting to prevent people visiting the emergency department due to primary headaches without any alarm criteria.

TITLE: Incidencia de criterios de alarma y actitud frente a los pacientes con cefalea atendidos en urgencias.Introduccion. Los criterios de alarma permiten identificar a las personas que consultan por cefaleas secundarias graves en los servicios de urgencias. Objetivo. Determinar las caracteristicas sociodemograficas de los pacientes que acuden a urgencias por cefalea, la incidencia de criterios de alarma, el tratamiento y el diagnostico tras un año de seguimiento. Pacientes y metodos. Estudio transversal retrospectivo y observacional de personas atendidas en el servicio de urgencias del Hospital Arnau de Vilanova entre junio de 2014 y mayo de 2015 por cefalea. Resultados. Se identifico a un total de 303 personas, de las cuales 165 se incluyeron finalmente en el estudio. Hubo un predomino de mujeres (66,7%). La edad media fue de 41,2 ± 15,9 años. Solo un 16,4% fue derivado desde atencion primaria y 52 (31,5%) presentaban criterios de alarma. En la mitad de estos casos se realizo una tomografia computarizada craneal, y en 4 (7,7%), una puncion lumbar. Se identifico una causa grave de la cefalea en 4 casos (2,4%). Tras un año de seguimiento, tres pacientes que inicialmente no consultaron por criterios de alarma fueron diagnosticados de enfermedades graves del sistema nervioso central, y 23 (13,9%) volvieron a urgencias por el mismo motivo. Conclusiones. Solo uno de cada dos pacientes cumple criterios de alarma. La proporcion de cefalea secundaria grave es realmente baja. Es necesario mejorar el abordaje multidisciplinar de la cefalea en nuestro ambito para evitar la consulta a urgencias por cefaleas primarias sin criterios de alarma.

Influence of drying process and particle size of persimmon fibre on its physicochemical, antioxidant, hydration and emulsifying properties.

Persimmon, given its current surplus production, could be an alternative source for the extraction of certain interesting ingredients for the food industry and human health, such as fibre. Thus, the aim of this study was to analyse the influence of hot air and freeze-drying, as well as the particle size of fibre extracted from persimmon peels or pulp on their physicochemical, antioxidant, hydration and emulsifying properties, compared to commercial fibres (from peach, lemon, orange and apple). The results showed that both freeze-dried persimmon pulp and freeze-dried peel had better hydration properties and oil holding capacity than other fibres analysed, although the swelling capacity was higher for lemon fibre. Freeze-dried persimmon peel fibre showed higher values of emulsion stability than commercial fibres. Finally, the antioxidant activity of the smallest sized persimmon peel fibre obtained by freeze-drying was higher than that for lemon, orange and peach fibre.

Erythema nodosum in kidney transplant recipient: a rare complication of pneumonia treatment.

Erythema nodosum (EN) is a cutaneous inflammatory reaction, usually reported in young women, but it is rarely observed among transplant patients. Localization in the lower extremities is typical, mostly involving the anterior surfaces of the legs. Several viral, bacterial, mycotic, and non-infectious etiologies, such as autommune disorders, drugs, inflammatory bowel diseases, sarcoidosis, pregnancy, and malignancies, have been found. We describe the case of a young woman kidney transplant recipient developing bilateral, erythematous, warm nodules localized on the anterior surface of her legs after antibiotic treatment for pneumonia with levofloxacin. Her immunosuppression was sirolimus and mycophenolate mofetil. EN was diagnosed by skin biopsy; microscopic examination showed septal panniculitis with granulomas. As a complete remission of the lesions was obtained in our patient after interruption of levofloxacin therapy, we suspect that levofloxacin was involved in the pathogenesis of EN. In fact, the management of EN is based on the treatment of underlying or associated conditions.

Use of the CYP2E1 genotype and phenotype for the biological monitoring of occupational exposure to styrene.

The CYP2E1 has been identified as the main cytochrome P450 isoform involved in human styrene metabolism. CYP2E1 presents polymorphism in humans and the different genotypes may, at least partly, be related to the different levels of individual expression of enzyme activity. We studied whether the genetic polymorphisms and phenotype of CYP2E1 modulate the level of urinary styrene metabolites and if they can be used for assessing risks of occupational exposure to styrene. A population of 49 male workers exposed to styrene (average level 362.7mg/m(3)) and a control group were selected. Samples of urine, blood and buccal swab were taken to determine the urinary biological indicators (phenylglyoxylic acid and mandelic acid), to quantify mRNA of CYP2E1 in blood using RT-PCR and to analyse different polymorphisms of enzyme CYP2E1 from buccal swab. We found decreased expression of mRNA of the enzyme, as well as decreased excretion of the styrene metabolites in individuals carrying the CYP2E1*5B heterozygote allele (cl/c2) with respect to the wild-type homozygote (c1/c1), which indicates a reduction in the inducibility of the enzyme in the presence of this polymorphism. The results show that the combined effect of both the CYP2E1 phenotype, measured by the expression of the specific mRNA in blood samples, and the CYP2E1*5B allele genotype, may explain the variability of urinary excretion of the styrene metabolites.

[The Fantoni translaryngeal tracheostomy: perioperative complications In a series of 220 consecutive patients]. / Tracheotomia translaringea secondo Fantoni. Complicanze perioperatorie su una serie consecutiva di 220 pazienti.

BACKGROUND: To evaluate problems arisen du-ring Fantoni translaryngeal tracheostomy (TLT). SETTING: intensive care unit. PATIENTS: 220 patients (aged from 18 to 87). EXCLUSION CRITERIA: coagulopathy, difficult intubation, local infections, previous neck surgery, suspected cervical spine lesion, severe hypoxemia, hemodynamic instability, patients close to be discharged from ICU. Operation: TLT was performed in general anesthesia, using the technique described by Fantoni in 206 cases; in the other 14 cases changes were made. RESULTS: Perioperative clinical complications were separated from instrumental problems. Clinical complications were 28 (12.7% of TLT): 20 (9.1% of total TLT, 71.4% of total complications) were considered minor and ascribed to medical staff training; among these the complete drawing of the cannula and the difficulty in pushing it in trachea. Eight complications (3.6% of TLT, 28.6% of total complications) were considered major; they were: the impossibility to place the cannula in trachea, the displacement of the prothesis in the peritracheal tissue, the rupture of tracheal ring, the bleeding and the infection of tracheostomy, the dental uprooting. Among instrumental problems, the faulty closure of the ring nut, the overdimension of rigid tracheoscope, and the difficult change of the cannula were observed. CONCLUSIONS: With expert medical staff, this technique is effective and safe, with a low rate of complications. Major complications were rare, and occurred in spite of patients selection, often needing changing of TLT in surgical tracheostomy.

[Nutritional status disorders prevalence rates in a sample of pediatric oncology Day Hospital patients]. / Prevalenza delle alterazioni dello stato nutrizionale in un campione di pazienti afferenti a un day hospital oncologico pediatrico.

BACKGROUND: Nutritional status is more important in children than in adults because it is necessary to support normal growth and development. In industrialized countries the prevalence of nutritional status disorders in the pediatric population are as follows: 35-40% of children are overweight/obese, while the underweight status disappeared in some reports or, when it is present, it is associated with other diseases. The aim of this study was to investigate the prevalence rates of nutritional status disorders among an unselected sample of Pediatric Oncology Day Hospital patients. METHODS: Anthropometric parameters of weight and height have been measured in patients affected with solid tumor either on-therapy or off-therapy (0-24 mo). Then Real Body Weight (% RBW) was estimated referring to National Center for Health Statistic percentiles. The sample was then divided into 4 weight classes (under-weight, normal-weight, over-weight and obese) according to % RBW. RESULTS: Overweight patients (overweight + obese) were 44.4%, and 13.9% underweight. Dividing the patients according to whether they are on-therapy or off-therapy, the prevalence of overweight was 36.9% in the former group and 52.9% in the latter, and the underweight prevalence was 26.3 vs 0%. CONCLUSIONS: Our preliminary data show that in this sample of patients on treatment obesity and overweight are present in a similar percentage of the healthy population, but underweight status prevalence is 26.3%. In the sample of patients off-therapy the underweight status disappeared while the overweight status increased. These data suggest that nutritional assessment in oncologic patients is required in order to provide nutritional strategies.

Nephron-sparing surgery for unilateral primary renal tumor in children.

PURPOSE: Definition of the role of nephron-sparing surgery (NSS) in the treatment of children with primary unilateral renal tumor (URT). METHODS: Between January 1992 and June 2000, 28 children with URT were admitted to our surgical unit. Criteria for selection of patients eligible for NSS were at least 50% of affected kidney preservable and stage I at surgery (frozen section biopsies from regional lymph nodes, perirenal fat, and surrounding renal parenchyma). Preoperative 2-drug chemotherapy was given to all patients more than 6 months of age. Between 1992 and 1995, 3-drug chemotherapy was used after NSS. Thereafter, following NSS, 2-drug chemotherapy was given if no microscopic residual disease was found on final histologic examination. RESULTS: NSS was feasible in 10 of 28 children (35%). Enucleation of 6 tumors (1 metachronous) was performed in 5 patients. NSS was elective in 5 patients, mandatory in 3 patients (1 with aniridia and genitourinary anomalies, 1 with chronic glomerulonephritis, 1 with bilateral hyperplastic nephroblastomatosis), and advisable in 2 patients (1 with familial vesicoureteric reflux and 1 with cystic nephroma). Seven children had standard histology nephroblastoma, 1 highly differentiated epithelial type nephroblastoma, 1 oncocytoma, and 1 cystic nephroma. The only post-NSS complication was macroscopic hematuria in 1 patient. None of the patients had a relapse. All children are alive and disease free with good functioning of the affected kidney after NSS, at a mean follow-up of 40.7 months (range, 2 to 100 months). CONCLUSION: NSS should be considered in selected children with URT, especially in patients with increased risk for metachronous tumor or renal disease, and in patients with benign or low-grade malignant URT.

Ten-day schedule oral etoposide therapy in advanced childhood malignancies.

PURPOSE: The activity of etoposide (VP-16) has been demonstrated to be schedule-dependent. Several studies have been conducted on the efficacy and safety of different schedules of VP-16 both in adults and in children, but the optimal schedule has not been determined. METHODS: In the current study, the feasibility and effectiveness of prolonged oral VP-16 in children with high-risk malignancies were evaluated. Between April 1995 and February 1999, 15 pretreated patients with high-risk tumors received oral VP-16. The schedule of therapy was oral VP-16 50 mg/m2/day for 10 consecutive days and 1-week interval between cycles. Therapy was stopped after 1 year of treatment or at time of progressive disease or possible surgery. All patients had received parenteral VP-16 in their earlier chemotherapy. RESULTS: Twelve patients were evaluable for tumor response. After 2 to 4 months of treatment, one patient had complete remission (CR), two had partial response (PR), two had minor response (MR), two had mixed response (MxR), three had stable disease (SD), and two had progressive disease (PD). A useful palliative effect was noted in patients with stable disease. In three patients, oral VP-16 was administered for maintenance therapy. After an average follow-up of 27.5 months (range, 7-41 months), five patients are alive without disease (in three, total surgery was performed after VP-16 therapy) and three patients are alive with disease. Six patients died of progressive disease, and one died of promyelocytic leukemia. One patient had Grade 34 thrombocytopenia; in the remaining patients, no acute toxicity was observed during treatment. CONCLUSIONS: This schedule of oral VP-16 produced CRs, PRs, and MRs in medulloblastoma, neuroblastoma, teratocarcinoma, and ependymoma. Stable disease was observed in three patients, one with an Askin tumor, one with medulloblastoma, and one with hepatoblastoma. Given the possible leukemogenic risk, this schedule should be used as a palliative form of therapy or in patients with poor prognosis..

Hypersensitivity to carboplatin in children.

BACKGROUND: Hypersensitivity reactions are rare but at times severe complications to cytostatic drugs. PROCEDURE: The percentage of allergic reactions to carboplatin and their clinical features were evaluated in 185 children affected by different solid tumors and treated with etoposide-carboplatin chemotherapy. Allergic reactions that occurred during or immediately following etoposide infusion (5 cases, 2.8%) were excluded from the study. RESULTS: Seventeen out of 185 patients (9.2%) suffered from allergic responses to carboplatin. The first of these occurred after an average of 10.1 courses (range, 1-23; median, 9). The risk calculated according to the number of courses is 2% at 6 courses, 11.3% at 12 courses, and 47% at more than 12 courses. CONCLUSIONS: The high risk of allergic reactions to multiple courses of carboplatin should be kept in mind when developing treatment regimens that include the drug.

Metastatic medulloblastoma in 10-year-old girl treated successfully with chemotherapy without radiotherapy.

We report a case of high risk medulloblastoma with leptomeningeal intracranial and spinal metastasis in a 10-year-old girl treated successfully with conventional prolonged chemotherapy without radiotherapy. This is a particular case of medulloblastoma that at onset did not receive standard therapy for medulloblastoma i.e. neither surgery nor craniospinal irradiation. This 10-year-old Chinese girl affected with localized medulloblastoma was previously treated at a medical department in China only with radiotherapy on the posterior fossa. When the child arrived in Italy with progressed metastatic medulloblastoma, she was treated with carboplatin/etoposide association i.v. followed by oral etoposide and partial surgery of the primitive mass. The schedule of chemotherapy was etoposide 300 mg/sqm followed by carboplatin 1000 mg/sqm in one day every 21-28 days for the first six courses, then etoposide 200 mg/sqm and carboplatin 600 mg/sqm in one day every 28-35 days for further 11 courses and oral etoposide 50 mg/sqm/day for ten consecutive days and one week interval between two cycles for one year. At present the girl is alive and disease-free, and has been off-therapy for 31 months. Interestingly, in this case a long-lasting complete remission was obtained without radiotherapy and without myeloablative chemotherapy. Oral etoposide played an important role in achieving a complete remission.

Chemotherapy in low-grade astrocytoma management.

The role of chemotherapy (CHT) in the management of low-grade astrocytoma (LGA) is still unclear. Nineteen children with nonresectable symptomatic LGA were treated with carboplatin (CBDCA) and etoposide (E). There were 15 newly diagnosed cases and 4 were relapses; 6 of the children were under 5 years old. In all children radiological evaluation by CT scan and/or MRI was performed after four courses of CHT. We observed complete response (CR)+ minor response (MR) in 37% of these cases and an improvement in neurological symptoms in 63%. Radiological evaluation performed in 6 patients who received CHT for longer periods (8-12 courses) showed major responses (CR+PR) in 67%. Local radiotherapy (40 Gy) was administered after CHT in 14 cases, but in 3 of these radiotherapy was delayed for 2 years. Five patients did not receive radiotherapy. The overall survival was 58% after an average follow-up of 60 months. All patients with brain stem tumors died of progressive disease even though 3 of these had shown clinical improvement after chemotherapy. In conclusion, in the treatment of nonresectable symptomatic LGA, CHT with CBDCA associated with E can be used to postpone radiotherapy in young children and even to avoid radiotherapy in some cases.

Ceftriaxone as a single agent in empirical therapy of unexplained fever in granulocytopenic children with solid tumors.

The optimal management of fever in granulocytopenic cancer patients remains controversial. Antibiotic monotherapy is increasingly an option for the initial empiric treatment of febrile granulocytopenic patients with solid tumors. Available data show that response to empiric therapy is often more related to disease classification (solid tumors vs. acute leukemia) than to the regimen used. In this study we based empiric monotherapy on the underlying disease (solid tumors) in treating 33 episodes of fever in 26 granulocytopenic children with cancer. We investigated the potential effectiveness of single daily doses of ceftriaxone administered empirically in febrile granulocytopenic children with solid tumors. Fever was treated successfully with ceftriaxone monotherapy in 91% (30/33) of febrile episodes. None of the patients died as a result of primary infection. These results suggest that empirical monotherapy with once-daily ceftriaxone is safe and effective. In addition, when compared with other extended-spectrum cephalosporins such as ceftazidime, once-daily administration of ceftriaxone reduces cost and patient inconvenience, allowing convenient parenteral therapy even on an outpatient basis.

Use of ICRF-187 for prevention of anthracycline cardiotoxicity in children: preliminary results.

The objective of this study is to assess the efficacy of ICRF-187 as a protective agent against anthracycline cardiotoxicity. Cardiac function was evaluated by echocardiography before and after each cycle of anthracycline chemotherapy associated with ICRF-187 and compared with that of a second group receiving anthracycline chemotherapy without ICRF-187. The patients were a group of 15 consecutive children affected with various types of solid tumors who were treated with either doxorubicin-daunomycin or epirubicin (average doses 340 and 280 mg/m2, respectively), and treatment was associated with ICRF-187. A second group of 15 consecutive children affected with different malignancies were simultaneously treated with either doxorubicin-daunomycin or epirubicin (average doses 309 and 270 mg/m2, respectively), but without ICRF-187 association. None of the patients treated with anthracyclines and ICRF-187 association showed abnormalities on echocardiographic examination. In the second group of patients treated with anthracyclines but without ICRF-187 association, we observed a decrease in the left ventricular ejection fraction to < 55% and a decrease in the left ventricular fractional shortening to < 28% in two patients (13.3%). One of these (6.6%) showed a dilatative cardiomyopathy. Both groups of patients were treated with low doses of anthracyclines. Although this study was not randomized, in patients without ICRF-87 cardioprotection, there was a trend for a worse evolution with one case of clinical cardiomyopathy as well as subclinical cardiac abnormalities.

Successful management with interferon alpha-2a after prednisone therapy failure in an infant with a giant cavernous hemangioma.

A giant cavernous hemangioma of the left arm with severe thrombocytopenia and consumptive coagulopathy was observed in a neonate. Initial treatment with prednisone, platelet transfusions, and clotting replacement failed to control the bleedings. The child was then treated with daily subcutaneous infusions of interferon alpha-2a. Coagulopathy rapidly improved and transfusions were drastically reduced. The hemangioma regressed progressively and disappeared after 4 months of treatment.

Long-lasting complete remission after prolonged administration of etoposide in a child with a second recurrence of alveolar rhabdomyosarcoma.

The authors report a case of alveolar rhabdomyosarcoma (RMS) of the thigh complicated by two successive distant relapses shortly after radio- and chemotherapy, treated with etoposide, and resulting in complete long-lasting remission. The schedule of etoposide was 100 mg/ m2/d intravenously for three days weekly for 3 weeks, with an interval of 1 week between courses. This was administered for 11 months. The child is alive without disease and off therapy 20 months after completion of etoposide treatment. Preclinical studies and experience in adults have suggested that the cytotoxic effects of etoposide show a marked dependence on schedule. A divided dose regimen of single-agent etoposide has previously been shown to have activity in relapsed rhabdomyosarcoma, but the outcome or the duration of complete response has not yet been fully evaluated. In out poor-prognosis case, the prolonged administration of etoposide achieved a long-lasting complete response.

Ganciclovir therapy for cytomegalovirus-associated liver disease in immunocompetent or immunocompromised children.

Ganciclovir therapy was given intravenously to 20 children with cytomegalovirus (CMV)-associated liver disease, of whom 6 were immunocompetent and 14 were immunocompromised (9 had AIDS and 5 had solid tumors). Immunocompetent children had isolated liver disease diagnosed at birth (4 children), or systemic congenital CMV infection including liver disease (2 children). Ganciclovir was used following two regimens: A) 5 mg/kg twice daily for 8 to 86 days (mean 21); B) 7.5 mg/kg twice daily for 14 days followed by 10 mg/kg three times weekly for three months. CMV infection was diagnosed by viral isolation, detection of viral antigens, and/or CMV DNA from blood and urine. All immunocompetent children had negative CMV culture and CMV DNA detection from blood and/or urine after 14 weeks of treatment. However, the three children who were treated with regimen B showed normal ALT levels at the end of the maintenance course, whereas the children who received ganciclovir with regimen A had normal ALT levels only after about 1 year. All children with tumors initiated regimen B, but only three, who had negative CMV detection and markedly decreased ALT levels, received full treatment; of the remaining two children, one recovered after only an initial course, and the other had therapy interrupted because of hepatic failure and died 9 days later. In contrast, the children with AIDS received several ganciclovir courses for different periods at the lower dosage: they generally improved during treatment but did not recover completely, and five children died with active CMV infections. Based on our study, CMV-associated liver disease can be efficiently treated with ganciclovir both in immunocompetent and immunodeficient children. However, a single ganciclovir course including a higher dosage and prolonged therapy appeared to be more effective than several courses with lower dosages.

Immunohistochemical detection of p140trkA and p75LNGFR neurotrophin receptors in neuroblastoma.

In neuroblastoma, high levels of mRNA for p140trkA and p75LNGFR neurotrophin receptors are predictive of favorable outcome. Their evaluation by Northern blot, however, requires substantial amounts of tissue and this prevents their routine evaluation as well as the possibility for multicenter studies to be easily carried out. In an attempt to overcome these limitations, the feasibility and reliability of determining both neurotrophin receptors on cryostat sections by immunohistochemistry were assessed, and these findings were compared to those obtained from Northern blot analysis. Primary tumor samples from 28 untreated patients at all stages were evaluated by using H10 anti-p140trkA and ME20.4 anti-p75LNGFR mAbs. Although weak, positive immunostaining was found in 9 of 28 tumors for p140trkA and in 5 of 28 tumors for p75LNGFR. As compared to Northern blot, the concordance rate was 79% (22 of 28 cases) for p140trkA (p < 0.05) and 71% (20 of 28 cases) for p75LNGFR (p < 0.05). No case negative for Northern blot was found to be positive with immunohistochemistry. Since only high mRNA levels for both receptors have been shown to be clinically relevant, their immunohistochemical detection, although less sensitive than Northern blot, can be just as sufficient and reliable as a prognostic tool, and possibly with a better cost-benefit ratio.