Primary Hyperparathyroidism overlapping with Multiple Sclerosis: a catastrophic marriage.

Primary hyperparathyroidism (PHPT) often leads to neurological or psychiatric disorders, thus mimicking different diseases. Here we present a 77-years old man visited in the Emergency Department complaining for fatigue, multiple falls, nausea, anorexia, and constipation. Symptoms were rapidly worsening, and on admission he appeared sleepy, responsive to verbal stimulus, disoriented, dehydrated, unable to maintain upright position. He suffered from mild, relapsing and remitting Multiple Sclerosis (MS) since the age of 45, at that moment not requiring treatment. The laboratory tests displayed severe hypercalcemia (16.8 mg/dL), slightly decreased level of serum phosphorus (2.8 mg/dL), very high levels of parathyroid hormone (PTH) (508 pg/mL). A parathyroid mass (35x21x32 mm) in left paratracheal position was found with Computed Tomography (CT) of the neck. After correcting hypercalcemia, he was operated on day 18, thus confirming the parathyroid adenoma, that was successfully removed. One month later, the patient was completely well, and able to walk without any help, like three months before. The lab tests' values obtained during the control visit showed complete normalization of calcium-phosphate metabolism. Diabetes, too, was going better, allowing a reduction in metformin dosage. At the best of our knowledge this is the first described case of a clinically significant overlapping between symptoms due to a long-lasting mild MS and an unrecognized, severe, PHPT. This case underlines the importance of a thorough metabolic evaluation of each patient presenting worsening of his neuromuscular and/or neuropsychiatric condition, even when previously known to be affected by a defined neurologic or psychiatric disease.

Hypovolemic shock due to Wunderlich syndrome (spontaneous renal haemorrhage): a case report and literature review.

Wunderlich syndrome (WS) or spontaneous renal haemorrhage is a rare and life-threatening condition often leading to haemorrhagic shock. WS is characterized by an acute onset of non-traumatic subcapsular and perirenal haematoma formation due to several causes, including neoplasms, cystic rupture, vasculitis, coagulopathies, and infections. The classical presentation includes acute flank or abdominal pain, a palpable flank mass and hypovolemic shock (Lenk's triad). Nausea, vomiting, fever, and haematuria can also be present. Computed tomography angiography is mandatory to localize the source of haemorrhage. Super-selective embolization can be performed to stop bleeding, while surgery is reserved to haemodynamic unstable patients and neoplastic cases. We describe a case of WS in a 79-year-old male patient, who rapidly developed hypovolemic shock requiring urgent nephrectomy.

Acute chest pain and dyspnoea as clinical presentation of primary membranous nephropathy. A case report and literature review.

Membranous nephropathy (MN) is the commonest cause of nephrotic syndrome (NS) in adult male patients worldwide. Most of the cases (80%) are idiopathic (primary MN, PMN), whereas about 20% are associated with autoimmune diseases, malignancies or exposures (secondary MN). PMN is a kidney-specific autoimmune glomerular disease mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) (85%), thrombospondin type 1 domain containing 7A (THSD7A) (3-5%), or by other still unidentified mechanisms (10%). Most of the patients with PMN present with NS (80%). Clinical course of PMN is characterised by spontaneous remissions (40%) and relapses (15-30%). One third develop end-stage renal disease (ESRD) within 5 to 15 years from the onset. Anti-PLA2R/THSD7A antibodies levels correlate with proteinuria, clinical course, and outcomes. The treatment still remains matter of debate. Hypertension, proteinuria, and hyperlipidaemia must be treated in all patients. Immunosuppressive therapy is indicated in patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis. With proper management, only 10% or less will develop ESRD over the subsequent 10 years. Here we report a case of a 34-year-old male patient with a ten-year history of asymptomatic PMN, treated with ACE-inhibitors, who presented to our emergency room for acute chest pain and exertional dyspnoea due to ESRD that required urgent dialysis. (www.actabiomedica.it).

Hypertensive crisis and pulmonary edema following rituximab-induced anaphylaxis.

Rituximab is a monoclonal antibody against the protein CD20. Various lymphomas as well as non-malignant immune disorders are treated with this antibody. Hypersensitivity reactions associated with the use of rituximab include urticaria, hypotension, chest tightness, vomiting, oxygen desaturation and bronchospasm. A very uncommon case of hypertensive crisis and pulmonary edema following rituximab-induced hypersensitivity reaction in an 80-year-old man receiving rituximab for non-Hodgkin lymphoma is reported. Anaphylaxis manifesting as coronary vasospasm following drug treatment, including rituximab, could be proved a serious condition in patients who need specific treatment. In these patients desensitization protocols seem to be mandatory.

Salernitan Medical School or Langobardic Medical School?

Already famous since the high Middle Ages, the Salernitan Medical School reached its whole scientific role between the 11th and 12th century, declining later due to the rising of modern universities. Information on the earliest period of the School is very poor but, starting from the 10th century, we know that Salernitan physicians were widely recognized as researchers and healers. This paper is focused on the heavy role recognized to the Langobards (first) and Normans (later) on development of the Salernitan Medical School. A special role must be recognized to Alfanus I, Gariopontus and Trotula de Ruggiero: they left memories on their enterprises and many manuscripts of great relevance for the development of Middle Ages and Renaissance Medicine. Their multicultural experience dragged the Salernitan School to become the greatest expression of medical science of its age. This role was expressed in the "Regimen Sanitatis Salernitanum" or "Flos Medicinae Salerni", a book that resumes the highest knowledges on general hygiene, dietetics, physiotherapy, comparative anatomy and surgery. The book had a tremendous success, having more than 300 editions in many languages up to 1846. It was an essential reference for western medical literature up to Renaissance. Furthermore, Langobards took care of health laws, mainly in the Rotari edict, which included laws on medical practice and on the physicians' role. (www.actabiomedica.it).

Predicting mortality with cardiac troponins: recent insights from meta-analyses.

The introduction of cardiac troponin (cTn) testing in clinical practice has been one of the most important breakthroughs that have occurred in the recent history of laboratory medicine. Although it is now uncontestable that cTn values are essential for diagnosing acute coronary syndrome (ACS), solid evidence is also emerging that assessment of either cardiac troponin I (cTnI) or T (cTnT) may provide valuable prognostic information in the general healthy population, as well as in patients with a vast array of cardiac and extra-cardiac diseases. We have hence performed a critical review of the scientific literature for identifying meta-analyses which have investigated the potential contribution of cTns in predicting the risk of death in health and disease. According to the articles identified with our research, we can conclude that increased cTn values may be considered independent risk factors for all-cause mortality in the general population, as well as in patients with ACS, in those undergoing revascularization procedures, or with stable coronary artery disease (CAD), heart failure (HF) and atrial fibrillation (AF). Measurement of cTn may then be helpful for stratifying the mortality risk in non-cardiac hospitalized patients, in those with critical illness or sepsis, syncope, stroke, acute aortic dissection, pulmonary diseases, brain injury, renal failure, vascular and non-cardiac surgery. Although this evidence has notable clinical implications, the cost-effectiveness of population screening with high-sensitivity (hs) cTn immunoassays has not been proven so far.

Two Masters of Surgery in Parma during the Middle Ages.

During the Middle Ages, Parma, in Northern Italy, undoubtedly represented a landmark for surgical science and practice all around Europe. Around the same period the Salernitan Medical School, already famous since the high Middle Ages, reached its whole scientific role. Due to the importance reached by the School, for centuries several physicians throughout Europe, aiming for an international fame, told they were "Salernitan". One of the most famous examples is represented by Roger Frugardi, or Ruggero Frugardo, or Ruggero da Parma (before 1140 - about 1195), who was widely known as "Rogerius Salernitanus" (Roger of Salerno), meaning that his scientific success was a consequence of the affiliation to the Salernitan Medical School. Roger wrote an important book, the "Practica Chirurgiae" (Surgical Practice), also known as "Rogerina", edited and published by his pupil Guido "the young" of Arezzo. It was the first Handbook of Surgery in the post-Latin Europe, containing important innovations, such as the very first description of a thyroidectomy, thus influencing surgical practice until late Renaissance. The Roger's pupil Rolando dei Capelluti was the successor and extensor of his Master's work. In his work he particularly developed the cranial surgery and the study of neurological diseases (e.g., epilepsy or mania). His masterwork, known as "Rolandina", also influenced European surgery for centuries.

Aspirin for thromboprophylaxis in major orthopedic surgery: old drug, new tricks?

Major orthopedic surgery, mainly entailing hip fracture surgery, hip and knee arthroplasty, is associated with significant morbidity and mortality, which are especially attributable to the high risk of postoperative VTE. Such a considerable risk is mainly due to a procoagulant state sustained by several important mechanisms, including massive release of procoagulants from tissue and bone damage, blood vessel injury, reduced venous emptying, perioperative immobilization and cement polymerization, among others. The risk of VTE during and after major orthopedic surgery approximates 50-80% in patients with no thromboprophylaxis, and persists for up 3 to 6 months after surgery. The anticoagulant or antithrombotic armamentarium entails several anticoagulants such as heparin, coumarins, fondaparinux, and the recently developed DOACs inhibiting either activated factor Xa (i.e., rivaroxaban, apixaban, edoxaban) or thrombin (i.e., dabigatran), as well as aspirin, i.e., the oldest antiplatelet drug to be ever discovered and used in clinical practice. The current guidelines are not in complete agreement regarding the choice of the ideal thromboprophylaxis, since some consider aspirin, and some discourage it. Recent evidence seems to support the use of aspirin in selected situations and in selected protocols. Therefore, we believe that consideration should be made about increasing the use of this old but still effective drug for perioperative prophylaxis of VTE, especially in patients for whom the administration of DOACs may be challenging.

Glyphosate ingestion causing multiple organ failure: a near-fatal case report.

A 55 years old man self-presented to our Emergency Department (ED) reporting an attempted suicide by cutting the left forearm veins and ingesting approximately 200 mL of an herbicide (Myrtos®, containing 36% of glyphosate as isopropylamine salt). Laboratory tests showed metabolic acidosis. Hydration with normal saline and alkalinization with sodium bicarbonate was started according to suggestion of the poison control center, since an antidote was unavailable. Cardiorespiratory condition gradually worsened, so that non-invasive positive pressure ventilation (NIPPV) was applied and infusion of fluids was established. Nevertheless, the patient deteriorated and he needed to be transferred to the Intensive Care Unit (ICU), where he underwent orotracheal intubation and invasive mechanical ventilation. Noradrenaline and adrenaline were infused and fluid resuscitation with crystalloids was incremented. An esophagogastroduodenoscopy (EGD) showed diffuse mucosal erosions of upper digestive tract. No signs of visceral perforation were found during ICU stay. In the following days, the clinical conditions improved and a new EGD showed marked improvement of erosive lesions. After 12 days of ICU stay, the patient was extubated and then transferred to the Psychiatric Unit, in good clinical conditions. Gliphosate ingestion is associated with rapid development of multiple organ failure (MOF). Since an effective antidote is unavailable, major attention should be placed to aggressive life-support care and careful monitoring of complications.

Indoor Tanning a Gianus Bifrons: Vitamin D and Human Cancer.

Despite it is now undeniable that indoor tanning exposure is associated with a number of skin cancers, its favorable effects on vitamin D status may bear some underestimated and currently unexplored health benefits. Vitamin D is a fat-soluble vitamin naturally present in a limited number of foods, the concentration of which largely depends on ultraviolet (UV) B sources exposure in humans. A strong, graded, and inverse association has been documented between serum vitamin D and the risk of developing certain types of malignancy, especially colorectal, breast, lung, bladder, and kidney cancers. The overall mortality from any type of cancer is also apparently lower in subjects with increased values of serum vitamin D. Both genomic and nongenomic mechanisms have been identified to support the anticancer effects of vitamin D. Notably, UVB radiation emitted from indoor tanning devices is effective to linearly increase the serum vitamin D concentration, up to twofold. Therefore, some favorable effects against the risk of developing many human diseases, including nonskin cancers, cannot be excluded at first glance, although they may not be only linked to vitamin D status. Further large, prospective or randomized studies should be hence planned to definitely establish whether the unfavorable effects of indoor tanning exposure on skin cancers may be outweighed by the still unexplored benefits attributable to amelioration of vitamin D status.

Italian intersociety consensus on prevention, diagnosis, and treatment of delirium in hospitalized older persons.

Delirium is a severe neuropsychiatric syndrome characterized by inattention and global cognitive dysfunction in the setting of an acute medical illness, medical complication, drug intoxication, or drug withdrawal. The most important risk factors are advanced age and dementia, whereas pain, dehydration, infections, stroke, metabolic disturbances, and surgery are the most common triggering factors. Although delirium is a common clinical syndrome in different settings of care (acute care hospitals, inpatient rehabilitation facilities, nursing homes, and hospices), it often remains under-recognized, poorly understood, and inadequately managed. There exists a clear need for improved understanding to overcome cultural stereotypes, and for the development and dissemination of a comprehensive model of implementation of general good practice points. A network of Italian national scientific societies was thus convened (1) to develop a collaborative multidisciplinary initiative report on delirium in elderly hospitalized patients, (2) to focus the attention of health care personnel on prevention, diagnosis, and therapy of patients suffering from delirium, and (3) to make the health services research community and policy-makers more aware of the potential risks of this condition providing a reference for training activities and data collection.

Clinical presentation and epidemiology of brain tumors firstly diagnosed in adults in the Emergency Department: a 10-year, single center retrospective study.

BACKGROUND: Several patients with new onset brain tumors present to the Emergency Department (ED) complaining for new symptoms. Although information exists on symptom prevalence in the entire population of patients with brain tumors, little is known about the clinical presentation in ED. This retrospective study was planned to investigate clinical presentation and epidemiology of brain tumors firstly diagnosed in a large urban ED throughout a 10-year period. METHODS: All medical records of patients aged ≥18 years, discharged from our ED with a diagnosis of brain tumor were retrieved from the electronic hospital database during a 10-year period (2006 to 2015). The records were reassessed for selecting only brain tumors firstly diagnosed in the ED. The symptoms at presentation were divided in six categories: (I) headache; (II) seizures; (III) focal signs; (IV) altered mental status; (V) nausea/vomiting/dizziness; (VI) trauma. For all cases, the hospital record was retrieved, to obtain histologic classification of tumors. Patients with inflammatory neoformations were excluded from the study. RESULTS: Overall, 205 patients with firstly diagnosed brain tumor were identified among 870,135 ED visits (i.e., <1%). Glial tumors were the most frequent (50% of the entire sample). No significant differences were found between mean age of patients in the different histologically based groups (meningiomas 66±14; glioblastomas 65±16 years; metastases 66±13 years; other miscellaneous 66±19 years). Focal signs accounted for more than 50% of all presentation signs/symptoms. CONCLUSIONS: First presentation of brain tumor in the ED is not a rare occurrence, so that the emergency physicians should be aware of this possibility.

Thromboprophylaxis after Knee Arthroscopy: Out of the Maze?

The use of thromboprophylaxis after knee arthroplasty is heterogeneous among orthopedic surgeons. Two recent studies showed that low molecular weight heparin is not effective for preventing venous thromboembolism, whereas thrombotic episodes may be significantly reduced using direct oral anticoagulants, thus opening an interesting perspective for periprocedural management of knee arthroscopy.

Reporting altered test results in hemolyzed samples: is the cure worse than the disease?

The management of laboratory data in unsuitable (hemolyzed) samples remains an almost unresolved dilemma. Whether or not laboratory test results obtained by measuring unsuitable specimens should be made available to the clinicians has been the matter of fierce debates over the past decades. Recently, an intriguing alternative to suppressing test results and recollecting the specimen has been put forward, entailing the definition and implementation of specific algorithms that would finally allow reporting a preanalytically altered laboratory value within a specific comment about its uncertainty of measurement. This approach carries some advantages, namely the timely communication of potentially life-threatening laboratory values, but also some drawbacks. These especially include the challenging definition of validated performance specifications for hemolyzed samples, the need to producing reliable data with the lowest possible uncertainty, the short turnaround time for repeating most laboratory tests, the risk that the comments may be overlooked in short-stay and frequently overcrowded units (e.g. the emergency department), as well as the many clinical advantages of a direct communication with the physician in charge of the patient. Despite the debate remains open, we continue supporting the suggestion that suppressing data in unsuitable (hemolyzed) samples and promptly notifying the clinicians about the need to recollect the samples remains the most (clinically and analytically) safe practice.

Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases.

BACKGROUND: Acute abdominal pain (AAP) accounts for 7-10% of all Emergency Department (ED) visits. Nevertheless, the epidemiology of AAP in the ED is scarcely known. The aim of this study was to investigate the epidemiology and the outcomes of AAP in an adult population admitted to an urban ED. METHODS: We made a retrospective analysis of all records of ED visits for AAP during the year 2014. All the patients with repeated ED admissions for AAP within 5 and 30 days were scrutinized. Five thousand three hundred and forty cases of AAP were analyzed. RESULTS: The mean age was 49 years. The most frequent causes were nonspecific abdominal pain (NSAP) (31.46%), and renal colic (31.18%). Biliary colic/cholecystitis, and diverticulitis were more prevalent in patients aged >65 years (13.17% vs. 5.95%, and 7.28% vs. 2.47%, respectively). Appendicitis (i.e., 4.54% vs. 1.47%) and renal colic (34.48% vs. 20.84%) were more frequent in patients aged <65 years. NSAP was the most common cause in both age classes. Renal colic was the most frequent cause of ED admission in men, whereas NSAP was more prevalent in women. Urinary tract infection was higher in women. Overall, 885 patients (16.57%) were hospitalized. Four hundred and eighty-five patients had repeated ED visits throughout the study period. Among these, 302 patients (6.46%) were readmitted within 30 days, whereas 187 patients (3.82%) were readmitted within 5 days. Renal colic was the first cause for ED readmission, followed by NSAP. In 13 cases readmitted to the ED within 5 days, and in 16 cases readmitted between 5-30 days the diagnosis was changed. CONCLUSIONS: Our study showed that AAP represented 5.76% of total ED visits. Two conditions (i.e., NSAP and renal colic) represented >60% of all causes. A large use of active clinical observations during ED stay (52% of our patients) lead to a negligible percentage of changing diagnosis at the second visit.

Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES).

Traumatic wounds are one of the most common problems leading people to the Emergency Department (ED), accounting for approximately 5,4 % of all the visits, and up to 24 % of all the medical lawsuits. In order to provide a standardized method for wound management in the ED, we have organized a workshop, involving several Italian and European experts. Later, all the discussed statements have been submitted for external validation to a multidisciplinary expert team, based on the so called Delphi method. Eight main statements have been established, each of them comprising different issues, covering the fields of wound classification, infectious risk stratification, tetanus and rabies prophylaxis, wound cleansing, pain management, and suture. Here we present the results of this work, shared by the Academy of Emergency Medicine and Care (AcEMC), and the World Society of Emergency Surgery (WSES).

The Mean Platelet Volume Is Decreased in Patients Diagnosed with Venous Thromboembolism in the Emergency Department.

Platelets are small corpuscular elements, which play an essential role in hemostasis and thrombosis. As active players in the thrombotic process, hyperactive platelets are involved in the pathogenesis of cardiovascular disorders. Nevertheless, the role of platelet size, as a biological marker of platelet activation, remains debated in the setting of venous thrombosis. Therefore, we conducted a retrospective case-control study to clarify the potential association between mean platelet volume (MPV) and newly diagnosed venous thromboembolism (VTE) by reviewing data of all consecutive patients receiving a diagnosis of VTE at the emergency department (ED) of the University Hospital of Parma (Italy) between January and December, 2014. The control population was represented by outpatients undergoing routine laboratory testing for health checkup at the phlebotomy center of the same University Hospital during the same period. MPV was found to be comparatively decreased in the entire cohort of patients with VTE compared with the outpatient population, as well as in those with isolated deep vein thrombosis (DVT) or pulmonary embolism (PE). A decreased MPV value (i.e., < 10.8 fL) was found to be associated with an increased risk of diagnosing VTE (relative risk, 1.18; 95% CI, 1.09-1.28; p < 0.001), as well as of diagnosing isolated DVT (relative risk, 1.19; 95% CI, 1.07-1.31; p = 0.001) and isolated PE (relative risk, 1.17; 95% CI, 1.04-1.30; p = 0.007). A decreased MPV value in active cancer patients was associated with the highest risk of diagnosing thrombosis (relative risk, 1.29; 95% CI, 1.10-1.51; p = 0.002). These results support an inverse association between MPV and the risk of venous thrombosis at diagnosis.