Predicting haemorrhage in pre-hospital traumatic patients: evaluation of the novel heart-to-arm time index.

BACKGROUND: Early recognition of hypovolaemia in trauma patients is very important. However, the most often used clinical signs, such as hypotension and tachycardia, lack specificity and sensitivity. METHODS: We propose a non-invasive index of hypovolaemia, the heart to arm time (iHAT), based on a modified pulse transit time indexed to heart rate. Pulse transit time is the sum of pre-ejection period and vascular transit time. Following pre-load reductions due to hypovolaemia, ventricular diastolic filling time increases causing an increase in pre-ejection-period, pulse transit time, and hence iHAT. One hundred and four consecutive patients with suspected major trauma were enrolled. The primary aim was to evaluate the use of the iHAT for detecting haemorrhage in major trauma. The secondary end point was to compare the specificity and sensitivity of iHAT compared to commonly used indexes. RESULTS: iHAT was calculated in 84 subjects, 11 of whom were haemorrhagic. iHAT discriminated haemorrhagic from non-haemorrhagic group (46.8% vs. 66.9%, P < 0.0001). The cut-off for iHAT with the best compromise between sensitivity (90.9%) and specificity (100%) was reached at the 58.78% level. Comparing haemorrhagic and non-haemorrhagic patients, the area under the ROC curve was 0.952 for iHAT, 0.835 for heart rate, and 0.911 for systolic blood pressure, showing no significant differences. CONCLUSIONS: iHAT is a non-invasive index that can identify haemorrhage in trauma patients with high sensitivity and specificity. These data should be considered as an exploration, but any conclusion should be validated in a new set of consecutive patients.

[Primary gastric lymphoma. 14 clinical cases]. / Linfoma gastrico primitivo. 14 casi clinici.

Fourteen patients affected by primary gastric lymphoma were observed retrospectively to verify the results of surgical and adjuvant chemotherapy. After a 85% preoperative diagnostic specificity, 79% of patients were subjected to surgical therapy by subtotal gastrectomy (93%) and by total gastrectomy (7%), and 64% of patients were subjected to adjuvant chemotherapy in conformity with CHOP and CVP. Classified by the Working formulation, 57% of cases presented a high grade of malignancy, 29% a low grade and 14% an intermediate grade. Classified by Ann Arbor with Mushoff's modification, 43% of patients were assigned to stage IIE1, 36% to stage IE, 14% to stage IIE2 and 7% to stage IIIE. Operative mortality was null. The overall median survival have been of 21 months, while surgical and chemotherapeutical median survival reached 32 months. The 5-year actuarial survival was: 10% (overall), 14% (treated patients), 50% (low grade), 33% (stage IE). With negative influence by istology and staging.

Inadequacy of combined 5-Fluorouracil, very-high-dose leucovorin, mitomycin-C and Cisplatin as 2nd-line therapy for advanced colon-cancer.

Fourteen patients with metastatic colon cancer which had progressed under fluoro-folates chemotherapy were treated with MM-C (10 mg/m(2) on day 1), 5-FU (370 mg/m(2) for 5 consecutive days), l-LV (500 mg/m(2) for 5 consecutive days) and CDDP (70 mg/m(2) on day 4), every 29th day till further disease progression. Neither CR nor PR were observed; 3 patients only had stable disease, while the extant 11 patients progressed. Resulting toxicity was severe. Since no antitumor effects were evidenced in the first 14 patients, the study was discontinued according to commonly accepted criteria.

Plasma selenium levels of the general population of an area in northern Italy.

Plasma selenium (Se) levels of 293 subjects (160 males and 133 females) living in Desio (a small town near Milan) were determined. Analyses were performed by graphite-furnace atomic absorption spectrophotometry with Zeeman background correction. Plasma samples were not subjected to any treatment before analysis and serum samples containing a certified Se content were used as reference materials to control the quality of the analytical determinations. Plasma Se levels were found to be distributed normally with an average value of 118.8 micrograms/l and a S.D. of 27.2 (95% of the subjects lie between 64.4 and 173.2 micrograms/l). No statistically significant difference was found between males and females, and no correlation was found between plasma Se levels and age or smoking habits.

Behaviour of urinary nickel in low-level occupational exposure.

The study tested the feasibility of using urinary nickel (Ni-U) as a biological indicator to assess exposure to soluble nickel compounds in electroplating departments at concentrations well below the current TLV-TWA. Two groups of workers were studied: Group A, consisting of 13 subjects and Group B consisting of 10 subjects, with an average weekly nickel exposure of nickel in air (Ni-A) greater than or equal to 10 micrograms/m3 (Group A) and less than 10 micrograms/m3 (Group B). Air samples and urine specimens were taken on 4 consecutive days from Monday to Thursday. The mean Ni-U levels in both groups were significantly higher than in the reference group. The Ni-U levels in end-of-shift spot samples showed a tendency to increase over the week; this trend was more marked in Group A. Closer correlations between Ni-A and Ni-U were found using the postshift Ni-U values of Thursday: the test was well correlated both with the Ni-A levels of the same day and with the mean levels of the previous days. The results suggest that Ni-U is a sufficiently sensitive indicator for use in monitoring low-level occupational exposure, especially if Ni-A concentrations are above 10 micrograms/m3.

Behaviour of biological indicators of cadmium in relation to occupational exposure.

Cadmium in blood (CdB), cadmium in urine (CdU) and beta 2-microglobulins (beta 2MU) were determined in 83 male workers exposed to cadmium fumes. CdU was measured both on 24-h urine samples and on spot samples. The behaviour of the biological indicators of cadmium was assessed in relation to degree of current exposure, length of exposure and cumulative exposure (computed as concentration of cadmium at the workplace multiplied by duration of exposure). CdB values were significantly higher in the subgroups of subjects with higher current cadmium exposure and in the subgroups of subjects with greater cumulative exposure, but the test levels were not influenced by duration of exposure. CdU levels were significantly higher in the subgroup of subjects with greater cumulative exposure, but were less influenced by current exposure or duration of exposure. Considering the entire population, a rather close correlation (r = 0.69) was observed between CdB and CdU. When the population was divided according to level of current exposure, a close relationship was observed between the two indicators in all subgroups; nevertheless, for identical CdU values, the CdB values were higher in the subjects with heavier current exposure. Even if in all Cd workers the beta 2MU levels were in the range of reference values, the highest beta 2MU levels were found in the subjects with CdU greater than 10 micrograms/l. The data confirm that CdU is prevalently influenced by the body burden of metal, but they also suggest that the CdB levels are not influenced solely by the intensity of current exposure but also depend to a considerable degree on the body burden.

Problems concerning the usefulness of adjustment of urinary cadmium for creatinine and specific gravity.

A previous study concluded that there are some doubts as to the validity of creatinine as a parameter for adjusting the values of biological indicators determined on spot samples of urine, since it is subject to marked inter- and intraindividual variations. Furthermore, since there was only a moderate correlation between creatinine levels and specific density, it can be assumed that these two parameters cannot be used indifferently for adjustment. Nevertheless, it seemed advisable to verify whether correction of cadmium values determined from spot samples offers any practical advantages. For this purpose, 105 subjects with occupational exposure to cadmium were examined. They collected their 24-h urine and spot samples separately at 8.00 h. There was a close correlation between CdU/spot samples and CdU/24 h. The correlation index was very similar both for CdU/spot values expressed in microgram/l and for values adjusted according to creatinine or 1024 specific gravity. These results show that no particular advantages are offered by adjusting CdU according to creatinine or specific gravity.