Prenatal visualisation of the torcular herophili by means of a Doppler technology highly sensitive for low-velocity flow in the expert assessment of the posterior fossa: a prospective study.

OBJECTIVE: To evaluate the usefulness of a Doppler technology highly sensitive for low-velocity flow in the antenatal imaging of the torcular herophili (TH) in the second trimester of pregnancy. DESIGN: Prospective study. SETTING: Referral Fetal Medicine Unit. POPULATION: Non-consecutive series of singleton pregnancies submitted to antenatal neurosonogram between 20 and 28 weeks of gestation. METHODS: A midsagittal section of the fetal brain was obtained by insonating through the anterior fontanelle, then the MV-Flow™ and LumiFlow™ presets were selected to visualise the TH as the posterior confluence of the superior sagittal sinus and the straight sinus. MAIN OUTCOME MEASURES: Evaluation of the anatomic relationship of the TH with the 'transpalatal line' joining the upper bony palate to the fetal skull. RESULTS: A total of 99 pregnant women were recruited, including one fetus with open spina bifida, one with Dandy-Walker malformation (DWM) and two with Blake's pouch cysts. In normal fetuses, the TH appeared to lie on or just below the 'transpalatal line'. In the cases of Blake's pouch cyst, the position of the TH appeared normal if compared with controls, whereas in DWM a supra-elevated position of the TH in respect of the transpalatal line was demonstrated. Finally, in the fetus with Chiari II malformation the TH was identified below the 'transpalatal plane'. CONCLUSIONS: Prenatal ultrasound visualisation of the TH by means of newly developed Doppler technologies characterised by high sensitivity for low-velocity flow is feasible and allows the indirect evaluation of the insertion of cerebellar tentorium in the second trimester. TWEETABLE ABSTRACT: Prenatal imaging of the torcular herophili using a Doppler technology highly sensitive for low-velocity flow.

Bilateral salpingo-oophorectomy and adhesiolysis with single port access laparoscopy and use of diode laser in a BRCA carrier.

Herein the authors report the first case of prophylactic bilateral salpingo-ovariectomy (BSO) in single port access laparoscopy (SPAL) with use of diode laser in a patient with BRCA1 mutation. As fimbria could be considered the site of origin for many serous carcinomas in BRCA mutation carriers, many studies are carried out to evaluate the possibility of preventing ovarian carcinoma with BSO. SPAL is a development of endoscopic surgery which further reduces invasiveness of surgical procedures. Diode laser presents a recognized precision for tissue cutting and coagulation and its use could be highly advantageous in SPAL surgery and in particular in such situations avoiding fallopian tube histology distortion and consequently improve the prognosis of BRCA carriers.

The role of hysteroscopy in the diagnostic work-up of infertile asymptomatic patients.

PURPOSE OF INVESTIGATION: To demonstrate that office hysteroscopy has a key-role in the diagnostic work-up of infertile couples. MATERIALS AND METHODS: The entire database of hysteroscopies performed in 572 menstruated women from 2008 to 2011, was retrospectively analyzed. A two-dimensional correspondence analysis among endometrial patterns, age ranges, and indication for hysteroscopies was made. A main-effect hierarchical log-linear model was built to assess the goodness of the correspondences found. RESULTS: A clear cluster of aggregation appears in case of both primary and secondary infertility, with and without other indications for hysteroscopy, as well as in case of primary infertility with irregular menstrual bleeding. In such patients, chronic endometritis, normal pattern, and uterine malformations were frequently found. The most significant correspondence was found for normal pattern and chronic endometritis in case of secondary infertility and primary infertility, respectively. CONCLUSIONS: Office hysteroscopy should be reconsidered in the diagnostic work-up of infertile couples. It is able to assess or rule out endometrial factor for female infertility.

[Differentiated microcarcinoma of the thyroid gland]. / Il microcarcinoma differenziato della tiroide.

BACKGROUND: The thyroid microcarcinoma is a tumor with maximum diameter of 10 mm (WHO). For the most part is not clinically palpable and not evident by imaging investigations. The papillary microcarcinoma is the most common form of thyroid cancer, followed by follicular microcarcinoma. The aim of our study is to assess the frequency of microcarcinoma, the association of benign thyroid disease himself and the controversial surgery. PATIENTS AND METHODS: We analyzed 391 patients (321 F and 70 M) who underwent total thyroidectomy from 2004 to 2009 at a Unit of General Surgery, Uremic and Organ Transplant, Hospital of Palermo. RESULTS: 42 carcinomas were detected, of which 24 PTMC and 1 follicular microcarcinoma. The PTMC was associated with cancer in only 2 cases (papillary carcinoma and parathyroid carcinoma) in the remaining thyroid tissue was suffering from benign disease (20 goiters, 3 Hashimoto thyroiditis, a trabecular adenoma). TALK: Controversial is still the type of surgery to be performed in case of differentiated thyroid microcarcinomas, as well as the indication is still debated to lymphadenectomy. CONCLUSIONS: Papillary microcarcinoma of the thyroid in our series, represents 57% of all thyroid cancers. Microcarcinoma and benign thyroid disease association (76.92% of cases) was high. The therapeutic attitude adopted by us was total thyroidectomy associated with conservative lymphadenectomy in the presence of palpable lymph nodes, instead to abstaining in the absence of clinical evidence of nodal metastases.

High-resolution ultrasonography (HRUS) of the meniscal cyst of the knee: our experience.

PURPOSE: This study was undertaken to assess the diagnostic accuracy of high-resolution ultrasonography (HRUS) in the detection of meniscal cysts. MATERIALS AND METHODS: Over a 2-year period, 1,857 patients underwent magnetic resonance imaging (MRI) of the knee for traumatic or degenerative disorders. All patients with MRI evidence of a meniscal cyst were studied by HRUS. HRUS was also performed on an equal number of patients without MRI evidence of meniscal cyst who were used as a control group. All HRUS examinations were conducted by a radiologist blinded to the MRI findings. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of HRUS were assessed with reference to MRI. All patients underwent surgery, and the resected masses were studied by histological examination. RESULTS: MRI allowed identification of a meniscal cyst in 52 patients. HRUS enabled correct detection of the meniscal cyst in 49/52 cases. In the control group, HRUS excluded the presence of meniscal cysts in all cases. HRUS had a sensitivity, specificity, PPV and NPV of 94.23%, 100%, 100% and 94.54%, respectively, for the detection of meniscal cysts. CONCLUSIONS: HRUS is a fairly reliable technique in the detection, characterisation and differentiation of the different forms of meniscal cyst.

The usefulness of clinical indexes in the evaluation of cardiovascular risk in non cardiac surgery.

AIM: The preoperative cardiac evaluation of a patient who undergoes noncardiac surgery is a very important problem, particularly for diagnostic tools used. Aim of this study is to test the usefulness of 4 most used clinical indexes for the evaluation of cardiovascular risk in the management of patients who undergo noncardiac surgery. METHODS: The study is based on a retrospective analysis of a group of 45 patients, who underwent extracardiac surgery in biennium 2002-2004. The cardiovascular risk scores of Goldman, Detsky, Lee and Eagle were used; a comparison among the different scores was done. RESULTS: Six out of our 45 patients had perioperative cardiovascular complications, and 4 of them died. The Eagle and Lee scores were more predictive than Goldman and Detsky ones. About the 13 echocardiographic tests recorded, no one of them modified the patient preoperative risk. CONCLUSIONS: In the preoperative assessment of risk, the Eagle score was more useful than the others ones and improved the negative predictive value of the Goldman and Detsky scores. The preventive application of the clinical indexes allows optimizing the preoperative stratification of the risk, limiting the request of useless examinations and offering to the patient a well appropriated preoperative management, reducing the incidence of complications.

MR findings in lipoma arborescens of the knee: our experience.

PURPOSE: This paper describes the role of MR imaging in the identification of the different macroscopic patterns of lipoma arborescens. MATERIALS AND METHODS: Between June 1995 and January 2004, a total of 6387 MR examinations of the knee were retrospectively assessed for the presence of lipoma arborescens. The MR examinations were performed using a superconductive 0.5 T MR unit with a transmitting/ receiving coil dedicated for the extremities. The MR images were acquired with SE T1-weighted, GE T2-weighted and STIR sequences in sagittal, coronal and axial planes with 3-mm thickness and 1-mm gap. RESULTS: Lipoma arborescens was identified in 9 patients (mean age: 36 years). In 2/9 cases a localized lipoma arborescens was detected as a well-marginated single nodule on the suprapatellar bursa without irregularity or synovial hyperplasia. In the remaining 7 cases diffuse lipoma arborescens was identified on the wall of the suprapatellar bursa. In one case of diffuse lipoma arborescens there was involvement of both knees. In all cases the MR findings were verified at surgery and the final diagnosis was made by histological examination. CONCLUSIONS: MR imaging shows a high accuracy in the identification and characterization of lipoma arborescens, due to its multiplanar capabilities and high contrast resolution. MRI allows correct evaluation of size and grade, accurate treatment planning and effective follow-up, avoiding the need for synovial biopsy.

Cardiovascular involvement in thalassaemic patients with pseudoxanthoma elasticum-like skin lesions: a long-term follow-up study.

BACKGROUND: Congenital haemolytic anaemia may be associated with pseudoxanthoma elasticum (PXE)-like clinical manifestations. METHODS: The cardiovascular system of 14 homozygous and double heterozygous beta-thalassaemia patients with skin and retinal vessel alterations similar to those in genetic PXE was analysed over a period of 12 years and compared with that of 13 relatives (five sets of parents, one single parent, two thalassaemic brothers), and that of the control group composed of 16, age- and sex-matched, thalassaemic patients. RESULTS: All patients with clinical PXE-like skin lesions exhibited, by light and electron microscopy, dermal alterations and mineralization of elastic fibres identical to those typical of inherited PXE. None of the relatives and none of the control group showed clinical or structural findings of PXE. The follow-up started in 1988. After 12 years of clinical observation, six patients showed dramatic progression of skin involvement, angioid streaks had progressed in two subjects. One patient had recurrent gastrointestinal bleeding and underwent partial stomach removal for gastric artery aneurysm, one underwent colon resection for intestinal infarct, one patient had a transitory ischaemic attack, one died after an intracranial haemorrhage, two patients died from cardiovascular disease and one from neoplasia. CONCLUSIONS: Thalassaemic patients with PXE-like skin lesions also manifest PXE-like vessel alterations that progress with time. Considering the severe outcome of these lesions, accurate monitoring should be routinely performed on the cardiovascular system of thalassaemic patients with PXE-like skin manifestations.

Hydroxyurea therapy in paraparesis and cauda equina syndrome due to extramedullary haematopoiesis in thalassaemia: improvement of clinical and haematological parameters.

Patients with beta-globin disorders show amelioration of clinical condition by sustained synthesis of fetal haemoglobin in adult life. We report data on a patient with beta(o)-thalassaemia genotype and thalassaemia intermedia clinical phenotype. He received therapy with hydroxyurea (20 mg/kg/d) because of the presence of extramedullary masses causing paraparesis, neurogenic bladder and impotence. During therapy, the patient showed an improved clinical picture and a significant increase in total Hb (from 71.8 to 103.2 g/L) and a gamma/alpha globin synthetic ratio (from 0.39 to 0.68). The myelosuppressive effect of hydroxyurea was revealed by a decrease in CFU-GEMM, BFU-E, and CFU-GM. Therefore hydroxyurea can be effective in the treatment of patients with extramedullary haematopoiesis (EMH) who are not transfusion-dependent and cannot be treated with radiotherapy.

[Missed compartment syndrome after anterior cruciate ligament-plasty following continuous peridural anesthesia]. / Verpasstes Kompartmentsyndrom nach vorderer Kreuzbandplastik infolge kontinuierlicher Periduralanästhesie.

In this article we report a case of an early postoperative compartment syndrome of the anterior tibial compartment with complete sensomotoric palsy of the peroneal nerve after arthroscopic-assisted replacement of the anterior cruciate ligament (ACL) of the knee. The tourniquet pressure was 360 mm Hg and operation time was 1.75 h. After the operation the leg was bandaged to avoid swelling of the leg and as antithrombotic prophylaxis. Analgesic therapy was by continuous epidural bupivacaine infusion. Increasing pain of the lower leg was suppressed by additional analgesia. Due to persistent pain despite regular analgesia, the patient was sent to a main hospital on the 3rd postoperative day, where an extremely painful and swollen anterior tibial compartment with intracompartmental pressure of over 100 mm Hg was found. The compartment was released immediately. Despite the appearance of severe muscle damage, no extensive débridement was done. At the second examination, at 48 h, there was minimal perfusion of the muscles without contraction and islands of ischemic necrosis. Clinically, there was complete palsy of the dorsiflexors of the foot. The case shows the danger of a compartment syndrome when tourniquet of the limb, arthroscopy and a firm bandage are combined. Continuous epidural analgesia masks the classic symptoms of compartment syndrome.

Continuous low-dose subcutaneous desferrioxamine (DFO) to prevent allergic manifestations in patients with iron overload.

In some patients compliance to subcutaneous desferrioxamine therapy is reduced because of allergic symptoms. Effective drug desensitization consists of bringing patients to tolerate the same mode of administration. We evaluated three thalassemic patients with severe allergies to desferrioxamine. Each patient received weekly three prefilled infusors with desferrioxamine 4 g/48 m1/48 h for s.c. therapy. Follow-up was performed for 12 consecutive weeks. During follow-up no allergic events were noted. The s-ferritin levels decreased from 2583 micrograms/l +/- 485 to 1916 micrograms/l +/- 275 (mean decrease 25.8%, p = 0.038). Compliance to the infusional system was excellent. Our results show that continuous infusion of desferrioxamine using a new infusional delivery system is effective in preventing allergic reactions and in reducing iron overload.

Radiotherapy combined with erythropoietin for the treatment of extramedullary hematopoiesis in an alloimmunized patient with thalassemia intermedia.

We report a patient with thalassemia intermedia who developed a mediastinal syndrome due to the growth of paravertebral hematopoietic masses in the posterior mediastinum. Because the patient did not receive blood transfusions due to alloimmunization, she was first treated with human recombinant erythropoietin (escalating low-moderate doses) to recover hemoglobin levels, then in association with radiotherapy to prevent a worsening of her anemia. The mean Hb level dramatically increased and peaked at week 11, to 83 g/l, and remained unchanged before and after radiotherapy (81 versus 78 g/l). Immediately after radiotherapy extramedullary hematopoiesis volume decreased by 16.4%.

Preventive effect of some substances on experimental oxalic calculogenesis in the frog.

Rana esculenta tadpoles that are fed spinach develop an oxalic calculogenesis. The addition of cholestyramine, orthophosphate, citrate, allopurinol and tungstate to the tank water prevented calculi formation while succinimide, magnesium oxide, hydrochlorothiazide and tetracycline were ineffective. Methylene blue proved lethal to tadpoles, and its anti-lithogenic activity could not be assessed. These findings, except for the non-effectiveness of magnesium oxide, are in agreement with both the theoretical expectations and the results obtained in other experimental models. Experimental frog calculogenesis seems to be a simple and valid method for evaluating anti-lithogenic activity.