Whiplash-Associated Disorders : Clinical and medico-legal guidelines on the methods of ascertainment.

The manuscript presents the International Guidelines developed by the Working Group on Personal Injury and Damage under the patronage of the International Academy of Legal Medicine (IALM) regarding the Methods of Ascertainment of any suspected Whiplash-Associated Disorders (WAD).The document includes a detailed description of the logical and methodological steps of the ascertainment process as well as a synoptic diagram in the form of Flow Chart.

Unexpected delayed death after manual strangulation: need for careful examination in the emergency room.

The aim of this case report was to demonstrate the importance of detailed clinical assessment in victims of attempted manual strangulation, to prevent the occurrence of delayed death due to an airway collapse; and to provide an update on clinical management of these patients. An elderly male patient presented with a sore throat and speech impairment after attempting manual strangulation. Physical examination showed reddish skin of the neck, an extensive haematoma of the hard palate and anterior tongue. Flexible laryngoscopy failed to show any swelling of the hypopharynx or larynx. A few hours after presentation, the patient developed acute dyspnoea and died. Autopsy and post-mortem CT scan showed a haematoma in the thyro-epiglottal space. In conclusion, victims of manual strangulation can survive despite internal neck injury which can lead to delayed fatal airway collapse. This is because often there are few or no signs of assault, therefore medical evaluation should be thorough and timely. Sometimes immediate tracheotomy can be life saving.

Clinical effects of erdosteine in the treatment of acute respiratory tract diseases in children.

Erdosteine has positive effects on mucus rheology and transport due to the active metabolite (Metabolite I) which contains a free thiol group. Erdosteine inhibits bacterial adhesiveness and has antioxidant properties. A synergistic effect of erdosteine with various antibiotics has been demonstrated in pharmacological and clinical studies. The present study was multicenter, randomized, double-blind and placebo-controlled. The aims of the study were to compare a combination of erdosteine with amoxicillin against an amoxicillin-placebo combination in pediatric patients with acute lower respiratory tract disease. A total of 158 patients (78 in the erdosteine group and 80 in the placebo group) were treated for 7 +/- 2 days. The efficacy parameters were cough (primary), polypnea, rhonchi, rales and body temperature (all measured at baseline, on Day 3 and at the end of treatment). Safety was assessed by strictly monitoring the occurrence of adverse events and using standard laboratory parameters. The results of the intention-to-treat analysis showed that the severity of cough was decreased by 47% at Day 3 in the erdosteine group with a statistically significant difference compared to placebo, the difference was still significant at the final visit. The decrease in the severity of rales was significantly greater at Day 3 in the erdosteine group than in the placebo group. The incidence of polypnea and rhonchi in the two groups showed similar decreases, an improvement mainly due to the antibiotic. No adverse events occurred and no adverse changes in laboratory parameters were observed. It is concluded that the combination of erdosteine and amoxicillin is a safe medication which is clinically superior to that of the antibiotic combined with placebo, especially in regard to the effects on cough.

Y-chromosome haplotypes in Italy: the GEFI collaborative database.

A sample of 1176 males from 10 Italian regions have been typed for DYS19, DYS389-I, DYS389-II, DYS390, DYS391, DYS392, DYS393, and DYS385. Individual haplotype data are available on line. A low degree of variation is present among regions. Use of this database is specifically recommended for forensic applications in Italy.

[Guidance for the obstetrician encountering a multiple pregnancy]. / L'orientamento dell'ostetrico nei confronti della gravidanza multipla.

A retrospective review of multiple birth of higher order delivered at the Obstetric Clinic of University of Rome "La Sapienza" from 1982-1991 was performed. Comparison was made between this group (study group) and other published data. Since 1982 there has been more liberal use of abdominal delivery. Of the 25 multiple pregnancies, 17 were delivered by cesarean section (CS) and 8 by vaginal delivery. The corrected mortality rate in the study group was 19.2% (5/26) for vaginal delivery and 17.5% (10/57) for CS. Indication for CS was: elective (35%), fetal (18%) and maternal (47%). The main neonatal complications resulted from prematurity, and maternal noted complication were post-partum hemorrhage necessitating hysterectomy in one patient. The preferable mode of delivery cannot be stated dogmatically.

[Clinical evaluation of an immunological test for premature rupture of the fetal membranes (ROM check test)]. / Valutazione clinica di un test immunologico nella rottura prematura delle membrane (ROM check test).

Commonly used methods for detecting amniotic fluid in the vagina include research LA cells, ferning, nitrazina paper, ultrasound and dye injection. These methods are difficult to interpret or invasive. We have tested a new method which detects a fetal isoform of fibronectin in vaginal secretion when amniotic fluid is present. Clinical trials demonstrate the sufficient reliability in detecting amniotic fluid in the vagina of women with rupture of amniotic membranes.

[Epidemiologic study of cervico-vaginal pathology in IUD users]. / Studio epidemiologico della patologia cervico-vaginale nelle pazienti portatrici di IUD.

1800 intrauterine contraceptive device users, during a period of more than thirteen years, and 1800 control non-users were examined clinically, cytologically and histopathologically for cervical pathological lesions. There was an increase, but not statistically significant, in the incidence of metaplasia, dyskariosis or mild dysplasia. There was no difference in neoplastic lesions.

The coeliac iceberg in Italy. A multicentre antigliadin antibodies screening for coeliac disease in school-age subjects.

BACKGROUND: Recent studies suggest that coeliac disease (CD) is one of the commonest, life-long disorders in Italy. The aims of this multicentre work were: (a) to establish the prevalence of CD on a nationwide basis; and (b) to characterize the CD clinical spectrum in Italy. PATIENTS AND METHODS: Fifteen centres screened 17,201 students aged 6-15 years (68.6% of the eligible population) by the combined determination of serum IgG- and IgA-antigliadin antibody (AGA) test; 1289 (7.5%) were IgG and/or IgA-AGA positive and were recalled for the second-level investigation; 111 of them met the criteria for the intestinal biopsy: IgA-AGA positivity and/or AEA positivity or IgG-AGA positivity plus serum IgA deficiency. RESULTS: Intestinal biopsy was performed on 98 of the 111 subjects. CD was diagnosed in 82 subjects (75 biopsy proven, 7 not biopsied but with associated AGA and AEA positivity). Most of the screening-detected coeliac patients showed low-grade intensity illness often associated with decreased psychophysical well-being. There were two AEA negative cases with associated CD and IgA deficiency. The prevalence of undiagnosed CD was 4.77 x 1000 (95% CI 3.79-5.91), 1 in 210 subjects. The overall prevalence of CD, including known CD cases, was 5.44 x 1000 (95% CI 4.57-6.44), 1 in 184 subjects. The ratio of known to undiagnosed CD cases was 1 in 7. CONCLUSIONS: These findings confirm that, in Italy, CD is one of the most common chronic disorders showing a wide and heterogeneous clinical spectrum. Most CD cases remain undiagnosed unless actively searched.

The evolution of the management of "CIN" lesions.

During the years 1961-1986 a total of 378 CIN lesions were diagnosed among 4875 women screened for cervical pathology; 285 of them were followed-up for a minimum of 5 years. All 169 cases diagnosed as CIN-3 and 18 classified as CIN-2 were treated surgically, whereas 89 patients diagnosed as CIN-1 and 65 classified as CIN-2 were treated conservatively. Finally, 37 cases (23 diagnosed as CIN-1 and 14 diagnosed as CIN-2) did not receive any treatment. Of the 187 women treated surgically, 6 (3.8%) showed, within the five year follow-up period, progression or recurrence of the disease, which necessitated either additional surgery or radiation; 5 of these cases had been classified as severe dysplasia (CIN-3). Recurrence or progression necessitating major surgery, occurred in 8 (5.1%) of the 154 patients treated conservatively; 5 of these cases were classified as moderate dysplasia (CIN-2). The data indicate that present diagnostic procedures allow a better selection of patients to be submitted to surgery, increasing the proportion of those treated conservatively, without jeopardizing their prognosis.

[The surgical remodelling of prominent ears]. / Il modellamento chirurgico degli orecchi ad ansa.

It is a common fallacy that the prominent ear correction is easy; on the contrary it is difficult to obtain a perfect result, as indicated by the continuous growth of new methods. For a long time we have used Mustardè's mattress suture technique (Francesconi) but quite often the result was incomplete and not infrequently there was recurrence. In recent years, in order to obtain a more complete and permanent correction, we have added to the mattress sutures the superficial scratching of the anterior aspect of the cartilage as suggested by Stenstrom. A well formed contour of the antihelix and of the crura is so reproduced and maintained by the spontaneous bending tendency of the auricular cartilage following abrasion. The surgeon is dealing with an intact cartilage so that many common inconveniences met with in other techniques are eliminated. No irregularities and no sharp ridges, which may project beneath the skin on the anterior surface, are formed and there is no persistent protrusion on the upper or lower portion of the ear. The technique is equally well suited when insufficient folding of the antihelix or when excessive cupping of the concha are pronounced features.

[The possibility of preventing interactive disorders in the case of prolonged mother-infant separation at birth]. / Possibilità di prevenzione dei disturbi interattivi in caso di prolungata separazione madre-bambino alla nascita.

Considerable concern has been expressed that separation of mother and child following birth may interfere with early parent-child relationship and give to problems in the later psychosocial development of the child. In earlier publications we have evaluated the aspects of parents' emotional state and parent-infant interaction in 43 high-risk babies, hospitalized at birth for a period of one-three months. Recurrent interactive patterns and psychosomatic disturbances have been defined in their peculiarities. In this study we expose the results of our experience with 35 infants having the same characteristics as the preceding group, after adopting measures which elicit the parents' participation in looking after the baby in NICU and after studying methodologies of intervention during the follow-up programs which assess the neuropsychological conditions of the infants and their relations with their parents. We have observed a significant reduction of psychosomatic disturbances in the second group (20% vs 64%).

[Localized scleroderma in childhood]. / Sclerodermia localizzata nell'infanzia.

Scleroderma is a rare disease in children: the clinical presentation in childhood is even more varied than in adult life. It is characterized by 'hard skin' with cutaneous features including hypo- and hyperpigmentation, thickening or thinning and loss of elasticity. It ranges from circumscribed and self-limiting pigmentary disorders to disabling and disfiguring involvement of an extremity and a rapidly fatal outcome. Scleroderma must be differentiated from many scleroderma-like conditions. Therapeutic problems are also discussed.

[Early separation of the mother and infant and psychosocial development. I. Theoretical considerations]. / Separazione precoce madre-bambino e sviluppo psicosociale. I. Considerazioni teoriche.

Considerable concern has been expressed that separation of mother and child following birth may interfere with early parent - child relationships and give rise to problems in the later psychosocial development of the child. This review highlights recent studies about the delays in maternal attachment to the child, the negative maternal perception of the child compared with the expectation of an "average" baby, the persistent parental anxiety, the effects that early separation can have at least short-term, but also long-term, influences on patterns of parental behavior and on the development of the children.

[Early mother-infant separation and psychosocial development. II. Longitudinal study on 42 subjects]. / Separazione precoce madre-bambino e sviluppo psicosociale. II. Indagine longitudinale su 42 soggetti.

It is the purpose of the present investigation to obtain some information as they can be drown from the activity of our follow-up for premature babies and infants at higher risk. The main objectives of the study were: - to evaluate the aspects of parent's emotional status and parent-infant interaction in the first year of life; - to evaluate possible effects of the early separation on later development of the children. We have observed 42 LBW infants (hospitalized at birth for a period of one-three months) and their parents for 7-8 years. Our study has included: interviews with parents, observation of interaction, clinical examinations, designs. Recurrent interactive patterns have been defined in their peculiarities in the first year of life. Patterns of later psychosocial development are also exposed: they are strictly related to the kind of the precocious interaction.

[Syncopal pathology in childhood (I)]. / La patologia sincopale nell'età evolutiva (prima parte).

Syncope is a common phenomenon, well-known to all pediatricians: it is defined as a sudden transient loss of consciousness associated with inability to maintain postural tone that is incompatible with a seizure disorder, vertigo, dizziness, coma, shock or other states of altered consciousness. The purpose of this study are to analyse the multiple causes of syncope, to determine the characteristics of pediatric patients with syncope, to define the pathophysiologic mechanisms that result in neurally mediated syncope.

[Thrombophlebitis of the cavernous sinus and inappropriate ADH secretion syndrome]. / Tromboflebite del seno cavernoso e sindrome da inappropriata secrezione di ADH.

The septic thrombosis of the cavernous sinus is a rare and serious disease which still occurs occasionally. The physician should be aware of this fact when treating infections of the nasal orbital areas. A case is presented in whom the septic thrombosis of the cavernous sinus is associated with the syndrome of inappropriate secretion of antidiuretic hormone.

[Tests of autonomic nervous system functioning in children: normal values]. / Le prove di funzionalità del sistema nervoso autonomo nel bambino: valori normali.

The study of cardiovascular autonomic reflexes is the most physiological and reliable test for the assessment of autonomic function: they consist of the analysis of variation of heart rate and arterial pressure provoked by many physiological stimuli. Up to now normal pediatric reference data were not available: we have standardized these tests in 198 normal children (94 M, 104 F), aged 8.3-15.7 years, without any symptom of possible autonomic dysfunction pathology. A complete auxological evaluation has been performed. Autonomic tests were performed by ECG recording and arterial pressure monitoring during normal and deep breathing, Valsalva manoeuvre, lying to standing postural change, isometric muscular contraction (sustained hand-grip and leg rising). Eleven autonomic parameters were obtained. Many statistical correlation between autonomic parameters and auxological features have been explored, without remarkable results. A significative difference emerged only between sexes. Normal reference values has been calculated. Their utility for the study of autonomic dysfunction is discussed.

[Autonomic neural functioning in children with the periodic syndrome]. / Studio della funzionalità neurovegetativa in bambini con sindrome periodica.

The pathogenesis of periodic syndrome (recurrent abdominal pain, cyclic vomiting, headache and other equivalents of childhood migraine) is often related in the literature to a "neuro-vegetative dysfunction", by which occasional stimuli (environmental, metabolic, emotional) should find a particular somatic expression. The homeostatic role of the autonomic nervous system could be deficient in these cases, but systematic research has never been done to explore this hypothesis. We have evaluated the autonomic nervous function in 38 children (12 M, 26 F) with periodic syndrome, by cardiovascular autonomic function tests. They consist of ortho- and parasympathetic parameters obtained by ECG registration and pressure monitoring during deep breathing, Valsalva manoeuvre, lying to standing postural change, sustained handgrip. In the absence of adequate pediatric references values, we have previously standardized these tests in a population of 198 healthy children (94 M, 104 F), aged 8.3-15.7 years. Results have been compared with our standard reference values, matching them by t-test for independent data: in both sexes, significant differences have been found out in only one of 11 parameters (p < 0.05) of the autonomic tests performed. Children affected by periodic syndrome reveal a reduced heart rate variation in transition from the early orthosympathetic phase to the late parasympathetic one after lying to standing passage, showing a smaller fluctuation of autonomic feedback systems. The physiological meaning of this result is unclear. However, in children with periodic syndrome no prevalence of ortho- or parasympathetic systems is evident.

[A diagnostic controversy: the significance of 14-6/sec positive spikes in clinical electroencephalography]. / Un problema controverso: il significato delle punte positive di 14-6 c/sec nella elettroencefalografia clinica.

There has been a great dealt of discussion as to the clinical significance of E.E.G. 14-6 per second positive spikes (14-6 PS), a short burst lasting one second or less which occurs during light sleep in monopolar recordings, mainly in the posterior temporal regions and usually involving the parietal and occipital regions as well, for the most part in unsymmetrical fashion. Early interpretations stress the epileptic nature of vegetative attacks in patients with an inter-critical E.E.G. reading characterized by 14-6 P.S. Subsequently, however, this hypothesis has been refuted, mainly because E.E.G. intra-critical recordings have never shown evidence of any sort of paroxysmal activity. At present time expert think that the presence of 14-6 PS may be merely an indication of an electrical alteration associated with disorders in the neurovegetative area. In order to evaluate the possibility of using them as a diagnostic marker of migraine equivalents and periodic syndromes, we reviewed wake and sleep E.E.G. recordings, carried out consecutively and hence not selectively, in 617 children aged 5-16 years. 14-6 PS were present in 109 children (17.6%), 63 of whom showed evident symptoms of periodic syndrome (headache, recurrent abdominal pain, cyclic vomiting, kinetosis, etc.); hence 46 E.E.G. recording were false positive. 510 children were lacking in 14-6 PS, 91 of these presented symptoms of periodic syndromes (false negative). 14-6 PS are hence a marker 40.9% sensitive, 90.1% specific, with a predictable value of 57.7%. The search for 14-6 PS in children with periodic syndrome is not particularly sensitive as a test, but it is fairly specific: it may well constitute an useful element in diagnosis.

[Fever as periodic disorder]. / La febbre come disturbo periodico.

Slight, moderate but also high rises in temperature, excluding other causes of fever, can be considered symptoms of periodic syndrome originating by hypothalamic centers as soon as headache, recurrent abdominal pains, growing pains, dizziness, kinetosis. These rises aren't uncommon, but often aren't considered important and this few statistics are available. The Authors present 16 case reports of fever as periodic symptom and discuss how common factors exist in the mechanism of hyperthermia and other clinical signs of periodic syndrome (ex. migraine) but they are generally modulated differently so that disturbance of temperature regulation predominates in the first case, pain in the second.