Catamenial pneumothorax.

Thoracic endometriosis syndrome is an under-recognised manifestation of endometriosis and includes catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and pulmonary nodules. Catamenial pneumothorax presents as recurrent spontaneous pneumothorax with a temporal relationship to the onset of menses, affecting mostly the right lung. A 48-year-old woman presented with an eight-year history of right-sided catamenial pneumothorax, during which time she had three episodes of pneumothorax. Serial chest imaging revealed an enlarging mass overlying the right hemi-diaphragm. She was referred to our trust where she underwent video-assisted thoracoscopic surgery for right pleurectomy. Intraoperatively, defects were found in the right hemidiaphragm, through which parts of the liver had herniated. We describe the presenting features and management of catamenial pneumothorax.

Mechanical thrombectomy for the treatment of acute ischaemic stroke following pulmonary lobectomy.

Acute ischaemic stroke is a devastating postoperative complication that significantly impacts upon a patient's quality of life. Endovascular retrieval of thromboembolic material from proximal cerebral arteries by mechanical thrombectomy is the new standard of care for patients presenting with a proximal artery occlusion. We report the case of a patient developing an acute ischaemic stroke following pulmonary lobectomy, who was transferred to the regional neurosciences unit, despite the absence of an established referral pathway, to undergo mechanical thrombectomy, with significant prognostic neurological benefit. We would advocate all cardiothoracic centres identify their regional neurosciences unit and initiate discussion to establish a referral pathway.

Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy.

INTRODUCTION: Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy. METHODS: Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners. RESULTS: Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05). CONCLUSIONS: MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery.

The clinical risk in heart transplantation: is it evaluable?

At the moment, there is no score to evaluate clinical risk in heart transplantation. There is a need for such an instrument due to the extended criteria for donations and for recipient evaluation for transplantation. We divided the 203 consecutive patients who underwent heart transplantation (HTx). Between January 1999 and December 2007 into two groups: high and low risk based on several common well-defined variables. Donors were also divided into high- and low-risk groups. We matched the four groups to obtain risk cohorts: GA (high risk), GB and GC (intermediate risk) versus GD (low risk). We analyzed the 30 day-mortality showing a significant difference between GD and the other groups (P = .05) in contrast to no significant difference in 1- and 3-year survival rates among GA, GB, GC, and GD. Although the development of a specific score for heart transplantation is desirable and would be useful, a careful, case-by-case evaluation is indispensable.

Long-term efficacy and toxicity of cyclosporin A + fluocortolone + methotrexate in the treatment of rheumatoid arthritis.

OBJECTIVE: The therapeutic efficacy and tolerability of the combination of cyclosporin A, methotrexate and fluocortolone was evaluated after 96 months of treatment in 140 patients with rheumatoid arthritis. METHODS: The initial dose of CyA was 5 mg/kg per day and was subsequently modified on the basis of the individual clinical response. Fluocortolone was initially administered at a dose that was sufficient to control disease activity (80-130 mg/week) and then was gradually tapered down to a maintenance dose of 15-20 mg/week. MTX was given intravenously at a dose of 15 mg once weekly for 4 consecutive weeks and then, after a 2-week interval, every 2 weeks or every month depending on the evolution of the disease. RESULTS: At the end of the study a statistically significant improvement was observed in both clinical (VAS, grip-strength, duration of morning stiffness, number of swollen joints, number of painful joints, Ritchie's index and Lee's functional index) and laboratory parameters: ESR (p = 0.000); alpha 2 globulins (p = 0.000); hemoglobin (p = 0.000); CRP (p < 0.001); and rheumatoid factor (p = 0.000). Radiological evaluation revealed little progression in anatomic lesions (Larsen score p = 0.699; number of erosions p = 0.344), thus suggesting that our protocol may be capable of showing down both bone resorption and cartilage loss. Renal toxicity, defined as an increase in plasma creatinine concentrations of more than 50% of the baseline value, was observed in 12 patients (8.5%), but the drug was discontinued in only one, who simultaneously presented high blood pressure. CONCLUSION: The positive results so far achieved in our study must be interpreted as being due to the combined action of the individual drugs, which made it possible for them to be used at relatively low dosages that minimised the onset of their side effects while maintaining the efficacy of their suppressive action.

Evaluation of the efficacy and toxicity of the cyclosporine A-flucortolone-methotrexate combination in the treatment of sarcoidosis.

Eleven patients with chronic sarcoidosis resistant to high-dose corticosteroids and other immunosuppressive treatments were treated with cyclosporine A at the initial daily dose of 5 mg per kg body weight (ideal weight in the case of overweight subjects) combined with flucortolone and methotrexate. A complete and lasting remission of the disease was obtained in all patients with total disappearance of pulmonary and extrapulmonary manifestations. In addition, the disease activity indexes normalized and remained normal for the rest of the follow-up period (24.82 +/- 8.22 months, range 12-33). No renal or hepatic toxicity was observed in any patient. Two of them presented hypertrichosis and one nausea.

Combined cyclosporin A-steroid-MTX treatment in endogenous non-infectious uveitis.

Thirty-two patients with endogenous uveitis resistant to treatment with high doses of cortisone and other immunosuppressive agents were treated with cyclosporin A (at an initial dose of 5 mg/kg/die, subsequently modified according to individual clinical response), fluocortolone and methotrexate. Total and lasting disease remission was obtained in all patients, together with the recovery of normal visual acuity in 20 cases and its significant improvement in the remaining 12. Furthermore, in all patients the total disappearance of all ocular inflammatory activity was observed and maintained for a period of 10.87 +/- 5.31 (6-18) months. No signs of renal or hepatic toxicity were observed in any of the patients. A form of hirsutism appeared in only two cases.

[Radiosensitivity of lymphocyte subpopulations in subjects with systemic lupus erythematosus. An in vitro preliminary study]. / Radiosensibilità delle sottopopolazioni linfocitarie in soggetti affetti da lupus eritematodes sistemico. Studio preliminare "in vitro".

The Authors have studied the radiosensitivity of lymphocyte cultures of patients affected by systemic lupus erythematosus in the active phase, and in the remissive phase after treatment with cyclosporine and fluocortolone, compared to a group of normal subjects. Total lymphocyte cultures and cultures of T, B, NK lymphocytes, T helper/inducer and T suppressor cytotoxic obtained with specific monoclonal antibodies were used and then irradiated with Co-60 gamma photons at scale doses between 0 and 10 Gy. Damage due to irradiation was evaluated using 3H-TdR. Patients in the clinically active phase of the disease showed an increased lymphocytic sensibility of the total lymphocytic population as well as of the various populations and T subpopulations studied. Radiosensitivity tended to become normal in patients in the remissive phase of the disease. The Authors conclude that a preliminary study of the lymphocytic sensitivity should be carried out in all patients treated with radiotherapy with autoimmune pathologies in order to avoid damages due to irradiation. Moreover, the Authors retain that a test for lymphocytic sensitivity to radiation could apply with regard to the evaluation of the clinical remissive conditions of patients affected by systemic lupus erithematosus.

Efficacy of teicoplanin and imipenem on respiratory infections in high risk patients.

The efficacy of teicoplanin and imipenem was assayed on microorganisms, mainly hospital opportunistic organisms, resistant to common therapy, isolated from bronchoaspirates of high risk hospitalized patients. Imipenem has shown remarkable activity against all isolated microorganisms with sensitivities ranging from 91.93% against Acinetobacter calcoaceticus to 75.86% against Pseudomonas sp. Teicoplanin has shown excellent activity against Staphylococcus aureus (sensitivity 83.66%).

[Detectable hypoechogenic images in diffuse hepatic steatosis: a new ultrasonic finding in the differential diagnosis of expansive lesions of the liver]. / Immagini ipoecogene rilevabili nella steatosi epatica diffusa: un nuovo reperto ultrasonografico nella diagnosi differenziale delle lesioni espansive del fegato.

The authors describe a particular ultrasound finding which can sometimes be observed in the echographic picture of diffused hepatic steatosis and which was seen by these Authors in 117 out of 312 patients affected by steatosis. This finding consists of the presence of one or more hypoechoic focal areas situated at the IV-V and/or II-III segment level surrounded by widespread increase in echogenicity of remaining parenchyma, which is typical of "bright liver". These areas, which can easily be mistaken for neoplastic formations, were instead seen to be limited areas of normal liver parenchyma free of fatty infiltration. In those patients presenting valid reasons for suspecting the presence of primary or secondary neoplastic formations, the Authors believe that echographic examination of these areas should always be accompanied by more invasive methods in order to confirm or exclude the possible presence of neoplastic formations with certainty. On the contrary, in those patients where no such diagnosis is suspected, it should prove sufficient to monitor these areas by means of ultrasounds.

Hypoechoic images in hepatic steatosis: a recent ultrasound finding in differential diagnosis of space-occupying lesions of the liver.

The Authors described a particular ultrasound finding which can sometimes be observed in the echographic picture of diffused hepatic steatosis and which was seen by these Authors in 117 out of 312 patients affected by steatosis. This finding consists of the presence of one or more hypoechoic focal areas situated at the IV-V and/or II-III segment level surrounded by wide-spread increase in echogenicity of remaining parenchyma, which is typical of "bright liver". These areas, which can easily be mistaken for neoplastic formations, were instead seen to be limited areas of normal liver parenchyma free of fatty infiltration. In those patients presenting valid reasons for suspecting the presence of primary or secondary neoplastic formations, the Authors believe that echographic examination of these areas should always be accompanied by more invasive methods in order to confirm or exclude the possible presence of neoplastic formations with certainty. On the contrary, in those patients where no such diagnosis is suspected, it should prove sufficient to monitor these ares by means of ultrasound.

[Behavior of blood copper, ceruloplasmin and procollagen III in acute myocardial infarction]. / Sul comportamento della cupremia, della ceruloplasminemia e del procollagene III sierico nell'infarto acuto del miocardio.

The authors report the determination of copper, ceruloplasmin and procollagen III peptide serum levels (sPIIIP) in patients affected by acute myocardial infarction. These measurements were taken daily during the first ten days after diagnosis and subsequently every five days until the fortieth after the acute event. A significant increase above the normal values was observed, proportioned to the extension of the infarctuated area, reaching a peak respectively for cupraemia, ceruloplasminaemia and sPIIIP on the fourth, sixth and eighth day after the acute event and still being evident in varying proportion till the 25th-35th day and even further, again in relation to the extension of the infarctuated area. The Authors relate this phenomenon to the involvement of the homeostatic mechanism supposed to face necrotic and critical processes as those which take place during acute myocardial infarction and subsequent riparation. The Authors suggest the clinical use of cupraemia, ceruloplasminaemia and sPIIIP determinations as diagnostic and prognostic indexes of acute myocardial infarction.

[The combination of cyclosporin A and fluocortolone in the treatment of autoimmune diseases]. / L'associazione ciclosporina A--fluocortolone nella terapia delle malattie autoimmuni.

The authors report the results obtained in treatment of various autoimmune diseases using cyclosporin A (CyA) in association with fluocortolone and/or methotrexate and cyclophosphamide. In all patients treated, complete long-lasting remission of the disease both from a clinical point of view and regarding laboratory tests was obtained. In some cases, this remission has lasted for several years since onset of therapy. The results obtained demonstrate the efficacy of CyA in treatment of autoimmune diseases and show that association with fluocortolone and/or methotrexate and cyclophosphamide by exploiting the combined action of these drugs, has enabled relatively low doses to be used. These however are still sufficient to induce satisfactory immunosuppression and avoid side effects. In this context, the importance of monitoring drug blood levels is underlined, also in view of the fact that each patient has a different capacity for intestinal CyA absorption.

[Mebendazole in the therapy of human hydatidosis. Evaluation of the results obtained in 9 patients with pulmonary localization]. / Il mebendazolo nella terapia dell'idatidosi umana. Valutazione dei risultati ottenuti su nove pazienti con localizzazione polmonare.

Nine patients with pulmonary cysts of echinococcus varying in size have been treated with Mebendazole. When the cysts were small or medium in size a complete disappearance or an important reduction was observed, whereas in four patients in which the cyst was big in size the treatment did not cause any decrease in size. The Authors point out the efficacy of the Mebendazole in the small or medium size cysts if the drug is given at high doses and for a long period. Nevertheless the use of this drug may be suitable also in the treatment of big size cysts together with surgical treatment to avoid possible secondary local or distant implant and in all cases of human inoperable echinococcal cyst.

[Immunosuppressive therapy in ulcerative rectocolitis. Long-term assessment of results]. / La terapia immunosoppressiva nella rettocolite ulcerosa.

The short and long-term efficacy of the combined administration of azathioprine and sulphasalazine in the treatment of ulcerative colitis was evaluated. A complete and durable remission of the clinical, the endoscopic and the histological signs of the disease was achieved in all the patients but one, who did not follow the domiciliary therapeutic regimen. No adverse effects referable to the long-term assumption of the azathioprine have been noted.