Granuloma eosinofílico cervical en el adolescente: reporte de un caso y revisión de la literatura / Cervical eosinophilic granuloma in adolescents: case report and literature review

INTRODUCCIÓN El granuloma eosinofílico (GE) es una patología infrecuente, sobre todo en adultos, que puede afectar la columna cervical. A pesar de la vasta literatura, esta enfermedad afecta principalmente a la población infantil, y no hay un consenso sobre el manejo en adultos. Con el objetivo de aportar conocimiento respecto a esta patología poco frecuente, se presenta un caso clínico de GE cervical en un paciente de 16 años, a quien se trató de manera conservadora, con buenos resultados y retorno completo a sus actividades. CASO CLÍNICO Un hombre de 16 años, seleccionado de rugby, consultó por dolor cervical axial persistente y nocturno de 6 semanas de evolución, sin trauma evidente. Al examen, destacó dolor a la compresión axial sin compromiso neurológico asociado. Los exámenes de tomografía computarizada (TC) y resonancia magnética (RM) revelaron lesión lítica en el cuerpo de C3 de características agresivas, de presentación monostótica en tomografía por emisión de positrones-tomografía computada (TEP-TC) compatible con tumor primario vertebral. Se decidió realizar biopsia percutánea bajo TC, para definir el diagnóstico y manejo adecuado, la cual fue compatible con células de Langerhans. Al no presentar clínica ni imagenología de inestabilidad ósea evidente o compromiso neurológico, se manejó con tratamiento conservador, inmovilización cervical, analgesia oral, y seguimiento estrecho. A los cuatro meses de evolución, se presentó con una TC con cambios reparativos del cuerpo vertebral y sin dolor, y logró retomar sus actividad habituales. CONCLUSIONES El diagnóstico de GE es infrecuente a esta edad, y se debe plantear entre diagnósticos diferenciales de lesiones líticas agresivas primarias vertebrales. Es necesario el uso de imágenes, y la biopsia vertebral es fundamental para confirmar el diagnóstico. Su manejo va a depender de la sintomatología, del compromiso de estructuras vecinas, y de la estabilidad de la vértebra afectada. El manejo conservador con seguimiento clínico e imagenológico es una opción viable.

INTRODUCTION Eosinophilic granuloma (EG) is a rare, tumor-like lesion, infrequently affecting the cervical spine, particularly in adults. Although vastly described in literature, this pathology mainly affects children, and there is still no consensus on its treatment in older patients. With the goal of contributing to increase the knowledge regarding this infrequent pathology, we present a case of a C3 eosinophilic granuloma in a 16-year-old patient, who was treated conservatively, with good results, including complete return to his previous activities. CLINICAL CASE a 16-year-old male, elite rugby player, presented with a history of persistent neck pain, mainly at night, with no previous trauma. Upon physical examination, he reported neck pain with axial compression of the head, without neurological impairment. Both computed tomography (CT) and magnetic resonance imaging (MRI) scan revealed an aggressive lytic lesion in the C3 vertebral body, a with monostotic presentation on positron emission tomography-computed tomography (PET-CT) compatible with a primary spine tumor. A CT-guided percutaneous biopsy was obtained to establish the diagnosis and provide the proper management. The results were compatible with Langerhans cells. As he presented no symptoms or imaging findings of evident bone instability, as well as no neurological impairment, the patient was treated conservatively, with a cervical brace, oral pain medication and close followup. A CT obtained after four months of treatment showed reparative changes of the C3 vertebral body; at this point, the patient reported no neck pain, so he was able to return to his previous activities. CONCLUSIONS Although an EG is rare at this age, it should be considered in the differential diagnosis of primary vertebral aggressive lytic lesions. Imaging and a vertebral biopsy are paramount to confirm the diagnosis. The treatment modality depends on the symptoms, the involvement of adjacent structures, and the stability of the affected vertebra. Conservative management including clinical and imaging followup is a viable option.

Mode of birth in women with low-lying placenta: protocol for a prospective multicentre 1:3 matched case-control study in Italy (the MODEL-PLACENTA study).

INTRODUCTION: The term placenta praevia defines a placenta that lies over the internal os, whereas the term low-lying placenta identifies a placenta that is partially implanted in the lower uterine segment with the inferior placental edge located at 1-20 mm from the internal cervical os (internal-os-distance). The most appropriate mode of birth in women with low-lying placenta is still controversial, with the majority of them undergoing caesarean section. The current project aims to evaluate the rate of vaginal birth and caesarean section in labour due to bleeding by offering a trial of labour to all women with an internal-os-distance >5 mm as assessed by transvaginal sonography in the late third trimester. METHODS AND ANALYSIS: The MODEL-PLACENTA is a prospective, multicentre, 1:3 matched case-control study involving 17 Maternity Units across Lombardy and Emilia-Romagna regions, Italy. The study includes women with a placenta located in the lower uterine segment at the second trimester scan. Women with a normally located placenta will be enrolled as controls. A sample size of 30 women with an internal-os-distance >5 mm at the late third trimester scan is needed at each participating Unit. Since the incidence of low-lying placenta decreases from 2% in the second trimester to 0.4% at the end of pregnancy, 150 women should be recruited at each centre at the second trimester scan. A vaginal birth rate ≥60% in women with an internal-os-distance >5 mm will be considered appropriate to start routinely admitting to labour these women. ETHICS AND DISSEMINATION: Ethical approval for the study was given by the Brianza Ethics Committee (No 3157, 2019). Written informed consent will be obtained from study participants. Results will be disseminated by publication in peer-reviewed journals and presentation in international conferences. TRIAL REGISTRATION NUMBER: NCT04827433 (pre-results stage).

[Spontaneous rectus sheath hematoma as a complication of anticoagulant and antiplatelet therapy: a case report.] / Ematoma spontaneo del retto addominale nell'anziano, complicanza di terapia anticoagulante e antiaggregante piastrinica: caso clinico.

Spontaneous rectus sheath hematoma (RSH) is an uncommon and often clinically misdiagnosed cause of abdominal pain, characterized by a presence of blood within rectus muscle sheath, with palpable mass. Hemorrhage may originate from the epigastric artery and branches or directly from rectus sheath rupture. The most frequent cause of hematoma is anticoagulant therapy. Diagnosis is based on ultrasonography and computed tomography. Conservative treatment and, in case of active bleeding, intravascular embolization is the treatment of choice, while surgery is indicated in case of failure of endovascular procedure or in patients with intra-abdominal rupture causing hemodynamic instability and abdominal compartment syndrome. Here we present a case of RSH that developed after hip replacement surgery in a patient on anticoagulant therapy and dual antiplatelet therapy.

Validity of the Italian Code of Ethics for everyday nursing practice.

BACKGROUND:: The research question for this study was as follows: Is the Code of Ethics for Nurses in Italy (Code) a valid or useful decision-making instrument for nurses faced with ethical problems in their daily clinical practice? METHOD:: Focus groups were conducted to analyze specific ethical problems through 11 case studies. The analysis was conducted using sections of the Code as well as other relevant documents. Each focus group had a specific theme and nurses participated freely in the discussions according to their respective clinical competencies. ETHICAL CONSIDERATIONS:: The executive administrative committee of the local nursing licensing council provided approval for conducting this project. Measures were taken to protect the confidentiality of consenting participants. FINDINGS:: The answer to the research question posed for this investigation was predominantly positive. Many sections of the Code were useful for discussion and identifying possible solutions for the ethical problems presented in the 11 cases. CONCLUSION:: We concluded that the Code of Ethics for Nurses in Italy can be a valuable aid in daily practice in most clinical situations that can give rise to ethical problems.

Pelvic heterotopic ossification: when CT comes to the aid of MR imaging.

OBJECTIVE: This article compares various imaging aspects of magnetic resonance (MR) and computed tomography (CT) of heterotopic ossification (HO) in the pelvic soft tissues in paraplegic patients. Our aim is to highlight the benefits of integrating MR and CT imaging in the diagnosis of immature HO, which may be challenging with MR images alone. METHODS: Paraplegic patients examined on the same day by contrast-enhanced 0.4-T pelvic MR and unenhanced CT for pressure-sore-related infections were selected. MR imaging was performed on a Hitachi-Aperto 0.4 T; the Open Magnet served as a more favourable configuration for the required limb positioning of these patients. CT images were attained on a six-slice Siemens-Somaton-Emotion. RESULTS: MR images of HO differ according to the degree of bone maturity. The more immature the HO process, the more heterogeneous is the signal, characterised mostly by focal iso-hypointensity on T1-weighted images and hyperintensity on T2-weighted/short TI inversion recovery (STIR). These characteristics correlate to different CT patterns. CONCLUSIONS: MR and CT features of pelvic HO in paralysed patients were reviewed with a focus on the different aspects associated with the degree of ossification. Based solely on the MR findings, immature heterotopic ossification may be difficult to differentiate from other soft tissue pelvic lesions. TEACHING POINTS: • The pelvis and hip are common locations of heterotopic ossifications (HO), often occurring in paraplegic patients. • With respect to HO, MR imaging allows for a confident diagnosis in mature ossified lesions only. The MR aspect of immature ossification may be confused with other pathologies. • Plain radiographs and CT may show various phases of ossification: amorphous calcification, immature and mature ossification. • Integrating MR with CT can help recognise HO foci and differentiate them from infections and other soft tissue lesions.

Tornar-se pediatra: o desenvolvimento do raciocinio clinico na residencia medica do Instituto Fernandes Figueira

Identifica em que medida a complexidade do Instituto Fernandes Figueira (IFF), hospital terciario e unidade de ensino e pesquisa da Fundacao Oswaldo Cruz, contribui para que os residentes adquiram a experiencia clinica, o raciocinio, o feeling de gravidade e o dominio das tecnicas diagnostico-terapeuticas durante a residencia medica de pediatria. Baseado em pesquisas bibliograficas e em fontes documentais primarias, verifica a construcao do saber medico, situa historicamente o surgimento da racionalidade medica ocidental contemporanea; descreve a especificidade do saber pediatrico; analisa a residencia como campo de pratica, com enfoque desta no IFF. A pesquisa demonstra que, para alem da racionalidade medica ocidental contemporanea, outros fatores afetam a formacao dos residentes em pediatria, evidenciando que a formacao dos residentes em pediatria, evidenciando que a complexidade do perfil de morbimortalidade da populacao atendida, embora enseje o dominio do manuseio do paciente grave, acaba por impor limites ao desenvolvimento do raciocinio clinico e, consequentemente, do feeling de gravidade. Verifica que os residentes do IFF sao habeis no manuseio do doente grave, o que significa que se sairao bem em servicos de terapia intensiva, onde a situacao de gravidade ja esta estabelecida. No entanto, o raciocinio clinico tende a ser prejudicado pela esteriotipacao de condutas, dando margem a inseguranca na tomada de decisoes.(AU)

Tornar-se pediatra: o desenvolvimento do raciocínio clínico na residência médica do Instituto Fernandes Figueira / To become a pediatrician: the development of the clinical reasoning in the medical residency of the Instituto Fernandes Figueira

Identifica em que medida a complexidade do Instituto Fernandes Figueira (IFF), hospital terciario e unidade de ensino e pesquisa da Fundacao Oswaldo Cruz, contribui para que os residentes adquiram a experiencia clinica, o raciocinio, o feeling de gravidade e o dominio das tecnicas diagnostico-terapeuticas durante a residencia medica de pediatria. Baseado em pesquisas bibliograficas e em fontes documentais primarias, verifica a construcao do saber medico, situa historicamente o surgimento da racionalidade medica ocidental contemporanea; descreve a especificidade do saber pediatrico; analisa a residencia como campo de pratica, com enfoque desta no IFF. A pesquisa demonstra que, para alem da racionalidade medica ocidental contemporanea, outros fatores afetam a formacao dos residentes em pediatria, evidenciando que a formacao dos residentes em pediatria, evidenciando que a complexidade do perfil de morbimortalidade da populacao atendida, embora enseje o dominio do manuseio do paciente grave, acaba por impor limites ao desenvolvimento do raciocinio clinico e, consequentemente, do feeling de gravidade. Verifica que os residentes do IFF sao habeis no manuseio do doente grave, o que significa que se sairao bem em servicos de terapia intensiva, onde a situacao de gravidade ja esta estabelecida. No entanto, o raciocinio clinico tende a ser prejudicado pela esteriotipacao de condutas, dando margem a inseguranca na tomada de decisoes.