Neonatal bacterial meningitis.

Neonatal bacterial meningitis (NM) continues to be a serious disease with an unchanging rate of adverse outcome of 20-60%, despite a worldwide decline in mortality. The 3 major pathogens in developed countries are: Group B streptococcus, gram negative rods and Lysteria monocytogenes. Signs and symptoms of NM may be subtle, unspecific, vague, atypical or absent. In order to exclude NM, all infants with proven or suspected sepsis should undergo lumbar puncture. Positive culture of cerebrospinal fluid may be the only way to diagnose NM and to identify the pathogen, as CSF parameters Smay be normal at early stages and NM may occur frequently (up to 30% of cases) in the absence of bacteraemia. When NM is suspected, treatment must be aggressive, as the goal is to achieve bactericidal concentration of antibiotics and to sterilize CSF as soon as possible. Antibiotics should be administered intravenously, at the highest clinically validated doses. Empiric antibiotic treatment should include agents active against all main pathogens; currently the recommended empiric treatment of NM is ampicillin, plus an aminoglycoside and a third-generation cephalosporn. Therapy should be reassessed after cultures and antibiotic susceptibility is available. Prevention of neonatal sepsis, early recognition of infants at risk, prompt treatment and future adjunctive therapies will improve prognosis. Finally, we present the first preliminary Italian data on GBS meningitis. Data are obtained from an area-based study conducted In Emilia-Romagna during 2003 to 2009.

Focal breast lesions with benign appearances. Review of eight breast cancers with initial features of intramammary lymph node.

PURPOSE: The aim of this study was to evaluate whether certain histological types of early breast cancer may share radiographic features with intramammary lymph nodes. MATERIALS AND METHODS: The previous mammograms of patients with histologically proven breast cancer and lesions displaying the morphological features of intramammary lymph nodes were retrospectively reviewed. RESULTS: Retrospective evaluation demonstrated eight breast cancers of varying histological nature--mostly ductal carcinomas not otherwise specified (NOS)--whose early radiographic features were similar to intramammary lymph nodes. CONCLUSIONS: Although uncommon, a lesion with the radiographic features of an intramammary lymph node may hide an early breast cancer. No significant relationship exists between histological type and the presence of such features.

Intraperitoneal rupture of an infected urachal cyst: an unusual cause of acute abdomen in children. A case report and review of the literature.

Urachal cysts are rare and usually asymptomatic until they become infected. This is a report of a case of peritonitis due to intraperitoneal rupture of an infected urachal cyst in a 3-month-old girl. A review of the literature found 31 similar cases previously reported, only seven of which were described in children. The diagnosis and treatment of intraperitoneal perforation of an infected urachal cyst in a child are discussed.

Safety and immunogenicity of conventional subunit and MF59-adjuvanted influenza vaccines in human immunodeficiency virus-1-seropositive patients.

In this study of influenza vaccination, 37 human immunodeficiency virus (HIV)-1-seropositive patients were randomized to receive either a vaccine with a conventional subunit or one adjuvanted with MF59. Blood samples were collected at the time of vaccination, and then 30 and 180 days later, to evaluate immunogenicity, CD4+ T-lymphocyte count and HIV-1 RNA levels. Seroconversion rates against the three viral strains included in the vaccine ranged between 44% and 72% and 53% and 68% for the adjuvanted vaccine and the subunit vaccine, respectively. Other criteria of the European Medicines Evaluation Agency were also met. Vaccination was not associated with serious adverse events. Local and systemic effects were mild and of short duration. CD4+ T-lymphocyte counts and viraemia levels were not negatively affected by vaccination. These results confirmed the safety and immunogenicity of these currently available vaccines in HIV-1-seropositive patients, thus supporting the recommendation for influenza immunization in this high-risk category.

Congenital anomalies of the venae cavae: embryological origin, imaging features and report of three new variants.

Due to the complexity of their developmental stages, the venae cavae may undergo a very large number of congenital anomalies. All the possible abnormalities which, to our knowledge, have been observed in the literature are reported, differentiating those of the superior vena cava and the azygos system, those of the inferior vena cava and the complex anomalies that concern the venous system as a whole. Moreover, we present three new variants: a right double inferior vena cava with azygos continuation of the posterior-medial vein; an agenesis of the superior vena cava with drainage through the azygos and hemiazygos veins to the inferior vena cava; and a double inferior vena cava with hemiazygos and azygos continuation of the left one.

Nonfunctioning endocrine tumors of the pancreas: possibilities of spiral CT characterization.

The aim of this study was to assess the ability of spiral CT to adequately characterize the nonfunctioning endocrine tumors (NFETs) of the pancreas, distinguishing this lesion from the other pancreatic tumors. The spiral CT examinations of 21 cases of histologically proven NFETs, along with those of 29 cases of other pancreatic tumors and tumor-like lesions, were retrospectively reviewed in a blinded fashion by two radiologists, in order to correctly classify the lesions, highlighting the typical signs reported in the literature. Discordant cases were further analyzed in the presence of a third radiologist. The final diagnosis was acquired by means of a majority or overall consensus. The histopathologic examination was considered the gold standard. The sensitivity, specificity, and positive and negative predictive values of CT were calculated. After the consensus evaluation, the correct diagnosis was reached in 72% of cases, with 10% of nonspecific diagnoses of solid pancreatic tumor and 18% of wrong diagnoses. The sensitivity and specificity of spiral CT in identifying NFETs were 66.6 and 82.7%, respectively. The positive and negative predictive values were 73.7 and 77.4%, respectively. In up to 70% of cases the NFET demonstrates a typical aspect of a mass hyperdense in the arterial contrastographic phase eventually associated with hyperdense hepatic metastases in more than half of the patients. This finding does allow the diagnosis of NFET but without certainty indeed, since other tumors can show a similar densitometric behavior and among them particularly the ductal adenocarcinoma. On the other hand, both the solid, hypovascularized NFETs, and the cystic form, cannot be differentiated from the other solid and cystic tumors of the pancreas.

Therapeutic embolization of idiopathic renal arteriovenous fistula using the "stop-flow" technique.

PURPOSE: To present a case of massive idiopathic arteriovenous fistula (AVF) successfully treated with an endovascular procedure. CASE REPORT: A 42-year-old woman with microscopic hematuria was found to have a massive idiopathic renal AVF. Percutaneous embolization was undertaken using a dual approach to deliver an occluding balloon through the draining vein and an arterial access to selectively catheterize the aneurysmal afferent artery. With the balloon inflated to interrupt flow ("stop-flow" technique), acrylic glue was delivered precisely to occlude the lesion. Duplex scans at 12 months have documented continued complete occlusion of the anomalous communication. CONCLUSIONS: The dual arterial and venous approach with the "stop-flow" technique makes it possible to successfully treat idiopathic AVFs that have constant high-flow connections.

Usefulness of ultrasonography in gastric foreign body retention.

Foreign-body ingestion occurs frequently in childhood. The diagnosis of ingestion is usually made by plain film radiography. Ultrasound is not routinely used in the investigation of gastric foreign bodies because of the limitations imposed by intestinal gas. This drawback can be overcome by distending the stomach with an anechoic liquid, which acts as an acoustic window. In a child who had ingested a coin, US performed after drinking tea was diagnostic and showed a hyperechoic image with an acoustic shadow inside the stomach. We believe that US is an appropriate technique for follow-up of gastric foreign bodies.

Strangulated traumatic hernia of the diaphragm. A report of two cases.

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.

Serum cytokines as predictors of clinical outcome in AIDS-related intestinal cryptosporidiosis.

BACKGROUND: Clinical variability in the natural course of cryptosporidiosis in patients affected by acquired immunodeficiency syndrome has been correlated to the degree of T-cell immunosuppression; however, cryptosporidiosis can occur as a self-limiting disease even in patients with very low T-lymphocyte count. AIMS: We tested the serum values of a panel of cytokines in AIDS patients with cryptosporidial enteritis in order to evaluate their role in predicting the clinical outcome of the disease. PATIENTS AND METHODS: Thirty one HIV-positive patients with cryptosporidiosis and a CD4+ count of less than 100/mm3 were studied. Interleukin-2, Interleukin-4, Interleukin-10, Interferon-gamma, Interleukin-12, Tumor Necrosis Factor alpha values were measured in serum at diagnosis. RESULTS: Interleukin-4 and Interleukin-10 concentration was significantly lower in patients with mild disease whereas serum Interleukin-2 and -12 was higher in this same group. The serum level of Interferon-gamma did not differ in relation to the severity of the disease. Patients with self-limiting diarrhoea showed significantly lower levels of Tumor Necrosis Factor-alpha than subjects who did not show any clinical improvement. CONCLUSIONS: In our study, it has been shown that cytokine levels in serum may represent early predictive markers both for the severity of symptoms and the clinical outcome of cryptosporidial enteritis in AIDS patients with a low CD4+ count.

[Digital radiography of the thorax with selenium detector. Clinical results and optimization potential of the technique]. / Radiografia digitale del torace con detettore al selenio. Risultati clinici e possibilità di ottimizzazione della tecnica.

INTRODUCTION: We compared the image quality of the chest radiograph obtained with a digital selenium detector and with a conventional system and investigated the possible improvements in the digital technique resulting from kilovoltage (kV) lowering, antiscattering grid addition and image format reduction. MATERIAL AND METHODS: 150 subjects in the first series were submitted to posteroanterior chest radiography with both the selenium and the conventional systems. Image quality was compared by giving a score to the depiction of anatominal and pathologic findings. Thirty-two and 31 subjects from two other series were submitted to two digital chest radiographs each: the former at high (150) and low (90) kV, and the latter at 150 kV with the antiscattering grid and at 90 kV without the grid. Comparisons were made by choosing the better of the two images of each subjects. A score was given to the depiction quality of several difficult-to-detect findings in full-size and small-size format digital images obtained in another series of 27 subjects. RESULTS: As for anatomical detailing, digital selenium images were of much better quality than conventional images: the mean scores given by 3 observers to digital images (5.32; 5.55; 6.68) are higher than those given to the corresponding conventional images (4.49; 5.02; 5.81) and the difference is statistically significant (p < 0.001 in all cases). The advantage of digital over conventional images is also significant with reference to diagnostic confidence in the identification of pathologic findings (p < 0.001; p < 0.005; p < 0.01), but to a lessere extent (mean scores: 3.98; 4.22; 3.60 for the digital system, versus 3.43; 3.69; 3.38 for the conventional system). The digital images acquired at lower kV (90 kV) were much more frequently chosen by the two observes (87.5% and 96.8% of cases) than the images acquired at 150 kV; the entry dose at lower energies (91 muGy using an anthropomorphic phantom) is not significantly higher than the dose given at 150 kV (85 muGy). No significant difference was found in the two observers' choice between the digital images taken at 90 kV without antiscattering grid and those taken at 150 kV with the grid, the former being preferred in 38.7% and 58% of cases. The level of diagnostic confidence in the detailing of difficult-to-detect findings was slightly higher in full-size digital images (mean scores: 5.33 and 6.77) than in small-size ones (4.88 and 5.96). DISCUSSION AND CONCLUSIONS: Digital selenium images always exibit better quality than conventional images: the difference is very marked relative to anatomical detailing and not so striking, though still significant, in showing pathologic findings. Digital selenium image quality can be improved relative to the manufacturer's guidelines (150 kV exposure with no grid), by lowering the kV and adding the antiscattering grid, without increasing patient exposure too much. Digital image format reduction allows cost containment without affecting diagnostic reliability.

[A case of severe thrombocytopenia in infectious mononucleosis]. / Su un caso di grave piastrinopenia in corso di mononucleosi infettiva.

The authors discuss a case of thrombocytopenia with bleeding occurred in a young woman with infectious mononucleosis admitted to the Infectious Disease Department of University of Catania. It is reported the pathogenetic hypothesis of virus-induced thrombocytopenia and therapy.

[A follow-up study in individuals subjected to ileo-cecal resection in infancy and childhood]. / Controlli a distanza di individui sottoposti in età pediatrica a resezioni intestinali interessanti anche la valvola ileo-cecale.

It is stated that the ileocecal valve delays the passage of ileal contents into the cecum and acts as a barrier against reflux and ascension of colonic bacterial flora into the small bowel: its resection may lead to bacterial colonization of the ileum and to abnormalities of intestinal motility, transit and absorption. In this study twenty individuals subjected in pediatric age (1 day to 11 years) to ileocecal resection have been evaluated from 2 to 19 years after surgery. Three patients underwent limited ileocecal resection, in four this was associated with a significant ileal resection, in five with extensive right colon resection and in eight with extensive ileal and right colon resection. Growth, stool habit, hematology and serum biochemistry were examined; all patients also underwent abdominal ultrasonography. In all body weight and height were within normal limits; seven had moderate diarrhea up to 18 months after surgery and two who required extensive intestinal resection (40 and 30 cm of small bowel left) had diarrhea until about 36 months after surgery: now all of them have daily fecal evacuation. Hematological, biochemical, urinary and fecal studies proved normal except in one treated with TPN who presented transaminases slightly increased and in three suffering from mucoviscidosis in whom steatorrhea with moderate alterations of fats and elevation of alkaline phosphatase and transaminases were present. Urinary and gall stones were not seen in anyone. In conclusion from this study it can be postulated that removal of ileocecal valve can be done safely in children.

Visceral leishmaniasis in HIV infected patients: treatment with high dose liposomal amphotericin B (AmBisome).

Visceral leishmaniasis (VL) in patients coinfected with human immunodeficiency virus (HIV) is often atypical, and characteristically relapses after treatment. We treated 10 HIV infected patients (9 men) with parasitologically confirmed VL with liposomal amphotericin B ("AmBisome': L-AMB) at a dose of 4 mg/kg/day on days 1, 2, 3, 4, 5, 10, 17, 24, 31, and 38. Patients were hospitalized for the first 5 days, and were monitored during, and 1 week and 1, 3 and 6 months after, L-AMB therapy. There were no serious adverse events, and L-AMB was well tolerated. 9/10 patients completed therapy, one patient defaulted at day 24. Clinical improvement was seen in all nine patients and the bone marrow aspirate was cleared of visible/culturable parasites in 8/9 patients. During follow-up, one patient defaulted. The seven remaining patients relapsed at 2, 3, 3, 5, 5, 6 and 7 months. Re-treatment with a variety of antileishmanial drugs was unsatisfactory. The time from first diagnosis of VL to death in six patients was 5-40 months (mean 18.8 months). Only one patient remained alive 26 months after treatment. L-AMB is safe and provides a good initial clinical response. Intermittent dosing enables a short period of hospitalization. However, relapse is probably inevitable.

[Follow-up study of pulmonary function in individuals subjected to lobectomy in infancy and childhood]. / Valutazione a distanza della funzionalità respiratoria in individui sottoposti a lobectomia polmonare in età pediatrica.

Experimental research in animals have demonstrated that pulmonary development continues after birth. This happens in man as well: alveolar proliferation and enlargement go on until the eighth year of age, furthermore complete pulmonary development is achieved until the 20-22 years of age. It is therefore possible to hypothesise that respiratory deficit following pulmonary exeresis in children would regress with time. In the Pediatric Surgery of IRCCS Policlinico S. Matteo of Pavia eight children, 4 days to 8 years of age, underwent lobectomy for pulmonary hypertensive emphysema (3), lung abscess (2), bronchogenic cysts (2) and hystiocytoma (1). One of them was lost to follow-up; the remainders were controlled from 3 to 25 years after surgery: all of them enjoy a normal active life. Respiratory function was evaluated through blood chemistry, blood gas analysis, basal and after strain ECG, chest X-ray, spirometry, basal and after strain pulmonary scintigraphy. Basal and after strain ECG, chest X-ray, and arterial blood gas were normal in every examined subjects; spirometry, although results are quite variable, did not show serious respiratory deficits; basal after strain pulmonary scintigraphies weren't homogeneous. These results, although they aren't univocally interpretable, positively confirmed that the residual lung after lobectomy has a satisfactory possibility of functional recovery.

Surgical treatment of necrotizing enterocolitis: when? how?

In 10 years (1981-1990) 28 out of 54 neonates (51.8%) with definite necrotizing enterocolitis (NEC) underwent surgery. Operation was performed at 13.5 +/- 8.8 (range 3-38) days of life, after 1.7 +/- 1.5 (range 1-6) days from the onset of symptoms. Aiming to perform laparotomy before the occurrence of perforation, surgery was liberally indicated in stage IIIa, according to Walsh-Kliegman. Explorative laparotomy (+peritoneal drainage in 2 cases) was performed in 4 patients with massive intestinal necrosis: all died within 3 days of surgery. In one neonate, only pneumatosis was present and resection was not considered mandatory. Intestinal resection and enterostomy was performed in 17 neonates, 5 of them with perforation; three developed an intestinal stenosis. Enterostomy was closed after 116.2 +/- 61.8 days (range 26-193); 11 patients (64.7%) are long-term survivors. Intestinal resection and primary anastomosis was performed in 6 babies, 3 of them with perforation. Postoperatively, 2 dehiscences and 1 stenosis were recorded, but all children survived. In our opinion, resection followed by primary anastomosis seems to be the most satisfactory surgical option.

[Intestinal atresia: what is changed in the last 30 years]. / L'atresia dell'intestino: cosa è cambiato negli ultimi 30 anni.

The changes occurred in the management of intestinal atresia in the last 30 years are presented. On the basis of a series of 55 neonates (29 M/26 F; 14 premature; mean body weight 2640 g, range 1340-4100 g; 23 duodenal, 30 small bowel, 2 colon) four aspects of this malformation are discussed; epidemiology, diagnostics, therapy and prognosis. Epidemiology. 40% incidence reduction is detected; unchanged the relative incidence of Down neonates with duodenal atresia. Diagnostics. Prenatal US scan useful in 4 of 8 cases only; emphasized the usefulness of plain X-ray abdomen. Perioperative treatment. Dramatic impact of the artificial nutrition on the management of short bowel syndrome, with 7 cases (residual small bowel from 75 to 9 cm, mean 40 cm) successfully treated. Surgical technique. Confirmed the validity of the one-stage termino-terminal anastomosis. Prognosis. Significant improvement in the last three decades respectively with 50%, 87% and 93% of long-term survivors. In the first decade 6 over 8 deaths were related to the atresia, while in the last 10 years the only death recorded was related to an associated severe cardiac malformation.