A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department.

INTRODUCTION: Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the most common cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED has been poorly studied. OBJECTIVE: To compare two protocols of the Epley maneuver for the treatment of PC-BPPV. PATIENTS AND METHODS: We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n = 46) or multiple maneuvers (n = 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus, resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. The DHI was stratified into mild (≤30) and moderate-severe (>30). RESULTS: Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EM group and 44.4% in the multiple EM group (p = 0.62). The DHI showed reduction from 42.2 (SD 18.4) to 31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group (p = 0.06). A higher number of patients improved from moderate-severe to mild DHI (p = 0.03) in the single EM group compared to the multi-EM group (p = 0.23). CONCLUSION: There was no statistically significant difference between performing a single EM versus multiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach is associated with shorter physical contact between patients and examiner, which is logically safer in a pandemic context.

[Giant benign gastric ulcer penetrating into the liver, pancreas and mesocolon]. / Ulcera gastrica gigante benigna penetrante nel fegato, nel pancreas e nel mesocolon.

Penetration of the liver, pancreas and transverse mesocolon by a giant benign gastric ulcer is relatively uncommon, and literature contains a few reports of this complication. The preoperative histological diagnosis may be difficult or impossible. A 63-year-old female patient with a history of seven months of lack of appetite, asthenia, epigastric pain, a remarkable weight decrease, presenting at physical examination a large, smooth margins, not pulsating, quite fixed abdominal mass, is reported. Echography confirmed the presence of a mass of approximately 14 x 19 cm, with solid and liquid content. Biopsy showed inflammatory elements and cellular detriti. Barium enema showed that the mass compressed the descendent colon, which appeared dislocated. Tumor markers (CEA, CA 19-9, alpha-fetoprotein) where in the normal range. Endoscopy showed a giant angular ulcer whose bottom was represented by necrotic material (after the definitive histological examination it proved to be hepatic tissue). At TC scan of the abdomen, a remarkable thickening of the gastric wall was present. At surgery the stomach appeared increased in volume, with remarkably thickened walls, tenaciously sticking to II and III hepatic segments, to the pancreas and transverse mesocolon. A total gastrectomy was performed because of the depth of the ulcer penetration and the extension of the alteration of the gastric wall, even if the giant gastric ulcer, in the literature, is more frequently benign than malignant.

[Acute pancreatitis. Our experience during 20 years]. / Pancreatite acuta. La nostra esperienza nell'arco di venti anni.

BACKGROUND: On the basis of personal experience and studies, the importance to diagnose quickly the seriousness of an acute pancreatitis with the help of simple and credible criteria of evaluation is underlined. It's also underlined the help of endoscopic papillosphincterotomy in the initial phase of a biliary pancreatitis; in fact this exam permits to perform a laparoscopic cholecystectomy in a second time and reduce surgical trauma. METHODS: Personal experience with 288 cases of acute pancreatitis (AP), during a twenty-year period (1975-1996) is described. In 61% of cases the AP was associated with biliary illness, and in 13% with alcohol abuse. Real important for therapeutic implication and prognostic significance is the classification of severity of acute attack, by using clinical evaluation (pain, fever, jaundice, abdominal tenderness), multiparametric score (i.e. Imrie's score, Ranson's criteria, SAPS or APACHE II score system) and morphological evaluation of the pancreas (echo and CT scan). 151 patients have been admitted at different times to surgery, the cholecystectomy being the more common surgical procedure, with a surgical rate of 52%. RESULTS: The overall mortality has been 7.2%, ranging from 45.4% in 17 severe necrotic haemorrhagic AP to 2.1% for the mild one. CONCLUSIONS: The widespread use of endoscopic retrograde colangiopancreatography (associated to endoscopic sphincterotomy if necessary) and the recent but universally accepted diffusion of laparoscopic cholecystectomy have changed the modern approach to surgical treatment of biliary associated AP, ensuring mininvasive less traumatic surgical procedures.

["Cast syndrome"]. / La "cast syndrome".

The term "cast syndrome" (also called Wilkie's syndrome or superior mesenteric artery syndrome) means an intestinal obstruction caused by a duodenal vascular compression from the superior mesenteric artery. A case of this rare syndrome is reported in a 12-year-old child associated with the treatment by a plastered cast for idiopathic scoliosis. The pathogenesis, diagnosis, medical and surgical treatment are described.

[Bilateral thrombosis of a femoral pseudoaneurysm]. / Trombosi bilaterale di pseudoaneurisma femorale.

One case has been described of acute thrombosis of bilateral femoral anastomotic pseudoaneurysm. The clinical finding of bilateral acute ischemia of the lower limbs required urgent surgical treatment. The operative technique consisted of excision of anastomotic aneurysms and replacement by a new segment of prosthesis with an end-to-end anastomosis to the deep femoral artery. Pathogenesis of the pseudoaneurysms at the femoral anastomosis generally recognized numerous factors such as mechanical, graft or suture defects, hypertension, wound complications. Recognition of femoral anastomotic aneurysms is usually simple, when a pulsative mass is noted. In such a case (reported) of thrombosis of bilateral femoral pseudoaneurysms, preoperative diagnosis was more difficult. Anastomotic aneurysms of little size that occur later after original intervention require observation by echography and angiodinography. When rapid enlargement arises, urgent surgical treatment is required, before rupture or thrombosis. The surgical intervention consists of excision of the anastomotic aneurysm and replacement by a new segment of prosthesis between the prosthesis and the common or deep femoral artery. If the reconstruction at the level of femoral artery is not possible, the anastomosis is performed more distally, at the level of popliteal artery. The results are affected by the degree of urgency of surgery, with significant difference in favour of the patients Who underwent elective procedures.

[Aneurysm of the iliac artery]. / Aneurismi dell'arteria iliaca.

The authors consider isolated iliac artery aneurysms. While the incidence of isolated iliac lesion is, as literature reports, quite low, it rises up to 20% when associated with aortic lesions. The clinical findings are often characterized by effects of compression on the intrapelvic structures, by neurological symptoms and decreased venous flow. Diagnosis is based on ecography, CT and angiography for the definition of side and extension of the aneurysmatic lesion. From the technical point of view, the surgical approach is based on the dimensions of aneurysm and its mono- or bilateral extension. The most common approach in case of bilateral aneurysms or aorto-iliac lesions is transperitoneal, while it's limited to extraperitoneal way, when isolated iliac lesion. If the aneurysm involves the hypogastric artery, mostly when bilateral, the risk of bowel ischemic complications becomes more significative.

[Emergency surgery in patients over eighty]. / L'urgenza chirurgica nell'ultraottantenne.

The authors describe a series of 139 over-eighty patients (M = 53, F = 86), who underwent emergency surgery between 1-1-1987 and 30-6-1993. They consider diagnosis, copathology, type of surgical procedures, postoperative complications and final results. In this series they study 73 large bowel obstruction and 48 peritonitis. They notice important copathologies in 78% of patients, in particular cardiovascular diseases. They performed 74 mayor surgical procedures with 48% of postoperative complications and exitus in 24% of cases, due overall to exacerbation of coexisting diseases. The authors underline the direct between mortality rate and number of copathologies, and analyze the basic rules to follow in surgical indications and during the postoperative period.

[Perforated colonic diverticulitis. Surgical technique]. / Le perforazioni diverticolitiche del colon. Tattica chirurgica.

Emergency surgery is required for performed colonic diverticulitis. Surgical indications are not uniform in literature. In the experience of the authors the operations have been performed in the case of peritonitis subsequent to the perforation or in the case of failure of the conservative treatment. Twenty-four patients underwent surgical intervention because of diffuse (17 cases) or localized peritonitis (7 cases). Exitus were related to cardiovascular complications in patients over seventy. Postoperative results are related to the age, the general conditions of the patient and to the intraoperative finding, of localized or generalized peritonitis. Operations may be divided into two groups: conservative procedures or primary resections. In the first one it is possible to suture the colonic wall without resection; in the second one the intraoperative finding or the extensive necrotic lesions indicates colonic resection or exteriorization. The surgical treatment adopted is correlated both to the age and cardiorespiratory conditions and to the other associated diseases.

Effects of ischaemia and reperfusion on liver regeneration in rats.

OBJECTIVE: To assess the effects of oxygen free radicals on liver regeneration in rats after 80% hepatectomy. DESIGN: Open laboratory study. SETTING: Institute of Biomedical Sciences, University of Milan, Italy. MATERIAL: Female Sprague-Dawley rats. INTERVENTIONS: After laparotomy 122 rats had ischaemia induced by clamping of the portal vein and hepatic artery, and 93 rats had manipulation of the vessels only. They were then allowed to recover before 80% hepatectomy was done. Absolute controls (n = 16) did not have a laparotomy. Mortality was recorded, and surviving rats were killed one, three, five, and seven days after operation. A further 10 rats had 80% hepatectomies and then underwent a 10 minute period of ischaemia 24 hours later. These animals were killed after three days. In yet more experiments 38 rats underwent 80% hepatectomies and were then divided into four groups: 8 were given allopurinol 50 mg/kg/day starting three days before operation; 8 were given superoxide dismutase 4.16 mg/kg intraperitoneally 30 minutes before induction of ischaemia; 12 were given verapamil 0.1 mg/kg 30 minutes before induction of ischaemia; and 10 were given saline (controls). MAIN OUTCOME MEASURES: Incorporation of tritiated thymidine into DNA, differences in liver weights, and lipid peroxide concentrations. RESULTS: 43 rats died after ischaemia/reperfusion and 19 after hepatectomy alone. Ischaemia/reperfusion caused a significant reduction in the incorporation of tritiated thymidine into DNA 24 hours after hepatectomy (p < 0.01), and significant inhibition of recovery of liver weight three (p < 0.01) and five (p < 0.05) days after hepatectomy. These effects were associated with high lipid peroxide concentrations at three days. Allopurinol (p < 0.01, p < 0.05), superoxide dismutase (p < 0.01, p < 0.01) and verapamil (p < 0.01, N.S.) reduced the effects of ischaemia/reperfusion on liver weights or lipid peroxide concentrations three days after hepatectomy. CONCLUSION: A 10 minute period of ischaemia followed by reperfusion temporarily reduces liver regeneration after 80% hepatectomy in rats.

Effects of autonomic nervous system on gastric damage by ethanol in the rat.

To study whether or not the autonomic nervous system influences the defense mechanisms of the gastric mucosa, groups of Sprague-Dawley rats were given stimulants and inhibitors of the different components of the vagus and celiac nerves before administration of absolute or 70% w/v ethanol. The effects of vagotomy and sympathectomy on "adaptive cytoprotection" were studied, as were the effects of blocking the muscarinic receptors and stimulation of beta-adrenergic receptors. We found that: (1) cholinomimetic agents and norepinephrine make the damage caused by 70% ethanol worse; (2) atropine is the only agent that fully protects against absolute ethanol; (3) vagotomy and sympathectomy abolish the effects of atropine and adaptive cytoprotection; and (4) beta-adrenergic stimulation replaces conditions that allow adaptive cytoprotection and the protection by anticholinergics. These results suggest that two different reflexes are triggered by ethanol: when low concentrations are given, the beta-adrenergic-mediated effect is prevalent, with protection of the mucosa; when high concentrations are given, the cholinergic-mediated effect is prevalent with damage of the mucosa.

Prostaglandin cytoprotection in man: effectiveness of rosaprostol.

We studied the effect of a new prostaglandin analogue, 9-hydroxy-19,20-bis-norprostanoic acid (rosaprostol), on the duodenal mucosa of humans after administration of 40% ethanol. Eighteen healthy volunteers entered the study, which followed a blind cross-over design. At time 0 all the volunteers received rosaprostol or placebo; 5 minutes later, 40% ethanol (50 ml dose) was given. The mucosa was examined for lesions 3, 60 and 180 min later under endoscopy, light and scanning microscopy. It was found that: (i) 40% ethanol damaged the duodenum, with blood extravasation, inflammation and necrosis of the mucosa, (ii) rosaprostol significantly protected the mucosa 3 min after 40% ethanol, and (iii) the damage became worse after 3 h when placebo was given, whereas it was reduced after 1 h when PG was administered. The results suggest that PGs not only protect the mucosa against ethanol damage, but also stimulate its recovery.

The role of mast cells in wound healing.

Mast cells are known to participate in three phases of wound healing: the inflammatory reaction, angiogenesis and extracellular-matrix reabsorption. The inflammatory reaction is mediated by released histamine and arachidonic acid metabolites. Compound 48/80 and disodium-cromoglycate are both able to increase skin breaking strength shortly after wounding. Under light and electron microscopy we found that small, granule-poor, irregular mast cells (MLMC) accumulate in the wound. This suggests that the small MLMC (mucosal-like mast cells) migrate into the skin during wound healing, and that both CTMC (connective-tissue mast cells) and MLMC are involved in tissue repair. Moreover, there is some evidence that mast cells participate in angiogenesis, since heparin is able to stimulate endothelial-cell migration and proliferation in vitro, and protamine to inhibit these processes and also angiogenesis in vivo. When the effect of protamine on wound breaking strength was examined, we encountered a decrease which was not prevented by heparin administration. Further studies are needed to demonstrate that protamine is specifically involved in inhibiting heparin-mediated angiogenesis in wounded tissue. Finally, mast cells may play a role in the extracellular matrix remodelling, on the basis of in-vitro experiments (but there are still no in-vivo data).

The effects of oxygen free radicals on wound healing.

We have examined the effects of oxygen free radicals, generated by xenobiotics administration, ischaemia-reperfusion or sepsis, on the healing of skin or intestinal wounds in rats. We found that 5 days after operation there was a significant decrease in the wound breaking strength in rats treated with phenazine methosulfate, zymosan, ischaemia-reperfusion or retroperitoneal infection. These changes were specifically prevented by administration of superoxide-dismutase (SOD), aprotinin and (in some models) allopurinol. On the contrary, none of these measures was effective when a local trauma caused the decrease in breaking strength. Our results suggest that oxygen free radicals mediate the inhibition of wound healing following ischaemia-reperfusion and sepsis.

Modulation of the Hoffmann reflex by rapid muscle contraction or release.

The inhibition of the H-reflex of the Soleus (Sol) muscle that takes place during and after voluntary release of Sol muscle has been attributed to presynaptic inhibition of autogenetic spindle afferences. In the present study, the time-relationship between onset of H-reflex depression and termination of Sol contraction was investigated to ascertain whether the reflex inhibition is linked to the command to release, or whether it is an accompanying phenomenon connected to changes in the neural outflow from the periphery. A parallel investigation was carried out on the temporal characteristics of the facilitation of the H-reflex that precedes onset of Sol contraction, in an attempt to point at the different functional organization of the two motor tasks. Voluntary releases from a bilateral isometric plantar torque, or bilateral plantar flexions, were performed in response to an acoustic stimulus, in a reaction time (RT) situation. The intervals from the starting signal to complete termination, or to beginning, of the Sol EMG were measured. The H-reflex was evoked at random during the tasks in one leg and its amplitude was referred in time to the end, or to the onset, of the EMG recorded from the contralateral Sol muscle. The RTs of the termination of Sol EMG had an average duration of about 100 ms, being some 20 ms shorter than those of the onset of EMG. In the release-task, the H-reflex amplitude was higher than that of the controls during the holding phase, and started to decrease about 20 ms before the cessation of the EMG.(ABSTRACT TRUNCATED AT 250 WORDS)

Interhemispheric transfer of voluntary motor commands in man.

The lack of callosal fibres between homotopic areas of the hand in the sensorimotor cortex in man and its possible functional correlates were investigated in normal adult subjects by comparing simple reaction times (RTs) of voluntary movements triggered by a somaesthetic stimulus to the same or opposite side of the body. An air jet was delivered to the skin of distal (index finger) or proximal (shoulder) ipsi- or contralateral zones, and triggered voluntary extension of the index finger or flexion of the forearm. The RT was measured from the arrival of the stimulus to the skin to the onset of the surface EMG of the muscle extensor indicis proprius or biceps brachii. The RTs of the contralateral finger movements triggered by either proximal or distal skin stimuli were significantly longer than the RTs of the corresponding ipsilateral movements (mean difference 11.72 and 15.10 msec respectively). When the task was flexion of the forearm, the differences in RTs between contra- and ipsilateral movements were instead compatible with a transcallosal transfer (mean difference about 2 msec in both cases). It is concluded that transcallosal connections between hand sensorimotor areas are conceivably absent also in man. Furthermore, the delay in contralateral distal performance appears to be due to a lack of transfer of the command through the motor areas, rather than to a lack of transfer of the triggering cutaneous afferent information to the performing hemisphere.