Diagnostic role of internal mammary lymph node involvement in tuberculous pleurisy: a multicenter study.

BACKGROUND AND OBJECTIVES: Diagnosis of tuberculous pleurisy (TP) may be challenging and it often requires pleural biopsy. A tool able to increase pre-test probability of TP may be helpful to guide diagnostic work-up and enlargement of internal mammary lymph node (IMLN) has been suggested to play a potential role. The aim of the present investigation was to assess role of IMLN involvement in TP in a multi-centric case-control study, by comparing its prevalence and test performance to those observed in patients with infectious, non-tuberculous pleurisy (NTIP), and in controls free from respiratory diseases (CP). METHODS: A total of 419 patients, from 14 Pulmonology Units across Italy were enrolled (127 patients affected by TP, 163 affected by NTIP and 129 CP). Prevalence, accuracy and predictive values of ipsilateral IMLN involvement between cases and control groups were assessed, as well as concordance between chest computed tomography (CT scan) and thoracic ultrasound (TUS) measurements. RESULTS: The prevalence of ipsilateral IMLN involvement in TP was significantly higher than that observed in NTIP and CP groups (respectively 77.2%, 39.3% and 14.7%). Results on test performance, stratified by age, revealed a high positive predictive value in patients aged ≤50 years, while a high negative predictive value in patients aged >50 years. The comparison between CT scan and ultrasound showed moderate agreement (Kappa=0.502). CONCLUSIONS: Evaluation of IMLN involvement plays a relevant role in assessing the pre-test probability of TP. Considering the increasing global prevalence of mycobacterial infections, a tool able to guide diagnostic work-up of suspected TP is crucial, especially where local sources are limited.

Pulmonary hypertension in idiopathic pulmonary fibrosis: prevalence and clinical progress.

The aims of the present study are to define the prevalence of pulmonary hypertension (PH) in a cohort of idiopathic pulmonary fibrosis (IPF) patients, to investigate any correlations between systolic pulmonary artery pressure (PAPs) and functional data, to evaluate clinical progress and to compare long-term survival in IPF patients with and without PH. A population of 126 IPF patients was recruited. A high prevalence of PH (39.7%, 50/126), evaluated by echocardiography on the basis of PAPs greater than 36 mmHg, was mainly observed in smokers and female patients. Regression analysis revealed a significant correlation between PAPs greater than 50 mmHg and DLCO/VA (p = 0.0294). Mean PAPs was significantly greater one year after onset of PH (p = 0.01). 11/21 patients with FVC less than 50% had a significant increase in PAPs one year after onset of PH (p = 0.02). There was a highly significant difference between survival of IPF patients with and without PH (p = 0.0001; hazard ratio = 3.56). This study revealed that PH has a high prevalence in patients with IPF and is associated with increased risk of mortality. Early diagnosis of IPF patients with pulmonary hypertension is important, so that they can be enrolled in waiting lists for lung transplant as soon as possible.

Amenorrhea after weight recover in anorexia nervosa: role of body composition and endocrine abnormalities.

UNLABELLED: Hypothalamic amenorrhea in anorexia nervosa often precedes weight loss and may persist after re-feeding and restoration of a stable normal weight. AIM: To assess the rate of persistent amenorrhea in anorexia nervosa (AN) after re-feeding and the relations of this condition with body composition changes and other endocrine parameters. METHODS: A cohort of 250 female outpatients was studied to assess persistent amenorrhea prevalence after stable weight recovery. Among these, we selected 20 AN female patients (age 16.5-35), 10 with amenorrhea (group 1) and 10 with normal menses (group 2). We collected data such as age, age at menarche, age at onset of AN, actual body mass index (BMI) and at onset of AN, duration of disease. Physical activity has been evaluated as minute per day. The following data were obtained: prolactin, growth hormone, estradiol, luteinizing hormone, follicle stimulating hormone, thyroid stimulating hormone, free triiodothyronine, free thyroxine, free urinary cortisol, serum calcium and phosphates, urinary calcium, phosphaturia and alkaline phosphatase. Body composition was assessed with a dual energy x-ray absorptiometry (DEXA). RESULTS: Thirty-five patients (14%) over a cohort of 250 where still amenorrhoic after stable weight recovery. No significance was found in the evaluation of blood biochemical tests of the 2 groups. Free urinary cortisol was significantly higher in amenorrhoic patients (58.14+/-0.4 vs 15.91+/-9.5), p=0.02. The analysis of body composition has shown a percentage of fat of 22.23+/-5.32% in group 1 and of 26.03%+/-9.1% in group 2, respectively, showing no significant differences. Amenorrhoic patients carried on doing a significantly heavier physical activity than eumenorrhoic patients. CONCLUSIONS: An adequate body composition and a well represented fat mass are certainly a necessary but not sufficient condition for the return of the menstrual cycle. Such menstrual cycle recovery would probably need other conditions at present being studied and evaluated to occur, such as secretory patterns of leptin and its correlations with adrenal function.

Densitometric evaluation in women with anorexia nervosa.

Anorexia nervosa (AN) is classified as a high-risk factor for osteoporotic fractures. Dual X-ray absorptiometry (DXA) is the most popular method for measuring bone loss, but it is less sensitive than quantitative computed tomography (QCT). We compared DXA and QCT in measuring the lumbar spine of 17 female patients with AN and 27 healthy subjects. We found discordance between DXA and QCT using World Health Organization (WHO) criteria with the T-score. With QCT as a reference method because of its sensitivity, we found one false-negative, one false-positive, and two misdiagnosed cases. We suggest some correction factors to improve DXA evaluation and screening of bone loss in AN.

Osteoporosis and anorexia nervosa: relative role of endocrine alterations and malnutrition.

BACKGROUND AND AIM: Anorexia nervosa (AN) is a psychiatric disorder characterised by self-induced starvation or a very reduced caloric intake, and frequently by severe life-threatening protein calory malnutrition. Its physiological consequences include amenorrhea, estrogen deficiency and osteoporosis. Osteoporosis may develop as a consequence of a lack of estrogens, low calcium or vitamin D intake, hypercortisolemia or the duration of the illness. The aim of this study was to identify the best endocrinological and nutritional indicators of bone density. SUBJECTS AND METHODS: The study involved 49 young females with AN and malnutrition and 24 age-matched normal controls in whom AN had been excluded on the basis of a clinical evaluation using DSM IV criteria. We studied bone density in early osteopenia, a condition in which the potential risk of fractures is certainly high and traditionally related to a variety of endocrinological and nutritional factors. RESULTS: Bone density was significantly lower in the AN than the control group in all of the examined bone districts: bone mineral density (BMD) spine 0.89 +/- 0.19 vs 1.27 +/- 0.2 (p<0.0001), BMD neck 0.75 +/- 0.14 vs 1.08 +/- 0.17 (p<0.001), BMD Ward 0.74 +/- 0.17 vs 1.12 +/- 0.11 (p<0.0001). Non-significant differences were found in the patients who had undergone previous estrogen medication. Body mass index (BMI) correlated with bone density, but caloric and calcium intake were not significant predictors. IGF-1, a known nutritionally dependent trophic bone factor, was significantly reduced in our patients but did not correlate with BMD. Like other authors, we found a close correlation between lean body mass and BMD in neck and spine. Physical exercise, urinary free cortisol osteocalcin and type I collagen-telopeptide (NTX) did not significantly correlate with the degree of osteopenia. CONCLUSIONS: Our data suggest the importance of nutritional factors (particularly lean body mass and BMI) in determining bone mass, and the relatively limited importance of endocrinological factors with the exception of the duration of amenorrhea as an indirect indicator of endocrinological status.

[Breast inflammations: clinical observations and principles of treatment]. / Le infiammazioni della mammella: considerazioni cliniche e principi di trattamento.

In this study some clinical and etiopathogenetic principles, and the most appropriate treatment for breast inflammation are discussed. In the majority of cases, differential diagnosis is made not only through clinical diagnosis but also through cytological examination and ultrasonography. Of the forms reported, we considered the different inflammatory, glandular and extraglandular, peripheral and central mastites; among the latter in particular periductal mastitis and duct ectasia. Medical treatment is the answer for some forms, while for others, as for example mammillary fistula, we prefer, in agreement with some authors, the surgery of fistulectomy and healing by first intention; for the peripheral abscesses we prefer US-guided percutaneous drainage. This article stresses the importance of clinical diagnosis, pathogenetic history, and adequate treatment in efforts to improve both the knowledge of the surgeon and the quality of life of the patient.

[Acquired phimosis due to lichen sclerosus et atrophicus]. / La fimosi acquisita da lichen sclero-atrofico.

From January 1986 to December 1991, 6 cases of acquired phimosis secondary to balanitis xerotica obliterans were observed. The authors report their experience in the diagnosis and treatment of this disease. Five patients were treated with plastic of the foreskin, one was circumcised and treated with local instillation of corticoids. The authors conclude that the histological study of the specimen is very important to demonstrate the nature of the lesion.

[The use of fibrin glue in the surgery of breast carcinoma]. / L'impiego della colla di fibrina nella chirurgia del carcinoma della mammella.

Twenty-four patients operated on for breast carcinoma with associated axillary node dissection were randomly assigned to two protocols. In the first group fibrin glue was applied intraoperatively, in the second group no complementary treatment was accomplished. The aim of the study was to evaluate the effect of fibrin glue in reducing postoperative axillary sero-lymphatic secretion. In the fibrin glue group a significant reduction of postoperative axillary secretion was observed.

[Reflux esophagitis. What factors influence the choice of antireflux surgery?]. / Esofagite da reflusso. Quali fattori influenzano la scelta della chirurgia antireflusso?

The surgical goal of gastroesophageal reflux treatment is to restore the ability of antireflux barrier. The basal tone and the length of lower esophageal sphincter are commonly considered the most important factors in the assessment of gastroesophageal reflux symptoms. However, reflux symptoms may also occur after surgical correction of sphincter incompetence. In the present study, 20 patients were evaluated pre- and postoperatively by 24 hours pH monitoring, esophageal manometry, endoscopy and analysis of gastric emptying of solids, in order to verify surgical results and connected functional changes. Preoperative data suggested to perform a partial fundoplication in 12 patients and a total fundoplication in 8 cases. Our results can indicate that fundoplications are able to significantly control reflux symptoms, to improve the competence of lower esophageal sphincter and finally to normalize gastric emptying of solids. This study emphasizes the value of normalizing a delayed gastric emptying to assure a satisfactory clinical outcome. The postoperative impaired gastric emptying rates in fact appear to associate with persistent symptoms.

[Treatment and prognosis of metachronous bilateral carcinoma of the breast]. / Trattamento e prognosi del carcinoma bilaterale metacrono della mammella.

In this study the incidence, the treatment and the survival of 7 patients with bilateral metachronous breast cancer have been evaluated. From this experience, the value of careful follow-up of mastectomized patients in order reach an early diagnosis of bilateral breast cancer is stressed.