Anterior and Posterior Nutcracker Syndrome Combined with May-Thurner Syndrome: First Report of This Unique Case.

BACKGROUND: Anterior nutcracker syndrome is defined as the compression of the left renal vein (LRV) between the superior mesenteric artery (SMA) and the aorta, whereas posterior nutcracker syndrome refers to the compression of the retroaortic LRV between the aorta and the vertebral column-the presence of the circumaortic left renal vein may predispose to "combined nutcracker syndrome". May-Thurner syndrome consists of obstruction of the left common iliac vein caused by the crossing right common iliac artery. We report a unique case of combined nutcracker syndrome associated with May-Thurner syndrome. CASE PRESENTATION: A 39-year-old Caucasian female came to our radiology unit for triple-negative breast cancer computed tomography (CT) staging. She complained of pain in hermid-back and low-back regions and intermittent abdominal pain in the left flank region. Multidetector computed tomography (MDCT) incidentally revealed a circumaortic left renal vein draining to the inferior vena cava, with bulbous dilatation of both the antero-superior and posterior-inferior branches, which was associated with pathological serpiginous dilation of the left ovarian vein with varicose pelvic veins. Axial CT imaging of the pelvis also showed compression of the left common iliac vein by the overlying right common iliac artery consistent with May-Thurner syndrome without signs of venous thrombosis. CONCLUSION: Contrast-enhanced CT is the best imaging modality for suspected vascular compression syndromes. CT findings showed a combination of anterior and posterior nutcracker syndrome in the left circumaortic renal vein, associated with May-Thurner syndrome, which has not previously been described in the literature.

The ability of lumbar spine DXA and phalanx QUS to detect previous fractures in young thalassemic patients with hypogonadism, hypothyroidism, diabetes, and hepatitis-B: A 2-year subgroup analysis from the Taranto Area of Apulia Region.

BACKGROUND: Osteoporosis is a leading cause of morbidity in patients affected by ß-thalassemia major or intermediate; we aimed to assess the association between demineralization observed in young thalassemic patients. METHODS: A total of 88 patients with ß-thalassemia were recruited at Microcitemia Center of Taranto Hospital under the Prevention Osteoporosis and Fractures research project from 2008 to 2010. All the patients were screened with both dual energy x-ray absorptiometry (DXA) and quantitative ultrasound (QUS). T score and Z score values were obtained for each subject. RESULTS: The overall prevalence of demineralization was 84% with DXA and 70% with QUS, whereas normality was found in 16% of patients screened with DXA and in 30% of cases with QUS. Hypogonadism, hypothyroidism, diabetes mellitus, hepatitis-B, and the presence of previous fragility fractures were significantly associated with the demineralization status (lower T scores values) both with DXA and QUS. CONCLUSION: Our data confirm that DXA and QUS examinations are both useful for detecting bone demineralization in thalassemic patients.

New insight into immunity and immunopathology of Rickettsial diseases.

Human rickettsial diseases comprise a variety of clinical entities caused by microorganisms belonging to the genera Rickettsia, Orientia, Ehrlichia, and Anaplasma. These microorganisms are characterized by a strictly intracellular location which has, for long, impaired their detailed study. In this paper, the critical steps taken by these microorganisms to play their pathogenic roles are discussed in detail on the basis of recent advances in our understanding of molecular Rickettsia-host interactions, preferential target cells, virulence mechanisms, three-dimensional structures of bacteria effector proteins, upstream signalling pathways and signal transduction systems, and modulation of gene expression. The roles of innate and adaptive immune responses are discussed, and potential new targets for therapies to block host-pathogen interactions and pathogen virulence mechanisms are considered.

Prevalence of antibodies anti-Bartonella henselae in western Sicily: children, blood donors, and cats.

To evaluate seroprevalence of B. henselae infection both in Sicilian children and healthy blood donors. Furthermore, circulation of Bartonella in the natural reservoir was also studied. Two hundred forty-three children, living in Sicily (Palermo), affected by various diseases, without clinical features suggesting B. henselae infection, together with 122 healthy blood donors were serologically investigated for IgG and IgM antibodies by indirect fluorescent antibody test (IFAT). One hundred twenty stray and 62 pet cats were also analyzed only for IgG. Among children 25.1% had IgG antibodies to B. henselae; 18.5% showed a titer 1:64, 2.4% 1:128, 2.4% 1:256, 0.8% 1:512, 0.4% 1:1024, and 0.4% 1:5120. Among healthy blood donors 11.4% had IgG class antibodies to B. henselae; 9.8% showed a titer 1:64 and 1.6% 1:128. All the human serum samples did not show positive results for B. henselae IgM class antibodies. Stray cats (68.3%) and pet cats (35.4%) also had IgG class antibodies to B. henselae. We demonstrated high frequency of serologic evidence of past B. henselae infection, in young Italian children, affected by various diseases, apparently free of any clinical features suggesting B. henselae infection. This observation is supported by high circulation of Bartonella in cats.

Significance of persistence of antibodies against Leishmania infantum in Sicilian patients affected by acute visceral leishmaniasis.

The background of this article is as follows: Few data are available about the persistence of serum-specific IgG antibodies to L. infantum after acute VL. The objective of this article is to evaluate the persistence of antibodies against L. infantum in patients healed from acute VL, and the kinetic of the same antibodies observed in 2 cases of VL relapse and 2 cases of resistance to therapy. The methods which we used to obtain our objective are the following: 55 apparently immunocompetent, HIV-negative patients were examined for antibodies to L. infantum by IFAT over 14 years period, and we got the following results: Serum-specific IgG antibodies titers decrease slowly, but constantly. In the patients with a diagnosis of VL relapse, the kinetic of antibodies was characterized by an initial reduction, and a subsequent antibody levels rapidly increase, while in the patients with a clinical and parasitological diagnosis of VL not responding to specific therapy, we demonstrated persistent high level of antibodies to L. infantum. Finally, we conclude that specific antibodies to L. infantum might persist for many years, and decrease slowly, but steadily. The persistence of these specific antibodies is not related to poor therapeutic response or prognosis, but an acute increase in their levels might be a sentinel of a VL relapse, while persistence of high antibody levels could suggest a resistance to therapy.

[Massive pulmonary embolism treated with selective infusion of tenecteplase]. / Embolia polmonare massiva trattata con infusione selettiva di tenecteplase.

Massive pulmonary embolism (PE) is a cardiovascular emergency due to a substantial obstruction of the pulmonary vascular bed, resulting in rapid right heart failure with a potentially fatal outcome.We present the case of a 50-year-old woman with massive PE and recent trans-sphenoid surgery because of pituitary adenoma. An occluding embolus, arising from deep venous thrombosis of the lower limbs, was demonstrated in the right pulmonary artery with selective angiography and treated with selective loco-regional infusion of low-dose tenecteplase. To the best of our knowledge, this is the first case of selective administration of low-dose tenecteplase in the pulmonary artery with successful resolution of PE without the need for adjunctive interventional procedures.

Treatment of relapsing mild-to-moderate ulcerative colitis with the probiotic VSL#3 as adjunctive to a standard pharmaceutical treatment: a double-blind, randomized, placebo-controlled study.

OBJECTIVES: VSL#3 is a high-potency probiotic mixture that has been used successfully in the treatment of pouchitis. The primary end point of the study was to assess the effects of supplementation with VSL#3 in patients affected by relapsing ulcerative colitis (UC) who are already under treatment with 5-aminosalicylic acid (ASA) and/or immunosuppressants at stable doses. METHODS: A total of 144 consecutive patients were randomly treated for 8 weeks with VSL#3 at a dose of 3,600 billion CFU/day (71 patients) or with placebo (73 patients). RESULTS: In all, 65 patients in the VSL#3 group and 66 patients in the placebo group completed the study. The decrease in ulcerative colitis disease activity index (UCDAI) scores of 50% or more was higher in the VSL#3 group than in the placebo group (63.1 vs. 40.8; per protocol (PP) P=0.010, confidence interval (CI)95(%) 0.51-0.74; intention to treat (ITT) P=0.031, CI95(%) 0.47-0.69). Significant results with VSL#3 were recorded in an improvement of three points or more in the UCDAI score (60.5% vs. 41.4%; PP P=0.017, CI95(%) 0.51-0.74; ITT P=0.046, CI95(%) 0.47-0.69) and in rectal bleeding (PP P=0.014, CI95(%) 0.46-0.70; ITT P=0.036, CI95(%) 0.41-0.65), whereas stool frequency (PP P=0.202, CI95(%) 0.39-0.63; ITT P=0.229, CI95(%) 0.35-0.57), physician's rate of disease activity (PP P=0.088, CI95(%) 0.34-0.58; ITT P=0.168, CI95(%) 0.31-0.53), and endoscopic scores (PP P=0.086, CI95(%) 0.74-0.92; ITT P=0.366, CI95(%) 0.66-0.86) did not show statistical differences. Remission was higher in the VSL#3 group than in the placebo group (47.7% vs. 32.4%; PP P=0.069, CI95(%) 0.36-0.60; ITT P=0.132, CI95(%) 0.33-0.56). Eight patients on VSL#3 (11.2%) and nine patients on placebo (12.3%) reported mild side effects. CONCLUSIONS: VSL#3 supplementation is safe and able to reduce UCDAI scores in patients affected by relapsing mild-to-moderate UC who are under treatment with 5-ASA and/or immunosuppressants. Moreover, VSL#3 improves rectal bleeding and seems to reinduce remission in relapsing UC patients after 8 weeks of treatment, although these parameters do not reach statistical significance.

Fever of unknown origin in a Mediterranean survey from a division of internal medicine: report of 91 cases during a 12-year-period (1991-2002).

Despite the availability of all advanced diagnostic tools, fever of unknown origin (FUO) remains a diagnostic challenge for physicians. The objective was to define, through a retrospective study, the categories of the diseases of Sicilian patients admitted at the Department of Clinical Medicine and Emerging Diseases, University of Palermo, Italy, for classical FUO. Using the registration system for patients admitted from 1991 to 2002, 508 charts of patients admitted because of fever were reviewed. Of these, only 91 patients fulfilled the criteria for classical FUO. The origin of FUO was diagnosed in 62 (68.1%) patients. Infection was the most common cause of FUO with 29 cases (31.8% of total of FUO), neoplasms accounted for 13 cases (14.2%), collagen vascular disease for 11 cases (12.0%), and miscellaneous for 9 cases (9.8%). Undiagnosed FUO were 29 (31.8%) and, of them, 22 cases were followed-up for 2 years. A definite diagnosis could be established only in 8 cases, 13 subjects completely recovered and 4 of them died. In the 73.4% of cases, the FUO have been the result of misleading factors in the diagnostic approaches as made by the physician. The results of our study are similar to those already reported by other authors in other populations, with infections as first, neoplasm as second, and collagen vascular diseases as third most important causes of FUO. In our study the prognosis for undiagnosed FUO cases was good, but a definite diagnosis could be established only in few cases. Therefore, further multicentric, prospective studies of good design are required.

Continous alert for rickettsiosis in Sicily: molecular characterization of Rickettsia sp. obtained from ticks and human beings (1986-2001).

Several strains of Rickettsia sp. were isolated from patients in western Sicily with MSF (Mediterranean Spotted Fever) as well as ticks. Strains isolated were examined by PCR and identified as belonging to R. conorii sp. Importantly a strain of Israeli Spotted Fever Rickettsiae, obtained from a tick, was also identified. Our data prove that strains other than the classical R. conorii also circulate in Sicily.

Syncope of psychiatric origin.

BACKGROUND: A well-defined relationship between transient loss of consciousness and a psychiatric disorder has not yet been established. REVIEW SUMMARY: In the past, psychiatric origin of syncope was considered to be uncommon, occurring only in 1-7% of patients with syncope. Recently, a much higher incidence ranging from 20 % to 81 % has been reported. One main difficulty may be an incorrect approach to the problem. Authors generally defined syncope as every loss of consciousness without regard to the specific pathophysiology of the symptom. Moreover, identification of psychiatric origin of transient unconsciousness may be very difficult. Some clinical features can suggest the diagnosis; none of them, however, is an identification mark. Thus, in most cases, the diagnosis may be certain only when direct observation of the clinical event occurs. A transient loss of consciousness may be related to a psychiatric disorder when the symptom ensues in the presence of normal values of both blood pressure and heart rate. The phenomenon resembles syncope and has been defined as "pseudosyncope". Unfortunately, direct observation of a spontaneous event is very uncommon. Recently, few cases of pseudosyncope induced by Tilting test (HUTT) have been reported. In these patients, HUTT revealed a previously unknown psychiatric disorder. In our experience, pseudosyncope represented an uncommon HUTT outcome in all patients referring for unexplained syncope; in selected patients, however, HUTT may be useful in the early identification of psychiatric syncope. CONCLUSIONS: Prospective researches are needed to assess HUTT utility in evaluating patients whose clinical features suggest psychiatric origin of transient loss of consciousness.

Trends in cardiovascular risk factors and their treatment among patients discharged from divisions of internal medicine. The FAPOI-1 and FADOI-2 studies.

BACKGROUND: There is an increasing interest in monitoring cardiovascular risk factor levels and their treatment. Two studies were run in patients discharged from Divisions of Internal Medicine. METHODS: Two studies, respectively conducted in 1996 and 1999, have collected data on the diagnoses of cardiovascular diseases and cardiovascular risk factor levels and treatment in 6450 and 8133 patients (age > or = 35 years) discharged during 1 week from 235 and 345 Italian Divisions of Internal Medicine. RESULTS: The second survey revealed: a relative increase in heart failure and cerebrovascular disease diagnoses; lower serum levels of total cholesterol and triglycerides, lower systolic and diastolic blood pressure mean levels, and a decreased incidence of the habit of smoking among males. The proportion of treated hypertensives (blood pressure > or = 140/90 mmHg, or the use of antihypertensive drugs) increased slightly (65 to 68% among men and 69 to 71% among women). A reduction in the use of ACE-inhibitors was observed, balanced by an increase in the use of angiotensin II antagonists. The proportion of treated dyslipidemic patients (total cholesterol levels > or = 250 mg/dl, or HDL cholesterol levels < 35 mg/dl or triglyceride levels > or = 200 mg/dl or the use of hypolipidemic drugs) significantly increased from 10 to 25% among males and from 12 to 25% among females, due to a substantial increase in the use of statins. CONCLUSIONS: During a 3-year period increasing attention for cardiovascular risk factors and their treatment among patients discharged from Divisions of Internal Medicine has been documented. In particular, there has been a large increase in the use of statins, although large segments of patients may need further attention and drug treatment.