Late treatment of orbital fractures: a new analysis for surgical planning.

Surgical treatment of orbital fractures should be performed without delay; in some cases acute management is not possible due to general conditions and might be delayed for weeks or months. In the latter case, the fractured fragments can consolidate improperly, causing secondary deformities of the orbital region with aesthetic and functional alteration. Surgical planning of secondary deformities is critical for adequate pre-operative planning. In the last decade an increasing number of dedicated software applications for surgical planning have been developed. Standard computed tomography (CT) or the relatively new cone beam CT can be used for diagnostic purposes, pre-surgical visual treatment outcome and virtual surgery. In this report, the authors propose their pre-operative planning analysis for surgical correction of secondary deformities of orbital fractures. The treatment of orbital fracture must, in fact, analyse not only the bone structures but the soft tissue and surrounding periorbital region. The position of the orbit in the space should be determined in relation to the surrounding structures compared to the contralateral side, if this is not affected by the trauma or pre-existing malformations.

Hepatocyte odd protein shuttling (HOPS) is a bridging protein in the nucleophosmin-p19 Arf network.

Nucleophosmin (NPM), a ubiquitously and abundantly expressed protein, occurs in the nucleolus, shuttling between the nucleoplasm and cytoplasm. The NPM gene is mutated in almost 30% of human acute myeloid leukemia cells. NPM interacts with p53 and p19(Arf), directs localization of p19(Arf) in the nucleolus and protects the latter from degradation. Hepatocyte odd protein shuttling (HOPS) is also a ubiquitously expressed protein that moves between the nucleus and cytoplasm. Within the nucleus of resting cells, HOPS overexpression causes cell cycle arrest in G0/G1. HOPS knockdown causes centrosome hyperamplification leading to multinucleated cells and the formation of micronuclei. We demonstrate a direct interaction of HOPS with NPM and p19(Arf), resulting in a functionally active trimeric complex. NPM appeared to regulate HOPS half-life, which, in turn, stabilized p19(Arf) and controlled its localization in the nucleolus. These findings suggest that HOPS acts as a functional bridge in the interaction between NPM and p19(Arf), providing new mechanistic insight into how NPM and p19(Arf) will oppose tumor cell proliferation.

Características y evolución de las urgencias psiquiátricas infantojuveniles en un servicio general de urgencias pediátricas hospitalarias / Evaluation of adolescent and child psychiatric emergency in a pediatric emergency service of a general hospital

Introducción: Desde hace varios años, se ha producido un aumento en las visitas por patología psiquiátrica en los servicios de urgencias pediátricas. Por ello, es importante la coordinación entre los equipos de urgencias pediátricas y los de salud mental para mejorar la atención de los pacientes pediátricos con una enfermedad mental. Objetivos: Analizar las características de los pacientes pediátricos del servicio de urgencias psiquiátricas de nuestro hospital. Metodología: Estudio transversal descriptivo de las urgencias psiquiátricas atendidas en el Servicio de Urgencias de Pediatría que precisaron atención en el Servicio de Psiquiatría de la Corporació Sanitària «Parc Taulí» de Sabadell (periodo 2006-2007). Analizamos las variables sociodemográficas y los diagnósticos psiquiátricos, así como la necesidad de tratamiento y el destino final del paciente. Resultados: Se realizaron 104 visitas psiquiátricas de un total de 93.908 urgencias (0,1%), con una media de edad de los pacientes de 12,37 años (rango: 6-15). Los motivos de consulta principales fueron: empeoramiento de la enfermedad de base (51%), alteración de la conducta de diversos tipos (31,7%) e intento de suicidio (17,3%). Muchos de los casos presentaban factores asociados o distocia social: un 68,2% presentaba antecedentes de enfermedad familiar psiquiátrica, un 39,4% abuso de alcohol y/o drogas, y un 25,9% una separación traumática de los padres. Sólo un 26% de los casos precisaron una intervención farmacológica fuera de su tratamiento habitual. Los diagnósticos principales al alta fueron, en el 50% de los casos, trastornos de conducta no especificados y conversivos. Se dio de alta a su domicilio al 64% de los pacientes, y un 36% precisó ingreso hospitalario. Conclusiones: Las urgencias psiquiátricas pediátricas son complejas y graves. Últimamente se ha producido un aumento de ellas, lo que puede obedecer a múltiples causas, algunas de las cuales representan tendencias epidemiológicas que pueden estudiarse y preverse (AU)

Introduction: For several years, there is an increase in visits due to psychiatric disorders in the pediatric emergency departments. Therefore the coordination between pediatric emergency department and mental health department is important to improve the care of pediatric patients with mental illness. Objectives: To analyze the characteristics of pediatric patients in the Pediatric Emergency Department in our hospital. Methodology: Transversal and descriptive study of the psychiatric emergencies treated in the Pediatric Emergency Department which required attention by psychiatry of the Corporació Sanitària Parc Taulí (Sabadell) (period 2006-2007). We analyzed social demographic variables, psychiatric diagnoses, as well as the need of treatment and final destination of the patient. Results: There were 104 psychiatric visits of 93,908 emergencies (0.1%), with a mean age of 12.37 years (range: 6-15).The main reasons for consultation were: worsening of their underlying disease (51%), different kinds of conduct alteration(31.7%) and suicide attempt (17.3%). Many of the cases showed associated factors or social dystocia: 68.2% had family history of psychiatric illness, a 39.4% alcohol or drugs abuse and 25.9% had a traumatic parent divorce. Only 26% of the cases needed drug treatment other than their usual treatment. The main diagnosis at discharge was, in 50% of the cases, unspecified conduct disorder or conversion disorders. A 64% of the patients were discharged, and 36% required admission. Conclusions: The pediatric psychiatric emergencies are complex and serious. There is an increase of these, which may be due to multiple causes. Some of the causes represent epidemiological trends and can be studied and foreseen (AU)

Intra-parotid facial nerve multiple plexiform neurofibroma in patient with NF1.

INTRODUCTION: Primary neurogenic tumours of facial nerve are uncommon with the majority found intra-temporally. Intracranial and intra-parotid neoplastic involvement of cranial nerve VII is much less common. There are 11 reported cases, in the English-language literature, of intra-parotid facial nerve plexiform neurofibromas with eight of them associated with NF1. MATERIALS AND METHODS: A child, 10 years old, with NF1, reached us for a cheek swelling, slowly increased in previous 8 years. At the age of 3 years, a plexiform neurofibroma was diagnosed by biopsy of the lesion. Clinical examination and NMR showed in the sub-cutaneous tissue of the right cheek, two contiguous nodular lesions, about 2 cm x 1.5 cm in diameter; a third neoformed lesion, about 1cm in diameter, was located above the ipsilateral labial commissure. No facial nerve impairment was seen. The patient underwent superficial parotidectomy with removal of the lesions and preservation of the facial nerve. RESULTS: The patient had a considerable regional swelling in the immediate post-operative course; no facial nerve impairment was observed. The swelling of the cheek did not show a fully regression in the post-operative course. Ultrasonography at 3 months showed a recurrence of disease. DISCUSSION: Plexiform neurofibromas should be distinguished due to their risk of malignant transformation seen in up to 15% of patients affected by NF1. Surgery is the only effective option currently available for the treatment of PNF. However, success of surgical intervention is limited by the infiltrating nature of the tumours, resulting in a high rate of tumour re-growth. Facial nerve preservation during surgery is unlikely and significant morbidity can result from their excision. The age of the patient at surgical resection seemed to influence outcome: tumours resected before age 10 years recurred in 60% of cases compared with only 30% recurrence in patients older than the age of 10 years. CONCLUSION: Indication and timing of surgery, in paediatrics patients with NF1, are complex. To avoid eventual physical and psychological consequences, it seems prudent to delay surgery as long as it is feasible for otherwise asymptomatic paediatric patients with facial plexiform neurofibroma.

Tortícolis secundaria a subluxación rotatoria atlanto-axial / Torticollis secondary to atlantoaxial rotatory subluxation

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[Emerging problems in enforcement of safe maternity and feeding protection at work: a public prevention service experience]. / Problematiche emerse nell'applicazione della tutela della lavoratrice in gravidanza, puerperio e allattamento: esperienza di un servizio pubblico di prevenzione.

We have examined the claims for advance maternity leave or prolonged benefits for breastfeeding addressed to Occupational Health Unity of Local Health Service 11 by women at harmful works in the period 2002-2005. The most frequent occupations were: shoemaker (29%), service company's employee (7%), tanners (7%), leather industry's employee (6%) and food industry's employee (6%). The most important risk factors were: bound postures, manual load handling, chemical hazards and biological agents. The numbers of claims increased during the period of interest. In the work place often risks for pregnancy and breastfeeding are not correctly assessed and women workers are not informed on their rights. The Occupational Health Unity of Local Health Service 11 tried to correct the lack of information for workers, employers, workers' representatives in health and safety and enterprise's occupational health physician.

Arsenic and porphyrins.

BACKGROUND: To evaluate the possible effect of inorganic arsenic (iAs) and of its species on the urinary excretion of porphyrin homologues. METHODS: Total porphyrins and their homologues (copro, penta, hexa, hepta, uroporphyrins) and arsenic species (trivalent and pentavalent As; monomethyl arsonic acid; dimethyl arsenic acid; arsenobetaine) were measured respectively by HPLC and HPLC-ICP MS in urine from 86 art glass workers exposed to iAs and from 54 controls. RESULTS: A significant increase in the excretion of penta and uroporphyrins was demonstrated for workers exposed to As; As3 was the species best correlated with urinary porphyrin excretion. CONCLUSIONS: The increase of urinary excretion for some porphyrin homologues appears to be consistent with the inhibition by As of URO-decarboxylase in the heme biosynthesis pathway. The determination of urinary porphyrin homologues could be useful to assess, on a group basis, some early effects of arsenic and to demonstrate possible individual susceptibility to the element.

[Cohort study of mortality among leather tanners in the Lower Valdarno area]. / Studio di coorte di mortalità degli addetti alla concia del cuoio e delle pelli nel territorio dell'azienda USL 11--Zona Valdarno Inferiore.

BACKGROUND: Epidemiological studies of tanners have shown increased risk for a number of cancer sites, namely: lung, bladder, kidney and urinary organs as well as stomach, intestine, pancreas, nose and nasal cavities, together with leukemias and soft tissue sarcomas. OBJECTIVE: To study cause specific mortality of leather tanners in Tuscany (Valdarno Inferiore area). METHODS: The cohort included 4874 workers (4150 males and 724 females) employed in 92 tanneries operating in 1996 (Valdarno Inferiore Tanneries Census) which were also operating on 31-12-1970. Ascertainment of vital status was completed for all individuals on 31-12-1998 (end of follow-up), and the cause of death was known for all deceased subjects. Demographic and work history data were obtained from factory payrolls. Regional mortality rates were used for comparison to calculate SMR (Standardised Mortality Ratio) and 90% Confidence Intervals (CI). In addition to the overall cohort analysis, for men only separate analyses were completed for finishers, chrome tanners and vegetable tanners. RESULTS: The study showed an increased mortality from lung cancer among finishers, Standardised Mortality Ratio (SMR) 145, 19 observed (obs) (90% Confidence Intervals, 90% CI 95-212), from bladder cancer in the overall cohort (SMR 134, 9 obs, 90% CI 70-233) and among finishers (SMR 125, 2 obs, 90% CI 22-393) and from pancreatic cancer among finishers (SMR 120, 2 obs, 90% CI 21-379). Mortality from lymphoemopoietic cancer is above expected, and the increase is mainly due to myeloid leukaemia, both in males (SMR 208, 5 obs, 90% CI 82-437) and females (SMR 599, 2 obs, 90% CI 106-1887). No deaths from soft tissue sarcoma were observed. A new finding of the study was the increased mortality from cancer of the endocrine glands (SMR 566, 4 obs, 90% CI 194-1297), psychiatric disorders (SMR 195, 6 obs, 90% CI 85-385) and blood diseases (SMR 329, 4 obs, IC 90% 112-752). CONCLUSIONS: The observations of increased lung cancer mortality among finishers, of bladder cancer in the overall cohort and among finishers, as well as an increase in pancreatic cancer among the latter, confirm previous epidemiological findings among tanners. The increase in myeloid leukemia mortality for both males and females, and the absence of deaths from cancer of the connective tissue, which includes soft tissue sarcomas, are worthy of note. The results should be valued with caution, given the small number of cases and the novelty of some observations.

Biological monitoring of occupational exposure to inorganic arsenic.

OBJECTIVES: This study was undertaken to assess reliable biological indicators for monitoring the occupational exposure to inorganic arsenic (iAs), taking into account the possible confounding role of arsenicals present in food and of the element present in drinking water. METHODS: 51 Glass workers exposed to As trioxide were monitored by measuring dust in the breathing zone, with personal air samplers. Urine samples at the end of work shift were analysed for biological monitoring. A control group of 39 subjects not exposed to As, and eight volunteers who drank water containing about 45 micrograms/l iAs for a week were also considered. Plasma mass spectrometry (ICP-MS) was used for the analysis of total As in air and urine samples, whereas the urinary As species (trivalent, As3; pentavalent, As5; monomethyl arsonic acid, MMA; dimethyl arsinic acid, DMA; arsenobetaine, AsB) were measured by liquid chromatography coupled with plasma mass spectrometry (HPLC-MS) RESULTS: Environmental concentrations of As in air varied widely (mean 84 micrograms/m3, SD 61, median 40) and also the sum of urinary iAs MMA and DMA, varied among the groups of exposed subjects (mean 106 micrograms/l, SD 84, median 65). AsB was the most excreted species (34% of total As) followed by DMA (28%), MMA (26%), and As3 + As5 (12%). In the volunteers who drank As in the water the excretion of MMA and DMA increased (from a median of 0.5 to 5 micrograms/day for MMA and from 4 to 13 micrograms/day for DMA). The best correlations between As in air and its urinary species were found for total iAs and As3 + As5. CONCLUSIONS: To avoid the effect of As from sources other than occupation on urinary species of the element, in particular on DMA, it is proposed that urinary As3 + As5 may an indicator for monitoring the exposure to iAs. For concentrations of 10 micrograms/m3 the current environmental limit for iAs, the limit for urinary As3 + As5 was calculated to be around 5 micrograms/l, even if the wide variation of values needs critical evaluation and application of data. The choice of this indicator might be relevant also from a toxicological point of view. Trivalent arsenic is in fact the most active species and its measure in urine could be the best indicator of some critical effects of the element, such as cancer.

Cancer mortality of art glass workers in Tuscany, Italy.

OBJECTIVES: This study considers the cause-specific mortality from cancer among art glass workers employed in 17 industrial facilities in Tuscany, Italy. METHODS: A cohort of 3390 workers, 3180 men and 210 women, employed at least 1 year, was taken from company payrolls. It was followed between the year each factory started operation, mostly the mid-1950s, and 31 December 1993. The cause-specific expected mortality from cancer was computed for men relative to Tuscany rates, specified for gender, 5-year age groups, and calendar year. Separate analyses were carried out for the job title of maker and former and for batch mixers. RESULTS: For 3180 men, the observed mortality was above the expected for larynx [standardized mortality ratio (SMR) 166, 90% confidence interval (90% CI) 90-282], lung (SMR 123, 90% CI 100-151), stomach (SMR 105, 90% CI76-142), and brain (SMR 150, 90%CI 71-282) cancer. Increases for these causes were also found for the makers and formers. Mortality from larynx and lung cancer increased with latency, and significantly increased SMR values were observed for > or =21 years since first exposure. The increasing pattern was also present after adjustment for smoking. CONCLUSIONS: The results showed consistently increased mortality from larynx and lung cancer in the overall cohort and among makers and formers. Stomach and brain cancer was also increased in the overall cohort and among the makers and formers.

[Blood lead levels in a non-professionally-exposed population from six Tuscan provinces]. / Livelli ematici di piombo in popolazioni non professionalmente esposte residenti in sei provincie toscane.

We report the results obtained in 1992 concerning the determination of blood lead levels (PbB) in 1321 subjects of the general population living in ten villages/towns of the Florence district characterised by the presence of artistic ceramic factories. We reported also the PbB values found in 2330 adults, 280 children, 39 pregnant women and their correspondent umbilical cords, who were examined during the second biological monitoring campaign against the risk of lead intoxication according to the DPR 496/82. Median PbB values were 92.5 micrograms/l (range 15-520 micrograms/l) for males and 62.5 micrograms/l (range 11-343 micrograms/l) for females. The lower PbB median values were found in the district of Livorno (76.25 micrograms/l and 48.25 micrograms/l in males and females, respectively) and Arezzo (80.5 micrograms/l and 52 micrograms/l in males and females, respectively). In comparison with the results obtained for the general Italian population during the previous biological monitoring campaign carried out in 1985-86 we observed PbB median values about 40% lower for both males and females and PbB median values about 55% lower for children. A significant statistic correlation (r = 0.53) was found between PbB of pregnant women and their umbilical cords.

Multiple exposure to arsenic, antimony, and other elements in art glass manufacturing.

Art glass manufacturing is one of the most interesting examples of exposure to complex mixtures. Among the raw materials used are silica sand, borax, carbonates, nitrates of Ca, Na, K, and a great number of compounds that are mainly oxides of As, Sb, Al, Zn, Cr, Ni, Sn, Se, Cd, Mn, Cu, Co, Fe, Nd, Er, Eu, and La. In six art glass factories that use As or Sb as fining agents, the exposure to these elements was investigated in 32 workers by means of environmental and biological monitoring. Analysis was conducted by atomic absorption spectrometry (AAS) and inductively coupled plasma mass spectrometry (ICP-MS). The results confirmed that As, which is the main carcinogen in glass production, reaches high air concentrations and is generally above the American Conference of Governmental Industrial Hygienists (ACGIH) threshold limit value-time-weighted average (TLV-TWA) of 10 micrograms/m3. When partly substituted by antimonial compounds, As air concentrations dropped dramatically, while the air levels of Sb (which is considered less toxic but is classified as a class 2B carcinogen by IARC) were relatively low and below the ACGIH TLV-TWA of 500 micrograms/m3. Exposure to As and Sb also differed in the three types of jobs investigated: As was high in oven chargers, Sb was higher in batch mixers, and both elements were low in makers-formers. Eleven to 18 elements were detected: arsenic, Al, Ba, Sb, Pb, and Zn were the elements most frequently measured (in tens, and in some cases hundreds, of micrograms/m3), followed by B, Li, Mn, Se, Sn, Sr, Ce, La, and Nd (in micrograms or in some cases tens of micrograms/m3. The results of biological monitoring for As, Sb, and other elements were in agreement with environmental monitoring data. We concluded that multiple detection of elements is a useful tool (or the evaluation of exposure to complex mixtures such as those used in the art glass industry and that such detection also allows a more accurate evaluation of related epidemiological data.

[A cohort study of art glass workers in the Empoli area]. / Studio di coorte dei lavoratori del vetro artistico nel territorio empolese.

The investigation aimed at studying cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3390 workers employed for at least 1 year was obtained from company payrolls. Follow-up was between the year each factory started operations, mostly in the mid-fifties, and the end of 1993. The cause specific expected mortality was computed relative to Tuscany rates, specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the job titles of makers, batch mixers and grinders. For males, 3180 individuals, the observed mortality for cancer causes was above the expected for the lung [standardized mortality ratio (SMR) 123, 10 observed (Obs)], larynx (SMR 166, 10 Obs), stomach (SMR 105, 30 Obs) and brain (SMR 150, 7 Obs). For non-cancer causes observed mortality was above expected for hypertensive diseases (SMR 178, 10 Obs) and diseases of the genitourinary system (SMR 169, 11 Obs). Increases for the above listed causes were shown also among makers. Mortality for larynx and lung cancer increased with time since first exposure and significantly increased SMRs were observed for 21 or more years since first exposure: this pattern was still present with smoking adjustment. The results showed consistently increased mortality for lung and larynx cancer in the overall cohort and among makers. Stomach cancer, brain cancer, hypertensive diseases and diseases of the genitourinary system were also increased in the overall cohort and among makers.

Cohort study of art glass workers in Tuscany, Italy: mortality from non-malignant diseases.

This investigation studies cause-specific mortality of art glass workers employed in 17 industrial facilities in Tuscany, Italy. A cohort of 3,390 workers employed for at least 1 year was enumerated from company payrolls. Follow-up was between the start of employment in each factory and 31 December 1993. The cause-specific expected mortality was computed relative to Tuscany rates and specified for gender, 5-year age groups and calendar year. Separate analyses were carried out for the jobs of makers and formers and for batch mixers. Among males (3, 180 individuals) observed mortality for non-cancer causes was higher than expected for hypertensive disease [standardized mortality ratio (SMR) = 178, 90% confidence interval (90% CI) = 96-301], pneumoconiosis (SMR = 200, 90% CI = 94-376) and diseases of the genitourinary system (SMR = 169, 90% CI = 95-279). Increases for the above causes were shown also among makers and formers: hypertensive disease (SMR = 182, 90% CI = 85-341), pneumoconiosis (SMR = 250, 90% CI = 109-493) and diseases of the genitourinary system (SMR = 224, 90% CI = 121-380). For batch mixers an increase was present for cerebrovascular disease. The observed mortality for cancer causes was above the expected for cancers of the larynx, lung, stomach and brain. This study points to the existence for Tuscan glass workers of health effects in addition to cancer; previously observed carcinogenic effects were also confirmed.

Art glassware and sinonasal cancer: report of three cases.

In a multicenter study on the occupational etiology of sinonasal cancer (s.n.c.) carried out in Italy, we collected information about three cases which had arisen among glass workers: an adenocarcinoma, a melanoma, and a squamocellular carcinoma. The three men worked many years as mixers and/or batchers in artistic glass factories in Tuscany (Italy). We propose a possible etiological role of arsenic dust.

Response of primary breast cancer to tamoxifen alone in elderly women.

The authors report on a consecutive series of 62 evaluable, elderly (age greater than 69 years) women with primary operable breast cancer treated only with tamoxifen. The treatment schedule was 160 mg on day 1 followed by a daily maintenance dose of 20 mg. Compliance to treatment was excellent, and subjective side effects were minimal. The best response achieved after at least 6 months of treatment was complete in 7, partial in 22 and minor in 3, whereas stable disease or progression was observed in 28 and 2 patients, respectively. The response rate decreased and progressions increased with time. At 6, 12, 24, 36 and 48 months of treatment, the complete + partial response rates were 30.6%, 45%, 45.6%, 38.7% and 25% and the progressive disease rates 4.8%, 19.6%, 34.8%, 45.2% and 66.6%, respectively. These results do not confirm some previous reports of a high response to tamoxifen. This difference is only partially explained by the use of mammography, which is more sensitive than palpation, to assess tumor size and treatment response. The present study does not support primary hormone therapy as a current alternative to surgery, which should be the standard treatment in otherwise healthy elderly patients with operable breast cancer.

[The Guillain-Barré syndrome. The clinico-electrophysiological correlations]. / La sindrome di Guillain-Barré. Correlazioni cliniche-elettrofisiologiche.

The authors refer about clinico-electrophysiological correlations in children with Guillain-Barré syndrome (GBS). The dates confirm the diagnostic and prognostic value of electrodiagnostic studies in GBS, so that the authors suggest an electrodiagnostic protocol. According to the authors, independently of the extent of electrophysiological abnormalities, young age has a favourable influence on the restoration of conduction abnormalities and on the evolution of damage to peripheral neurones.