Haemodynamically unstable pelvic trauma: initial validation of a dedicated protocol by a retrospective cohort study with historical controls

Background: We present our experience after the introduction of Advanced Trauma Life Support (ATLS)©, Trauma Team (TT) and Preperitoneal Pelvic Packing (PPP) protocols for the treatment of hemodynamically unstable pelvic blunt trauma.Methods: This is a retrospective study with historical controls: before (Control Group, CG) and after (Study Group SG) the introduction of the protocol. A single physician managed the CG and angiography was the emergency manoeuvre. A team with ATLS guidelines and PPP as an emergency manoeuvre managed the SG. Data were collected retrospectively. Patients were divided into two groups: before and after the introduction of protocols.Results: From January 2007 to October 2014, 36 patients were treated at our Centre. We consider patients from January 2007 to August 2011 (19 patients, CG) and from September 2011 to October 2014 (17 patients, SG). Median age was 54 years (43­69) in the CG vs. 47 (40­63) in the SG (p = 0.43), median initial SBP 90 mmHg (85­103) in the CG 94 (69­103) in the SG, (p = 0.60), heart rate was 90 (80­110) in the CG and 110 (95­130) in the SG, (p = 0.09). Median Injury Severity Score was 33 (21­41) in the CG and 34 (26­41) in the SG (p = 0.29). Time from arrival in the Emergency Department to first therapeutic manoeuvre was 132 minutes (109­180) in the CG and 87 minutes (51­204) in the SG (p = 0.4). The difference in mortality was statistically significant: 64.7% (11/17) in the CG and 23.5% (4/17) in the SG (p = 0.02).Conclusions: The introduction of protocols changed our approach in hemodynamically unstable pelvic trauma, achieving a remarkable improvement in early mortality

[Exercise electrocardiography in the sanitary surveillance of workers with physical strain]. / Elettrocardiografia da sforzo nella sorveglianza sanitaria di lavoratori con impegnativo dispendio energetico.

To evaluate the opportunity of exercise electrocardiography (ECG) in the sanitary surveillance of workers with physical strain, we estimated the energy consumption of the duties of 22 electrical workers (males; age: 35-56 years). They subsequently underwent Treadmill exercise ECG, determining for each worker the maximal METs (multiples of basal metabolism) and the critical potency (P(CRIT)). In one subject, myocardial ischemia arose 9 minutes after the beginning of the test. The others interrupted the test after 7-13 minutes for tiring; 5 of them showed ventricular extra systoles, paired or isolated. Twelve subjects presented arterial hypertension, at rest and/or during exercise. Ergonomic analysis revealed that the occupational duties were between 1.5 and 8.0 METs. The energy consumption of the job on the whole was 4-6 METs (medium intensity). The maximal METs reached by the examined subjects were between 8.8 and 15.6; however, only 11 workers went reassuringly over the 4 METs required by duty analysis at P(CRIT). One subject was declared unfit for the job, and a judgement of partial idoneity was expressed for 3 workers. Preventive and therapeutic indications were given to 12 subjects. Aerobic training was suggested to 10 workers. The study indicates that an ergonomic evaluation is advisable for the most energy consuming occupational duties. In such cases, the sanitary surveillance should include a cardiologic assessment with exercise ECG, reproducing the physical strain of the specific job.

[Management of occupational stress among patients with cardiac diseases]. / Gestione dello stress occupazionale in pazienti cardiopatici.

The object of our study was the evaluation of psycophysic condition, stress perception and coping in a sample of subject in cardiac rehabilitation. Our study recruited 48 worker patients (44 male, M = 50.5 +/- 8.8; 4 female, M = 50.8 +/- 8.7). They were submitted to: 1) cardiac evaluation and rehabilitation in DH regimen; 2) psychological assessment; 3) work's characteristic evaluation. The evaluation were made at the moment of recruitment and six month later 42 subjects went back to work after 81.8 +/- 49 days; 2 subjects had a worsening of their clinic conditions not consistent with an occupational resumption; 4 subjects didn't go back to work. In the 42 worker subjects we have find a significant decrease of anxiety (p < 0.019) and depression levels (p < 0.004); a significant improvement of Quality of Life perception in its physical (p < 0.000) and psychic aspects (p < 0.021) and an improvement about the ability to reorganize the work to better ménage stress (p < 0.012).

[Silicoasbestosis: report of three cases]. / Silicoasbestosi: presentazione di tre casi clinici.

Silicoasbestosis is a rare pneumoconiosis due to the combined sclerosing effect of crystalline silica and asbestos fibres. We present here three cases (males, age: 66-75 years), recently reported to the judicial and workers' compensation authorities. The exposures occurred in the building and siderurgic industries, several years before retirement. The radiological pictures were characterized by diffuse nodular opacities, interstitial alterations, emphysema, pleuric plaques and thickenings. The patients described show that, still nowadays, silicoasbestosis may be observed in the clinical setting. Accurate occupational and environmental anamnesis are helpful for the correct diagnosis which, in turn, is important for prognosis and treatment, and in relation to medicolegal issues.

A numerical and experimental study of compliance and collapsibility of preterm lamb tracheae.

Knowledge of the mechanical behaviour of immature tracheae is crucial in order to understand the effects exerted on central airways by ventilatory treatments, particularly of Total Liquid Ventilation. In this study, a combined experimental and computational approach was adopted to investigate the compliance and particularly collapsibility of preterm lamb tracheae in the range of pressure likely applied during Total Liquid Ventilation (-30 to 30 cmH2O). Tracheal samples of preterm lambs (n = 5; gestational age 120-130 days) were tested by altering transmural pressure from -30 to 30 cmH2O. Inflation (Si) and collapsing (Sc) compliance values were calculated in the ranges 0 to 10 cmH2O and -10 to 0 cmH2O, respectively. During the tests, an asymmetric behaviour of the DeltaV/V0 vs. P curves at positive and negative pressure was observed, with mean Si = 0.013 cmH2O(-1) and Sc = 0.053 cmH2O(-1). A different deformed configuration of the sample regions was observed, depending on the posterior shape of cartilaginous ring. A three-dimensional finite-element structural model of a single tracheal ring, based on histology measurements of the tested samples was developed. The model was parameterised in order to represent rings belonging to three different tracheal regions (craniad, median, caudal) and numerical analyses replicating the collapse test conditions were performed to evaluate the ring collapsibility at pressures between 0 and -30 cmH2O. Simulation results were compared to experimental data to verify the model's reliability. The best model predictions occurred at pressures -30 to -10 cmH2O. In this range, a model composed of median rings best interpreted the experimental data, with a maximum error of 2.7%; a model composed of an equal combination of all rings yielded an error of 12.6%.

Pressure drop vs flow relationship in isolated preterm lamb tracheae.

Knowledge of immature tracheae mechanical behavior is fundamental in understanding the effects exerted on the upper airways by tidal liquid ventilation (TLV). Particularly, negative pressure can take place along the airways during expiration, which can cause airway collapse and flow limitation; therefore, representing a critical issue in preterm infant patients, whose airways are less stiff than adult ones. In this study, we investigated the expiratory pressure drop vs flow relationship of isolated preterm lamb tracheal samples to determine their hydraulic resistance, collapse pressure and collapse flow rate; a liquid flow through the samples was obtained by applying negative pressure at the outlet (cephalad) extremity of the tra-cheal sample, while keeping the inlet (caudal) extremity at atmospheric pressure. Histological analyzes were performed on the tracheal samples after each test session, in order to examine the morphological structure of the tracheal wall. Flow resistance tests demonstrated progressive lumen narrowing at increasing pressure drop (∆P=P in -P out ). The flow rate increased with ∆P un-til a plateau was reached, and then decreased, describing the onset of a collapse phenomenon; however, complete occlusion was not reached. The tracheal samples demonstrated a similar behavior to that of a Starling resistor during the collapse phase: when a critical ∆P was reached, collapse was observed starting at the outlet region, which was subjected to the greatest negative pressure, then propagating towards the caudal direction. (Journal of Applied Biomaterials & Biomechanics 2004; 2: 177-82).

Cerebral hemodynamic and metabolic changes in patients with fulminant hepatic failure during liver transplantation.

BACKGROUND: Cerebral autoregulation and metabolism may be seriously compromised in patients with fulminant hepatic failure (FHF). The mechanism responsible for the alteration in cerebral blood flow (CBF) has not been yet clearly defined; however, it is known that it does correlate with liver function. Orthotopic liver transplant (OLT) rapidly restores normal liver function, but little is known about the restoration of cerebral metabolism and hemodynamics. To investigate the relationship between liver function and CBF, we evaluated autoregulation and metabolic changes during OLT in six patients comatose due to FHF. METHODS: We evaluated autoregulation based on a linear regression analysis between mean arterial blood pressure and parallel CBF velocity (CBFV) changes using transcranial Doppler ultrasound. Cerebral metabolism rate was estimated by the arterial-jugular venous oxygen content difference (a-jDO2), while the percentile variation in cerebral metabolic rate for oxygen (CMRO2) was estimated using CBFV percentile variation rather than CBF percentile variation (eCMRO2). RESULTS: Prior to transplant autoregulation was impaired in all patients. However it markedly improved at the end of surgery (P <.05). The eCMRO2 improved as well, particularly among subjects who displayed prompt neurological recovery. In all patients the a-jDO2 was low before transplantation increasing to normal values at the end of surgery. CONCLUSIONS: A hallmark of FHF seems to be failure of autoregulation, which is linked to uncoupling between CBF and CMRO2 as attested by an a-jDO2 lower than normal in all patients (luxury perfusion). The recovery of liver function rapidly improves cerebral hemodynamics and metabolic stability. The study of autoregulation and eCMRO2 recovery using Doppler monitoring proffers the possibility to predict early graft function after liver reperfusion. In our patients eCMRO2 seemed to be associated with improved neurological outcomes.

Primary pulmonary meningioma may arise from meningothelial-like nodules.

A rare case of primary pulmonary meningioma, associated with meningothelial-like nodules in the same lung resection, with preoperative fine needle aspiration cytological findings and ultrastructural features, is described. The simultaneous presence of meningioma and meningothelial-like nodules, never before described, corroborates the unifying hypothesis of their common origin and nature.

[An atypical case of Horton's arteritis and associated polymyalgia rheumatica]. / Un caso atipico di arterite di Horton e polimialgia reumatica associata.

The authors report a case of Horton's arteritis and associated rheumatic polymyalgia, which was complicated from a diagnostic point of view by the atypical clinical and biohumoral conditions. Both the subjective and objective symptoms were relatively unclear compared to laboratory and instrumental findings which pointed strongly to an autoimmune disorder. The coexistence of biohumoral data of a cholestatic hepatitic type, not common to other pathologies, although reported in the literature, led to further diagnostic difficulties. Diagnosis was finally confirmed by temporal artery biopsy.

Subacute combined degeneration in the spinal cords of totally gastrectomized rats. Ornithine decarboxylase induction, cobalamin status, and astroglial reaction.

BACKGROUND: The totally gastrectomized (TGX) rat is a new experimental model with which to produce widespread spongy vacuolation in spinal cord (SC) white matter, strongly reminiscent of that observed in subacute combined degeneration (SCD) of human SC. EXPERIMENTAL DESIGN: We did in long-term experiments combined biochemical and histologic studies on SCs from both TGX-rats and rats fed a cobalamin-deficient (Cbl-D) diet. We also investigated the effects of single in vivo administration of some neurotrophic growth factors on the activity of L-ornithine decarboxylase (ODC) (the key-point in the polyamine biosynthetic pathway) in rat SC. RESULTS: Biochemically, ODC activity was still induced 3 and 6 months after total gastrectomy (TG), while it did not change significantly even after 9 months of feeding a Cbl-D diet. Both TG and feeding the Cbl-D diet greatly decreased the cobalamin level in both serum and SC, although these decreases occurred more slowly in rats fed a Cbl-D diet. Nerve growth factor did not induce ODC in either Cbl-D myeloneuropathy; epidermal growth factor induced ODC in both Cbl-D myeloneuropathies. Basic fibroblast growth factor induced SC ODC only in TGX-rats. Histologically, spongy vacuolation was still widespread 3 and 6 months after TG, while it was spotty even after 9 months of feeding a Cbl-D diet. There was massively increased staining of astrocytes positive for glial fibrillary acidic protein, mainly in the gray matter, in both Cbl-D myeloneuropathies. Finally, repeated in vivo injections of cobalamin to TGX rats only partially reduced ODC induction, the severity of spongy vacuolation, and the increase in glial fibrillary acidic protein-positive astrocytes. CONCLUSIONS: These results suggest: (a) ODC induction is a persistent and inherent feature in the TG-induced SCD of rat SC; (b) an increase in glial fibrillary acidic protein positive astrocytes in rat SC is not mandatorily connected with an increase in polyamine biosynthesis; (c) a mere deficiency of Cbl seems to be not the only key-point in the pathogenesis of the ODC induction and of the SCD-like lesions, both brought about in rat SC by TG.

Sarcomatoid carcinomas of the female genital tract (malignant mixed mullerian tumors).

Malignant mixed mullerian tumors (MMMTs) are the most common sarcomatoid neoplasms of the female genital tract. The clinical, histopathological, immunohistochemical, and differential diagnostic features of MMMTs and other gynecologic mixed tumors are discussed in this article. Current concepts regarding the histogenesis and differentiation of these tumors are discussed, with emphasis on biologic and immunohistological data, and the suggestion is made that MMMTs probably represent "metaplastic" (sarcomatoid) carcinomas rather than true carcinosarcomas. Finally, clinicopathological factors that affect the survival of patients with MMMTs are reviewed.

Establishment and characterization of a new murine cell line (SR-4987) derived from marrow stromal cells.

A new murine cell line designated as SR-4987 was established by treating a long-term bone marrow culture with the supernatant from Y-1 cells which actively produce viral C-particles (MuLV). The line showed a fibroblast-like morphology and its mesodermal origin was confirmed by immunocytochemical staining. Flow cytometric analysis of DNA index evidenced a tetraploid number of chromosomes whereas cell cycle analysis showed 34.8% of cells in S phase and 60.7% in G1. In vitro growth studies demonstrated a population doubling time of 14.7 h, a good plating efficiency (52.3%) and a very poor agar clonogenic capacity (0.6%). SR-4987 was tumorigenic only in syngeneic mice in which sarcomas were induced. The line produced M-CSF in the culture supernatant whereas G-CSF, IL-3 and GM-CSF were not detected. Studies are in progress to assess the production of other cytokines and to verify if same autocrine growth factor is involved in the control of SR-4987 proliferation. Our line provides a further model of stromal cells for studying the interaction between hemopoietic progenitors and their microenvironment, as well as to study factors produced by stromal cells acting as modulators of proliferation and differentiation of related cell populations.

Double contrast small bowel enema in a case of selective duodeno-jejunal amyloidosis.

Double contrast small bowel enema in a patient with selective amyloidosis of the duodenum and jejunum revealed an unusual radiologic pattern, mimicking multiple polyposis. Many submucosal polypoid lesions, sessile or pedunculated, were scattered throughout the duodenum and proximal jejunum. The lesions had smooth borders and did not show any retraction at the base. Other typical radiologic patterns of intestinal amyloidosis described in the literature were not observed in the present case. Differential diagnosis from multiple polyposis and diffuse lymphoproliferative neoplastic diseases is discussed.

Cell kinetics: a prognostic marker in epithelial ovarian cancer.

The proliferative activities (3H-thymidine labeling index, LI) of 72 primary ovarian cancers and 76 metastatic lesions from untreated patients were evaluated. Overall, median LI values for primary and metastatic lesions were similar (7.8 vs 7.0%), but cell kinetics significantly differed in metastases from different sites. The LI of the primary tumor was unrelated to pathologic stage and histology, but was significantly correlated with histologic grading (P = .014). The prognostic relevance of LI was assessed for 43 untreated patients at stage III-IV (90% with bulky residual disease), treated after staging laparatomy with five cycles of cisplatin or of carboplatin. For 19 patients the LI was determined for both primary tumor and metastases, for 15 for the primary, and for 12 for the metastatic lesions. Complete remission (CR) was unrelated to pretreatment LI, although a trend toward a higher rate of CR was observed with rapidly proliferating tumors. Patients with slowly proliferating primary tumors had a higher probability of 1.5-year survival than patients with rapidly proliferating tumors (83 vs 50%). The difference was even greater between patients with both primary and metastatic lesions proliferating slowly (100%) and patients with at least one (61%) or both lesions proliferating rapidly (60%). Pretreatment LI was not predictive for survival in subgroups of patients who attained CR, but it was quite predictive for survival in patients responding only partially or not at all (90 vs 32%, P = .025).

Infantile digital fibromatosis-like tumour (inclusion body fibromatosis) of adulthood: report of two cases with ultrastructural and immunocytochemical findings.

Two adult cases of a cutaneous lesion indistinguishable from typical infantile digital fibromatosis are added to the unique similar case so far reported in adulthood. The immunocytochemical localization of vimentin and muscle actin in the proliferating cells confirms their myofibroblastic nature and establishes closer relationships between the adult and the infantile variants of this entity. These two variants, however, appear to be clinically different, since all the adult cases were extradigital and did not recur after surgical excision. The term inclusion body fibromatosis underlines the histological hallmark of the lesion and should be used to identify this entity in place of recurrent infantile digital fibromatosis which does not seem any longer appropriate.

Ultrastructural immunolabeling in renal diseases. Past, present and future expectations.

The use of immunoelectron microscopy in the evaluation of renal diseases represents a valuable addition to existing techniques. The ability to immunolabel immune-complex deposits for light- and heavy-chain determinants, and complement fractions virtually eliminates the need for traditional immunofluorescence. One of the main advantages of performing immunoelectron microscopy relates to the fact that immunologic events can be adequately correlated morphologically with the degree and type of tissue reactions in the various renal compartments. Immunopathogenetic mechanisms can be clearly evaluated with this technique. The need to submit specimens in different fixatives is eliminated and all diagnostic modalities can be performed on a single fragment of tissue. The examination of the thick sections prepared from plastic-embedded tissue for survey provides excellent material for interpretation of findings at the light-microscopic level. These sections can be stained with hematoxylin/eosin, trichrome, silver methenamine and PAS stains with excellent results. The time and resources needed for processing renal biopsies can be significantly reduced by utilizing the proposed methodology. Likewise, interpretation of results may benefit from utilization of the same fragment for all diagnostic modalities.

Ultrastructural localization of extracellular immunoglobulins in immune-complex-mediated glomerulonephritis. Immunoelectron microscopy of Epon-embedded human renal biopsies using the immunogold staining procedure.

The ultrastructural localization of immunoglobulins (Igs) in immunologically mediated glomerulonephritis was achieved in ultrathin sections of glutaraldehyde-fixed, post-osmicated, Epon-embedded human renal needle biopsies using the indirect immunogold staining procedure. Extracellular Igs were identified in electron-dense deposits in subendothelial, intramembranous, subepithelial and mesangial locations in different cases of immune-complex-mediated glomerulonephritis. The excellent preservation of the ultrastructural morphology of the tissue sections made it possible to precisely correlate the presence and distribution of the antigens with those of the electron-dense deposits, which are the ultrastructural hallmarks of these diseases. Our post-embedding staining procedure which allows extracellular Igs to the accurately localized should be a very useful tool for immunomorphological investigations of glomerulonephritis.