[Occult rupture of the spleen in a patient with infectious mononucleosis]. / Rottura splenica "occulta" in paziente con mononucleosi infettiva.

INTRODUCTION: Rupture of the spleen can be secondary to abdominal traumas (usually closed trauma) or spontaneous, can interest an organ normal or with morphological alterations secondary to various pathologies. Among the diseases responsible of occult rupture, infectious diseases are the most frequent and, among these, infectious mononucleosis, that is complicated with splenic rupture in 0.5% of the cases, with 30% of mortality. CASE REPORT: P.M., 16 years old female, admitted with acute abdomen, progressive anaemia and incipient cardiovascular instability, associated with suggestive clinical diagnosis of infectious mononucleosis, confirmed by serological findings and histological examination. Because of the imaging of subcapsular splenic haematoma, probably ruptured and with peritoneal bleeding we opt for emergency laparotomy intraoperative findings allows to splenectomy. DISCUSSION: Splenic rupture in infectious mononucleosis often presents as left hypochondrial pain, rare in uncomplicated cases; its occurrence in a patient with a recent diagnosis of infectious mononucleosis or with clinical or laboratory features suggestive of acute EBV infection, should always be investigated with an urgent abdominal ultrasound scan or CT. This approach is mandatory when hypochondrial pain is associated with pain referred to the left shoulder (Kehr's sign), peritoneal irritation and haemodynamic instability. Patients with splenic rupture in infectious mononucleosis generally undergo emergency splenectomy.

[Gastrointestinal stromal tumors (GISTs). Personal experience on three cases of the tumors of the small intestine complicated and emergency surgically treated]. / I tumori stromali gastrointestinali (GIST). Esperienza personale su tre casi a localizzazione nel tenue mesenteriale trattati in urgenza.

INTRODUCTION: GISTs, a new nosological entity recently described, represent a peculiar model of solid tumor: the identification of the molecular mechanism responsible for the oncogenesis led to the development of a new drug (imatinib) active on the specific molecular target, represented by the product of the mutated proto-oncogene c-kit which is a tyrosine kinase receptor that becomes constitutively active by mutation. Surgical resection, nevertheless, is still the primary treatment and it has to be as complete as possible. These two treatments can be integrated. GISTs are not uniformly kit-positive, and they can be alternatively due to mutations of the PDGFRA gene or, in patients with neurofibromatosis type 1 (NF-1), to generally isolated mutations of the NF-1 gene. PATIENTS AND METHODS: We describe 3 cases of kit-positive GISTs of the small intestine (SISTs), complicated and emergency surgically treated: case 1--53 years, female, with small bowel obstruction and concomitant acute intestinal bleeding; case 2--71 years, male, with NF-1 and acute intestinal bleeding; case 3--47 years, male, with perforation of the Treitz tract. The first two cases have been treated with intestinal resection and immediate mechanical anastomosis; the third one with resection of the pedunculated tumor at its base, where is situated the perforation too. CONCLUSIONS: SISTs (20-30%), with little or no symptoms in the initial phases, show notable diagnostic difficulties. Their aspecific and late clinical presentation--typical of this site and of the pathology that we are talking about--and the difficult physical-instrumental approach to small bowel limit the possibility of an accurate diagnosis and expose the patient to potentially fatal acute complications and to risks related to emergency surgery treatment that decreases the possibility of a radical resection.

Myocardial protection using HTK solution in minimally invasive mitral valve surgery.

BACKGROUND: Minimally invasive cardiac surgery (MICS) is a safe and satisfactory approach used mainly in mitral valve surgery with excellent results in many centers. Cardioplegia administration can be still a problem, especially when an endoaortic clamp is used. We retrospectively analyzed our early results with histidine-triptophane-ketoglutarate (HTK) solution used for myocardial protection in MICS. METHODS: Between February 2003 and February 2004, 8 patients underwent mitral valve surgery using an endo- cardiopulmonary bypass (CPB) system and HTK solution as myocardial protection. The mean patient age was 67.7 +/- 9.2 years, and the preoperative ejection fraction was normal in all patients. Three patients had valve repair and 5 had valve replacement. Mean CPB time was 129.2 +/- 19.4 minutes, and aortic cross-clamp duration was 88.5 +/- 15.4 minutes. RESULTS: In every case HTK solution was used for only a single dose for cardioplegia at the beginning of the procedure, without any recalls. The heart restarted spontaneously at reperfusion in 6 of 8 cases (75%), and there were no significant modifications in electrocardiogram results or myocardial cytonecrosis enzymes (creatine kinase and its MB fraction) during the postoperative period. CONCLUSIONS: HTK solution is a cold crystalloid cardioplegia solution that has demonstrated its utility in MICS because it provides a safe long cardioplegic arrest time and it reduces the risk of inadequate coronary perfusion due to dislodgement of the endoaortic clamp.

Haemolysis during cardiopulmonary bypass: how to reduce the free haemoglobin by managing the suctioned blood separately.

During cardiopulmonary bypass (CPB) the collection of the patient's blood from the operating area is of fundamental importance. This blood is collected in the cardiotomy reservoir using field suckers and can be managed in different ways. It can be filtered in the cardiotomy reservoir and redirected to the venous reservoir, then oxygenated and returned to the patient, or it can be managed separately: collected in the cardiotomy reservoir, treated at the end of the operation and only after this, returned to the patient. The aim of this study is to determine in vivo the effect of a separate management of the suction blood from the operative field, using the Avant D903 oxygenator (Dideco, Mirandola, Italy). Twenty-one patients undergoing coronary artery bypass graft surgery with CPB were selected and put into two groups at random. In the control group (n = 10) the suction blood in the cardiotomy reservoir was filtered and immediately redirected into the venous reservoir, oxygenated and returned to the patient. In the study group (n = 11) the suctioned blood was collected in the D903 Avant's (Dideco) cardiotomy reservoir and returned to the patient only after having been washed at the end of the operation, using a Compact Advanced (Dideco), as required. Clinical data demonstrated that while in the study group it was possible to keep the free plasma haemoglobin (FPH) concentrations the same as at the beginning, in the control group there was a significant increase in FPH from 5.0 +/- 3.5 mg/dl (baseline) to 37 +/- 16.7mg/dl (120min after CPB).

Predicting airway risk in angioedema: staging system based on presentation.

Angioedema is an immunologically mediated, anatomically limited, nonpitting edema that can lead to life-threatening airway obstruction. To predict the risk of airway compromise in angioedema, we retrospectively reviewed 93 episodes in 80 patients from 1985 to 1995. Intubation or tracheotomy was necessary in 9 (9.7%) cases. Angiotensin-converting enzyme inhibitor use in 36 cases (39%) was associated with intensive care unit (ICU) admission (P = 0.05). ICU stay correlated significantly with presentation with voice change, hoarseness, dyspnea, and rash (P < 0.05). Voice change, hoarseness, dyspnea, and stridor were present in patients requiring airway intervention (P < 0.05). On the basis of our data, we propose a staging system by which airway risk may be predicted from the anatomic site of presentation. Patients with facial rash, facial edema, lip edema (stage I), and soft palate edema (stage II) were treated as outpatients and on the hospital ward. Patients with lingual edema (stage III) usually required ICU admission. All patients with laryngeal edema (stage IV) were admitted to the ICU. Airway intervention was necessary in 7% of stage III patients and in 24% of stage IV cases. No deaths were caused by angioedema. Airway risk in angioedema may be predicted by anatomic site of presentation, allowing appropriate triage with preparation for airway intervention in selected cases.

Use of postoperative chest x-ray after elective adult tracheotomy.

Surgeons have been creating tracheotomies since at least 124 AD, when first reported by Asclepiades (Price HC, Postma DS. Ear Nose Throat J 1983;62:44-59). Intraoperative and postoperative complications specifically associated with this procedure have been well established. The incidence of pneumothorax ranges from 0% to 17%, depending on the age group studied. To evaluate this complication, it is generally accepted that a postoperative chest film should routinely be obtained after a tracheotomy in adult patients. In adult nonemergent tracheotomies, the routine use of a postoperative chest film has a low yield for detecting a pneumothorax in patients without clinical findings of pneumothorax. To evaluate the use of postoperative chest x-ray in adult tracheotomy patients, a retrospective review of tracheotomies performed at the Boston Medical Center from January 1994 to June 1996 was undertaken. Data examined consisted of age, sex, surgical indication, urgency, operating service, intraoperative and postoperative complications, difficulty of procedure, anesthetic technique, findings on postoperative chest film, signs and symptoms of pneumothorax, and specific treatment of pneumothorax if present. In total, 250 patients were identified. The main indication for tracheostomy in this study was ventilator dependence, accounting for 77% of the procedures. A complication rate of 11.6% was encountered, with no deaths. Postoperative hemorrhage was the most common complication (3.6%). Pneumothorax was documented by chest x-ray in 3 (1.2%) patients, 1 of whom had bilateral pneumothoraces. The most common symptom of a pneumothorax was tachycardia, with 8.8% of the patients exhibiting at least 1 episode. Of the 3 cases of pneumothorax in this study, only 1 was clinically relevant and required treatment. Furthermore, the clinical signs and symptoms in this patient clearly supported the diagnosis of pneumothorax before a postoperative chest film was obtained. Thus postoperative chest radiographs did not change the treatment or outcome of any of the patients undergoing a tracheotomy. This suggests that postoperative chest x-ray after adult tracheotomy is not required in routine cases. Chest radiographs should be obtained after emergent procedures, after difficult procedures, or in patients exhibiting signs or symptoms of pneumothorax.

Heparin-coated circuits for high-risk patients: a multicenter, prospective, randomized trial.

BACKGROUND: Heparin-coated circuits (HCCs) in low-risk cardiac patients who have coronary revascularization have a limited impact on postoperative outcome. In this prospective, randomized investigation, we studied high-risk patients who had cardiac operations with or without HCCs. METHODS: A total of 886 patients who had cardiac operations with cardiopulmonary bypass and at least one patient-related or procedure-related risk factor were enrolled in a multicenter study. They were randomly allocated to have cardiopulmonary bypass with Duraflo II HCCs (HCC group, n = 442) or conventional circuits (control group, n = 444). Postoperative outcome was investigated with respect to the occurrence of organ dysfunction. RESULTS: HCCs are associated with a shorter intensive care unit and postoperative hospital stay and with a lower rate of patients having a severely impaired clinical outcome (stay in intensive care unit for more than 5 days or death) (relative risk 0.66, p = 0.045). Lung dysfunction rate was significantly lower for the patients in HCC group affected by chronic obstructive pulmonary disease or who had mitral procedure (relative risk, respectively, 0.31, p = 0.018 and 0.05, p = 0.02). Renal dysfunction rate was significantly (p = 0.05) lower for diabetics in the HCC group (relative risk 0.28). CONCLUSIONS: When HCCs were used postoperative times decreased and they had a protective effect on lung and kidney function in high-risk patients.

In vivo correlation of neutrophil receptor expression, ischemia-reperfusion injury, and selective 5-lipoxygenase inhibition in guinea pigs.

OBJECTIVE: To determine whether selective 5-lipoxygenase (5-LO) inhibition decreases expression of adhesion molecules (beta2 integrins) on systemic neutrophils, decreases neutrophil infiltration in ischemic flap tissue, and improves flap survival. DESIGN: A randomized, controlled study of 91 adult female Hartley guinea pigs divided into 3 survival groups, 4 neutrophil assay groups, 1 sham group, and 1 control group. Ischemia of varying duration and reperfusion was induced in island flank skin flaps. The treated groups received zileuton, a 5-LO inhibitor, orally during flap ischemia. After reperfusion, systemic neutrophil receptor expression, neutrophil infiltration, and flap survival were measured. Surface receptor molecules on neutrophils from whole blood samples obtained via transcardiac puncture were analyzed using monoclonal antibodies and cell-associated fluorescence. Neutrophil infiltration into a distal 1 cm2 of flap tissue was assessed using myeloperoxidase antibodies. Flap survival was determined within 7 days of surgery. RESULTS: Untreated flaps with 10 hours of ischemia underwent total necrosis. Treated 2- and 10-hour ischemic flaps survived intact. A significant main effect of the drug treatment was detected using analysis of variance (P<.001). Neutrophil receptor detection in the untreated groups undergoing 2 and 10 hours of ischemia was significantly increased compared with that in the treated groups with the same ischemia times. Skin neutrophil infiltration was significantly decreased in the treated groups. CONCLUSIONS: Systemic administration of a 5-LO inhibitor is effective in reducing ischemia-reperfusion injury in flap tissue. Our data indicate that there is a significant reduction in neutrophil receptor expression with administration of 5-LO, reducing the priming of systemic neutrophils from circulating cytokines.

Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta.

BACKGROUND: The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital. METHODS: A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear. RESULTS: The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor. CONCLUSIONS: Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.

Inactivation of p53 and amplification of cyclin D1 correlate with clinical outcome in head and neck cancer.

The authors have investigated whether genetic abnormalities in two genes, loss of heterozygosity (LOH) of p53 and amplification of the cyclin D1 gene, correlate with clinical outcome in 56 matched pairs of blood and tumor from patients with squamous cell carcinoma of the head and neck (SCCHN). Frequency of p53 LOH was 47.4%, of cyclin D1 amplification 33.9%, and of both abnormalities together 23.7%. p53 LOH was associated with T4 (P = 0.003) and stage IV (P = 0.015) tumors. Cyclin D1 amplification was associated with recurrences and/or metachronous tumors (P = 0.007). The total number of p53 and cyclin D1 abnormalities (scored as zero, one, and two) show a pattern that seems to be additive; the increase in the number of these abnormalities is associated with a proportional increase in the frequency of T4, stage IV, presence of recurrences and/or metachronous tumors, and possibly a proportional decrease in the disease-free interval in the sample. The association of the markers with recurrences and/or metachronous tumors persists if the tumor stage effect is mathematically removed. The combined analysis of the p53 and cyclin D1 abnormalities seems to be more informative than either of them individually and may have predictive value in SCCHN.

Head and neck cancer screening among 4611 tobacco users older than forty years.

We implemented screening for squamous cell carcinomas of the oral cavity, pharynx, and larynx with symptom assessment and systematic inspection of the oral mucosa by primary care practitioners at health care sites serving inner-city residents of Boston; 4611 tobacco users older than 40 years were screened, and 313 with specific criteria were referred to otolaryngology for diagnostic evaluations. In these screened patients, the prevalence of oral mucosal lesions was almost 13% and prevalence of persistent hoarseness was more than 11%. Although the identification of these cancers was rare (nearly 3%), abnormal findings were seen in more than 70% of referred patients. These clinical and histologic diagnoses are described. We have documented the range of pathologic conditions in high-risk patients screened for upper aerodigestive tract malignancy.

[Heart surgery with cardiopulmonary bypass in patients on chronic dialysis treatment: our experience]. / Interventi cardiochirurgici in circolazione extracorporea in pazienti in trattamento dialitico cronico: nostra esperienza.

METHODS: To determine the mortality and the morbidity of cardiac surgery in patients on chronic hemodialysis, we retrospectively reviewed eighteen adult patients (13 males and 5 females) with a mean age of 54.7 years (range: 30-67 years) who underwent cardiopulmonary bypass procedures between 1987 and 1995. The operations included: isolated coronary artery bypass grafting in 12 patients, coronary artery bypass grafting plus mitral ring annuloplasty in 1 patient, mitro aortic valve replacement in 2 patients, isolated aortic valve replacement in 1 patient, aortic valved conduit implantation in 1 patients and mitral valve replacement plus tricuspid annuloplasty in 1 patient. There were 10 and 3 patients in CCS functional classification III and IV respectively; 1 and 4 patients were in NYHA classification II and III respectively. All of them were hemodialyzed the day before surgery: the average time they had been on hemodialysis was 6.5 years. Anesthesia and the cardiopulmonary bypass (CPB) in these patients required attention in order to provide the optimal fluids and electrolytes balance: particularly intravenously administered fluids were kept to a minimum and drug dosages were reduced to recommended levels for anephric patients. An hemoconcentrator was used in all patients during the CPB and, in the last 4 cases, we used a dialysis filter and a sterilized perfusional solution to reduce the level of potassium and to put off postoperative dialysis. RESULTS: In three patients there were major bleeding problems resulting in reoperation; 5 perioperative deaths occurred: two of them due to myocardial infarction and three due to irreversible low cardiac output state. In our experience there were four late deaths: one patient died four months after surgery for chronic heart failure, another one died twelve months after surgery for dilated cardiomyopathy and two patients died respectively seventeen and seventy two months after discharge for myocardial infarction. Two of the remaining patients reported recurrence of angina while the others achieved symptomatic improvement. CONCLUSIONS: In conclusion, cardiac surgery is performed on chronic renal dialysis patients with high mortality and morbidity and it's indicated only if medical treatment is ineffective. The successful surgical results, obtained with an adequate management between surgeons, anesthesiologists and nephrologists, don't assure the long-term survival of the patients.

Magnetization transfer contrast MR in lesions of the head and neck.

PURPOSE: To compare lesion-to-background contrast with and without magnetization transfer (MT) in lesions of the head and neck. METHODS: Twenty lesions (16 malignant, 4 benign) were evaluated in 17 patients (11 men, 6 women; mean age, 58 years; age range, 39-76 years). In 13 patients, MR imaging was performed at 0.1 T with continuous-wave, off-resonance MT; in 4 patients, MR imaging was performed at 1.5 T with on-resonance, binomial MT prepulses. Fifteen sequences were conducted before the administration of gadopentetate dimeglumine; 13 were conducted after the administration of that contrast material. The ratio of signal intensity with the MT pulses (Ms) to signal intensity without the MT pulses (Mo) was calculated, as were the lesion-to-background contrast and the contrast-to-noise ratios. RESULTS: Ms/Mo showed both wide variability and considerable overlap among different lesion types. Images from MT sequences showed better contrast than those from non-MT sequences in 23 of 28 lesions (12 of 15 before and 11 of 13 after the administration of contrast material). The mean contrast improvement percentages (+/- standard deviation) were 165.5% (+/- 58%) on unenhanced images and 186.6% (+/- 84.8%) on contrast-enhanced images. The mean improvements in contrast-to-noise ratios were 156% (+/- 60%) on unenhanced images and 171.6% (+/- 98.1%) on contrast-enhanced images. CONCLUSION: MT improved contrast between nodes or tumors showing an MT effect and background tissue (usually fat) not showing an MT effect. MT also improved contrast between contrast-enhanced neoplastic lesions and background tissue that showed an MT effect.

[Complications of pediatric anesthesia. Survey carried out by the Study Group SIAARTI for anesthesia and intensive therapy in children]. / Le complicanze in anestesia pediatrica. A cura e per l'iniziativa del Gruppo di Studio SIAARTI per l'anestesia e la terapia intensiva in età infantile.

This study was designed to asses in a prospective survey the intra and post-operative adverse outcome of paediatric patients in Italy. The data was carried out in representative samples of anaesthetics performed in different Italian Institutions, which were chosen by the National Study Group for Paediatric Anaesthesia, and included: paediatric, general, specialistic hospitals and departments. A total of 9289 anaesthetics were collected and studied. The mean age of the patients was 62.5 months. In the 320 cases (3.4%) 299 minor (3.2%) and 21 major (0.2%) complications occurred during or within 24 hours of surgery and anaesthesia. Seven of the major complications resulted in the exitus of the patients (0.07%). Fifty percent of the accidents regarded respiratory and twenty percent cardiovascular systems. The major incidence (risk factors) of the minor complications was present in patients less than 6 months, ASA group 2-3-4, emergency surgery, patients with associated pathology, long duration of anaesthesia and high risk operations. The incidence of the major complications appears closely related to: patients age and clinical assessment, weight, ASA group, kind of the operation, indications and durations of the surgery, while in the exitus group the major risk factor is the preoperative pathology, surgical procedures, and then: age, weight, ASA and finally surgery.

Treatment of adductor laryngeal breathing dystonia with botulinum toxin type A.

Adductor laryngeal breathing dystonia (ALBD) is a rare disorder in which patients have persistent inspiratory stridor, usually normal voice, and cough. Physical exam is characterized by paradoxical movement of the vocal cords on inspiration. These patients have involuntary action-induced spasms of the adductor laryngeal muscles on inspiration. There has been no uniformly satisfactory treatment for the disease. Speech therapy, psychotherapy, and pharmacotherapy have all had limited success. We report the successful use of botulinum toxin type A in seven patients with adductor laryngeal breathing dystonia. All patients received bilateral thyroarytenoid injections. All patients had toxin effect within 72 hours, reaching maximal effect within 2 weeks with sustained improvement for an average of 13.8 weeks. Adverse effects included breathy voice and mild choking on liquids. Both resolved, on average, within 2 weeks. This retrospective study supports the safe and effective use of botulinum toxin type A in the treatment of adductor laryngeal breathing dystonia.

Localized amyloidosis of the larynx: evidence for light chain composition.

We report the biochemical characterization of amyloid fibrils from a patient with localized amyloidosis of the epiglottis and larynx. Biopsy specimens showed amorphous material consistent with amyloid deposits with a plasmacytic infiltrate. Both plasma cells and amyloid deposits stained positively by immunohistochemistry for kappa light chains. Amyloid fibrils were isolated. The major constituent resolved as a 13 kd band was sequenced and found to be consistent with a kappa 1 light chain. A tryptic digest was carried out and 3 tryptic peptides were sequenced defining the first 45 residues of the protein and residues 110 through 119. Four amino acid substitutions were found, 3 of which have not been described previously. This study defines the immunoglobulin origin of amyloid deposits in localized amyloidosis. The benign nature of localized amyloidosis suggests that a localized clone of plasma cells producing an amyloidogenic light chain may represent the pathogenetic mechanism of this disease, which appears to be a form of plasma cell dyscrasia.

Otolaryngologic manifestations of phenytoin toxicity.

DPH may result in protean head and neck manifestations (Table 1). In some cases these effects are dose related and in others they appear to be idiosyncratic; some occur only at toxic levels (Table 2). Many of the conditions are reversible and withdrawal of DPH or re-establishment of therapeutic levels is the only treatment necessary. Failure to recognize this fact can result in expensive workups or, worse, in aggressive treatment, both of which are unnecessary. The otolaryngologist should therefore be aware of these conditions and consider them in the differential diagnosis.