Expected and actual adverse drug-drug interactions in elderly patients accessing the emergency department: data from the ANCESTRAL-ED study.

OBJECTIVE: This study was aimed at evaluating the frequency and describing the adverse drug-drug interactions (DDIs) recorded among elderly patients accessing the emergency department (ED). METHODS: Patients aged ≥65 years, accessing the ED of Pisa University Hospital (Italy) from 1 January 2015 to 31 December 2015 within the ANCESTRAL-ED program, were included in this study. 'Expected' DDIs were assessed using Thomson Micromedex®. Each ED admission (discharge diagnosis) consistent with the signs and symptoms of an expected DDI for each patient was classified as an 'actual' DDI. RESULTS: Throughout the study period, 3473 patients (3812 ED admissions, 58% females, mean age: 80.3) were recorded. The total number of expected DDIs was 12,578 (67 contraindicated; 3334 major; 8878 moderate; 299 minor) detected in 2147 (62%) patients. Overall 464 expected DDIs were found to be consistent with the ED admission in 194 patients (representing 9% of patients with expected DDIs). CONCLUSIONS: More than one half of elderly patients admitted to ED presented at least one expected DDI at the time of ED presentation. However, 9% of the expected DDIs were identified as actual DDIs, based on the consistency of the expected event with the ED discharge diagnosis.

Critical US visibility with tissue harmonic imaging of subcutaneous nodules().

INTRODUCTION: Assessment of US ability to identify subcutaneous nodular lesions using conventional B mode imaging (CBMI) and tissue second harmonic imaging (THI). MATERIALS AND METHODS: Three different types of equipment were used (Philips Envisor HDC, Philips HD 11 XE and GE Logic E) with 12-13 MHz probes and THI probes with variable frequency. One experienced operator studied 31 patients (24 women, 7 men, mean age 49 ± 15) with 52 subcutaneous nodular lesions of which 43 were palpable and 9 were nonpalpable. Statistical analysis was carried out using chi-square test. RESULTS: 19/52 subcutaneous nodular lesions were hyperechoic, 10/52 were isoechoic and 23/52 were hypoechoic. Of the hyperechoic nodules, 8/19 (42%) (p < 0.005) were not detected using THI, as they "disappeared" when THI was activated. Of the isoechoic nodules only 1/10 was not detected using THI, and of the hypoechoic nodules only 2/23 were not detected. Of the nodular lesions detected using CBMI and also using THI (41/52), 16/41 were shown more clearly using THI than using BMCI. No nodule was detected with the exclusive use of THI. CONCLUSIONS: The statistical significance of the "disappearing" lesions (p < 0.005), mainly hyperechoic (42%), at the activation of THI must lead to a reconsideration of routine activation of THI during the entire US examination in the evaluation of subcutaneous lesions in order to avoid the risk of missing important lesions. The present results suggest that both BMCI and THI should be used in the study of subcutaneous lesions.

Contrast-enhanced ultrasonography in nodular splenomegaly associated with type B Niemann-Pick disease: an atypical hemangioma enhancement pattern.

INTRODUCTION: Niemann-Pick disease (NPD) types A and B are lipid storage disorders. NPD type A is a fatal disorder of infancy. Type B is a non-neuronopathic form observed in children and adults. It is associated with enlargement of the liver, spleen, or both, and nodular splenomegaly may be detected with ultrasound. METHODS: A 21-year-old female was admitted to the Emergency Room with fever, pharyngitis, and left upper quadrant abdominal pain. Labwork revealed anemia, thrombocytopenia, increased levels of AST, ALT, GGT, AF, LDH, triglycerides, and total cholesterol and low levels of HDL-cholesterol. PCR blood assays for CMV and EBV were both negative. Chest X-ray was unremarkable. Transabdominal B-mode ultrasound (US) revealed splenomegaly (long axis: >22 cm), an irregular subcapsular hypoechoic lesion in the superior pole that was consistent with splenic infarction, and multiple round highly echogenic nodes measuring 1-5 cm in diameter. Contrast-enhanced ultrasonography (CEUS) was performed using SonoVue(®) (Bracco). RESULTS: The presence of a splenic infarction was confirmed. The nodular lesions showed arterial-phase enhancement with late parenchymal phase wash-out. (18)F-FDG-PET revealed splenic nodular uptake. Primary splenic lymphoma was suspected, and the patient underwent open splenectomy. The diagnosis was type B NPD with splenic hemangiomas. DISCUSSION: CEUS confirmed the diagnosis and extent of splenic infarction, but the nodular atypical enhancement pattern together with nodular (18)F-FDG-PET uptake was misleading, suggesting as it did lymphoproliferative involvement of the spleen.

Hodgkin's lymphoma: an isolated case of involvement of the ureter.

We report the case of a man in which a Hodgkin's lymphoma involved the ureter as the very first clinical situs of the disease. Ureteral involvement in lymphomas is very rare (0.86%-7% and 1%-16%, found in two studies, respectively, of cases of patients with lymphoma examined post mortem) and when it does occur it is secondary to renal involvement or retroperitoneal adenopathies. It is by all means exceptional as an isolated situs of disease. Those cases reported in the literature as presenting lymphomatous involvement of the ureter have always been diagnosed as Non-Hodgkin's lymphomas.

[Urotheliomas of the upper urinary tract. The role of computed tomography in integrated diagnostic imaging]. / Uroteliomi delle vie escretrici urinarie superiori. Ruolo della Tomografia Computerizzata nella diagnostica per immagini integrata.

INTRODUCTION: Transitional cell carcinomas are frequent in the bladder but rare in the renal pelvis. Most upper urinary tract cancers are suspected and detected with urography and retrograde pyelography; CT is important in the questionable cases at US, urography and retrograde pyelography, but it is also useful to detect locoregional disease. We report the findings of 35 patients, with ureteral lesions to assess the role of CT in the diagnosis and staging. MATERIALS AND METHODS: Thirty-five patients were examined with US and CT; 27 underwent urography, 16 retrograde pyelography and 4 nephrostomic pyelography, CT staging was made with Hahn's criteria related to TNM (stages CT I, CT II, CT III). All patients underwent surgery and the histologic findings were compared with CT staging. RESULTS: CT detected all lesions and characterized them from a morphological viewpoint (intraluminal minus, wall thickening). Using Hahn's CT staging we obtained agreement with histologic findings in 21 of 23 cases in CT stage I, six of 10 in CT stage II and 4 of 5 in CT stage III. CONCLUSIONS: CT is an important tool for both diagnosis and therapy because it shows the renal cavities and parenchyma and permits accurate staging, differentiating the tumors localized in the wall from those with local spread or distant metastases. In our experience, CT is not useful to differentiate mucosal from pelvic-ureteral muscle invasion but peripelvic and periureteral fat invasion can be suspected when the infiltrated wall exhibits an irregular and spiculated profile.

Mental retardation, epilepsy, short stature, and skeletal dysplasia: confirmation of the Gurrieri syndrome.

We report on a male with severe mental retardation, epilepsy, short stature, and skeletal dysplasia. The syndrome was first delineated by Gurrieri et al. in 1992 [Am J Med Genet 44:315-320]. This case seems to confirm the existence of the Gurrieri syndrome.

New autosomal recessive syndrome of mental retardation, coarse face, microcephaly, epilepsy and skeletal abnormalities.

We describe two sibs, one male and one female, presenting a new autosomal recessive multiple congenital anomalies/mental retardation syndrome of 'coarse face', microcephaly, moderate to severe mental retardation, epilepsy and skeletal abnormalities.

Sarcoidosis: single bulky mesenteric lymph node mimicking a lymphoma.

A previously healthy man presented with acute abdominal pain that extended from the left lumbar area to the left iliac fossa and to the omolateral testicular region. Abdominal ultrasonography and CT scan showed a bulky mesenteric mass and mesenteric, paraaortic, and paracaval lymph nodes. Biopsy specimens of the mass revealed non caseating granulomas. Chest CT scan and 67Gallium thoracic scan demonstrated lymph node and parenchymal pulmonary involvement. Bronchoalveolar lavage (BAL) confirmed the presence of a low intensity alveolitis. Serum angiotensin converting enzyme (SACE) level was elevated. Two years after steroid therapy, markers of disease activity and abdominal ultrasonography are in the normal range.

Cisapride improves gallbladder kinetics in patients affected with myotonic muscular dystrophy.

Smooth muscle involvement is relatively common in myotonic muscular dystrophy (MMD). The effects of cisapride on gallbladder motor function in myotonic patients have been investigated in 10 alithiasic patients and in 10 healthy volunteers. Gallbladder volumes were measured by ultrasonography in fasting state and 15, 30, 45 and 60 min after milk intake. The patients were treated with cisapride for two months, after which they underwent a second ultrasonographic examination. Gallbladder emptying was slower and less effective in dystrophic patients than in healthy volunteers. Cisapride was found to improve gallbladder kinetics (efficacy of contraction and rate of emptying) in patients affected with myotonic muscular dystrophy.

[Evaluation of the efficacy of bicarbonate-alkaline water action on gallbladder motility]. / Valutazione dell'efficacia di un'acqua bicarbonato-alcalina sulla motilità colecistica.

Physiological gallbladder contraction, delivering bile salts during meals, plays a key role in digestive mechanisms. A bicarbonate-alkaline water (Uliveto) shows a positive effect on gallbladder kinetics: so it may be useful in order to improve dyspepsia due to delayed gallbladder emptying.

[Loco-regional transcatheter thrombolysis]. / Trombolisi loco-regionale transcatetere.

Eight cases of recent arterial thrombosis (average time of symptoms: 11 days) are considered: 2 popliteal and 6 prosthetic thromboses (2 aorto-bifemoral and 4 femoropopliteal by-passes). After percutaneous catheterization, with catheter tip either in contact with or inside the thrombus, urokinase was locally injected (200,000 UI bolus, and 75,000 UI with slow infusion for 24 +/- 72 hours); general heparin treatment was also administered. PTA was employed in 2 cases (1 surgical anastomosis and 1 popliteal thrombosis). Arterial recanalization was always obtained within 72 hours in 2 aorto-bifemoral and in 1/4 femoropopliteal by-passes. Patency was also obtained in the 2 popliteal thrombosis.

[The echographic diagnosis of acute appendicitis and its complications]. / Diagnosi ecografica dell'appendicite acuta e delle sue complicanze.

The authors report their experience with emergency US in patients hospitalized for clinical suspicion of acute appendicitis or presenting with pain in the right lower abdominal quadrant. One hundred fifty-two patients were examined with US: 93/152 had pathologies of the right iliac region; 81 of them underwent surgery (50/81 appendectomies). In 27 of these patients the inflamed appendix presented with a typical US pattern. All of them had surgical confirmation. In 13/50 cases, US findings followed an atypical pattern (6 patients had a periappendiceal mass in the right iliac region, 3 had small amounts of fluid in the Douglas pouch, and 4 had gas-filled bowel loops of the ileum). The false negatives were 10/50. US sensitivity was 80%, and its specificity was 54%. The most common pathologic conditions are described whose symptoms mimic those of acute appendicitis. US role in inflamed acute appendicitis is still to be defined. Nonetheless, the authors suggest that US be performed on all patients with atypical pain in the lower abdominal quadrants, because of its high diagnostic accuracy in many common pathologies mimicking appendicitis, especially urinary and uterine adnexal pathologies.