Permanent brain damage following acute clonidine poisoning in Munchausen by proxy.

A child presented with recurrent episodes of lethargia for which he underwent several hospital admissions and investigations. A further episode culminated in respiratory arrest and hypoxic ischemic encephalopathy with permanent mental regression. Eighteen months later the mother was discovered while providing clonidine pills to the child; the mother appears to feature a Munchausen syndrome by proxy.

[Atypical and incomplete Kawasaki disease]. / Le forme atipiche ed incomplete della malattia di Kawasaki.

Kawasaki Disease (KD) is an acute systemic vasculitic disorder of childhood of unknown etiology. Initially KD was thought to be a benign disease, but later on it became obvious that cardiac manifestations are present in about 25-30% of patients and lead to death in about 0.5-2% of them. An early diagnosis and treatment are important to avoid an unfavourable prognosis. In recent years, a number of publications described patients in which the diagnosis was delayed because they did not fulfil the required criteria of KD. These forms of KD are known as atypical or incomplete KD. The aim of this work is to describe two cases of atypical KD observed at the Department of Pediatrics, University of Pisa during the year 1992.

[Screening for celiac disease in children attending secondary school around Lucca]. / Screening del morbo celiaco nei bambini delle scuole medie della Piana di Lucca.

UNLABELLED: A growing number of clinical and epidemiological data point to the fact that coeliac disease (CD) is a pauci- or asymptomatic occurrence, relatively more frequent than it was supposed in the past, manifested in atypical, silent and latent forms which are often undiagnosed or diagnosed only at a later age. The fact that resolutive treatment is now available means that CD is an ideal field for the application of a screening method. In this context the study by Catassi et al. (1994) is particularly important since it reported a prevalence of 0.38% of CD in healthy children in the Pesaro-Urbino area. AIM: The aim of this study was to verify the incidence of CD in a nonselected pediatric population in the province of Lucca, using the aforesaid screening method. METHOD: The eligible population consisted of 1585 students from 5 secondary schools around Lucca, aged between 10 and 15 years old, none of whom were known to be affected by CD. In the first phase of the study anti-gliadin-IgA (AGA-IgA) and IgG antibodies were assayed in capillary blood (collected at school) using Alfa-Gliatest (Eurospital); children with AGA-IgA, AGA-IgG over 7 and 15 U/ml respectively were considered positive. In the second phase children with positive results underwent a further assay of AGA-IgA, AGA-IgG, anti-endomysium antibodies (EMA) and total IgA in venous blood. Lastly, children positive for AGA-IgA and/or EMA, or those positive for AGA-IgG with IgA deficit underwent duodenal jejunal biopsy. RESULTS: 41 children were positive on screening (2.6% of the eligible population, 3.8% of subjects effectively tested). Of these, 39 were assayed for AGA (IgA and IgG), EMA and total IgA in peripheral blood, identifying 4 subjects positive for AGA-IgA and EMA. Of the 4 children selected in this way, only 2 underwent jejunal biopsy and both presented "duodenal mucosa with chronic phlogosis and subtotal villous atrophy". Two cases of CD were formally ascertained with a prevalence of 1 out of 793 (0.13%) of the eligible population and an estimated prevalence of 1 out of 546.5 (0.18%) of the subjects undergoing screening. The cost was approximately Lit. 23,000 per child screened and approximately Lit. 6,100,000 for each coeliac child diagnosed. COMMENTS AND CONCLUSIONS: The diagnostic iter proved efficacious and enabled 4 "high-risk" children to be selected. If the two subjects who did not undergo biopsy are also formally considered as coeliacs, the prevalence would be 1 out of 396 (0.25%) of the eligible subjects, namely 1 out of 273 (0.37%) of effectively tested subjects. This is a figure which is very similar to that reported by other studies. The 4 children identified here as strongly suspected of CD did not possess any anamnestic and/or objective elements which might have suggested "ex ante" a diagnosis of CD. If confirmed, these data provide concrete evidence of the need to perform mass screenings to identify CD. The economic convenience of this procedure depends on a careful analysis of the costs of the failure to diagnose CD.

[Neurocysticercosis: a rare cause of convulsive crises]. / Neurocisticercosi. Una rara causa di crisi convulsive.

The cysticercosis is an infestation caused from the larva of Taenia solium, which is demoniated Cysticercus cellulosae. Infestation by the encysted forms occur within brain, muscle, cutis, eye and more rarely within kidney, liver, thyroid. The cysties cause inflammation, oedema and residual calcification. In the SNC they are responsible for seizures, usually of focal type, hydrocephalus, meningitis, endocranic hypertension, stroke. One case of neurocysticercosis in a 15 years old boy is described: the clinical pictures, the neuroradiologic images and the treatment are discussed.

Immediate and long-term survival after intra-aortic balloon pumping: is advanced age an independent, unfavorable prognostic factor?

OBJECTIVE: To determine whether advanced age is an independent prognostic factor that may increase the risk of complications and reduce the immediate and long-term survival after treatment with intra-aortic balloon pumping (IABP) for acute ischemic heart disease. DESIGN: Retrospective analysis of a clinical series and long-term follow-up study. PATIENTS: A total of 142 patients (age range 23-86 years) in whom IABP was indicated following a standardized protocol. MEASUREMENTS: Univariate analysis of the association between age and anamnestic, clinical, and hemodynamic data significantly affecting prognosis; multivariate logistic regression analysis of variables showing significant associations. RESULTS: IABP-related complications were independent of age. At univariate analysis, pre-existing, noncardiac, associated conditions (chronic renal failure, stroke, bronchopulmonary disease) (P < .001), an indication to IABP for hemodynamic complications of acute myocardial infarction rather than for medically refractory myocardial ischemia (P < .001), a lack in hemodynamic response to IABP (P < .002), a prolonged delay to IABP initiation (P < .003), and advanced age (P < .025) were all predictors of in-hospital mortality. However, older patients were also more frequently affected by chronic comorbid conditions and by acute left ventricular failure as an indication to IABP. When these variables were entered into logistic regression models, the association between age and mortality was no longer statistically significant. Similarly, advancing age was associated (P < .012) with an increased mortality rate during an average follow-up of 94 +/- 9 months, but, again, such a significant association disappeared when simultaneously adjusting for New York Heart Association functional class, which was the single most important predictor of long-term mortality. CONCLUSIONS: Several anamnestic and clinical variables, rather than advanced age itself, are independent, prognostic factors negatively affecting the outcome of treatment with IABP. Technique-related complications are independent of age. Thus, old age should not be considered as a criterion to exclude any patient, a priori, from the potential benefits of this type of cardiocirculatory assistance.