Oblique capsular shift in anterior and anteroinferior shoulder instability.

Patients submitted to oblique capsular shift were followed-up; this is a personal method used to treat recurrent anterior and anteroinferior dislocation of the shoulder. A total of 186 patients were followed-up. The results were good as there were no recurrences, recovery of shoulder movement was early and ample, and the Constant score was about 81.2.

Treatment of fractures of the humeral head by cemented and cementless hemiarthroplasty. Our experience.

Patients submitted to shoulder hemiarthroplasty for the treatment of fracture of the humeral head were analyzed. The study was conducted from 1991 to June 2001 using 2 different prosthetic models: the Neer cemented prosthesis and the Randelli cementless prosthesis. The authors were able to evaluate 93 cases out of 148 operated on. A review of data revealed the essential importance of reconstruction of the tuberosity and rehabilitation. It was also observed that the age of the patient and the severity of the fracture did not in any way influence results. X-ray examinations did not shed light on loosening phenomena in prosthetic implants. Erosion of the glenoid was observed only when two factors coexisted: incorrect position of the prosthesis and low mobility of the shoulder. The study allowed us to reveal numerous prognostic elements, both favorable and adverse, and to measure their importance and priority.

Growth hormone (GH) responsiveness to combined administration of arginine and GH-releasing hormone does not vary with age in man.

At present, the mechanism(s) underlying the reduced spontaneous and stimulated GH secretion in aging is still unclear. To obtain new information on this mechanism(s), the GH responses to both single and combined administration of GH-releasing hormone (GHRH; 1 microgram/kg iv) and arginine (ARG; 30 g infused over 30 min), a well known GH secretagogue probably acting via inhibition of hypothalamic somatostatin release, were studied in seven elderly normal subjects and seven young healthy subjects. Basal GH levels were similar in both groups, while insulin-like growth factor-I levels were lower in elderly subjects (76.7 +/- 9.2 vs. 258.3 +/- 29.2 micrograms/L; P = 0.01). In aged subjects GHRH induced a GH increase (area under the curve, 314.9 +/- 91.9 micrograms/L.h) which was lower (P = 0.01) than that in young subjects (709.1 +/- 114.4 micrograms/L.h). On the other hand, the ARG-induced GH increase in the elderly was not significantly different from that in young subjects (372.8 +/- 81.8 vs. 470.6 +/- 126.5 micrograms/L.h). ARG potentiated GH responsiveness to GHRH in both elderly (1787.1 +/- 226.0 micrograms/L.h; P = 0.0001 vs. GHRH alone) and young subjects (2113.0 +/- 444.3 micrograms/L.h; P = 0.001 vs. GHRH alone). The potentiating effect of ARG on the GHRH-induced GH response was greater in elderly than in young subjects (1013.0 +/- 553.5% vs. 237.9 +/- 79.1%; P = 0.0001); thus, the GH increase induced by combined administration of ARG and GHRH overlapped in two groups. In conclusion, these results show that, differently from the GHRH-induced GH increase, the somatotroph response to combined administration of ARG and GHRH does not vary with age. Our finding suggests that an increased somatostatinergic activity may underlie the reduced GH secretion in normal aging.

Acute clonidine administration potentiates spontaneous diurnal, but not nocturnal, growth hormone secretion in normal short children.

It has been shown that alpha 2-adrenoreceptor activation induced by clonidine (CLON) increases plasma GH levels in both adults and children. In this study the effects of CLON (150 micrograms/m2, orally) on GH secretion were studied both in the morning (from 0800-1100 h) and at night (from 2300-0200 h) in nine short children previously shown to have normal spontaneous nocturnal GH secretion. In the morning, CLON induced a GH increase higher than placebo [peak (mean +/- SEM), 23.8 +/- 4.3 vs. 3.4 +/- 1.4 micrograms/L; P = 0.0001; area under curve (AUC), 624.4 +/- 62.7 vs. 135.6 +/- 33.3 micrograms/L.h; P less than 0.00001]. In the night, no difference was observed between GH secretion after CLON (peak, 15.4 +/- 3.2 micrograms/L; AUC, 562.2 +/- 57.5 micrograms/L.h) and placebo (peak, 13.1 +/- 4.7 micrograms/L; AUC, 497.2 +/- 83.5 micrograms/L.h). Spontaneous GH secretion was higher during the night than in the morning (P = 0.0001), whereas nocturnal GH secretion overlapped with that in the morning after CLON. The data presented show that alpha 2-adrenoreceptor activation is probably mediated by increased endogenous GHRH release; our results suggest that the endogenous GHRH secretion is maximally stimulated at night.

Pyridostigmine potentiates growth hormone (GH)-releasing hormone-induced GH release in both men and women.

It has been recently reported that pyridostigmine (PD), an indirect cholinergic agonist, probably acting via inhibition of hypothalamic somatostatin, potentiates the GH-releasing hormone (GHRH)-induced GH rise in men, but not in women. The aim of this study was to verify the sex-related, if any, GH response to GHRH (1 microgram/kg, i.v., as a bolus) both alone and preceded by two different doses of PD (120 mg, group A, and 60 mg, group B, given orally 60 min before GHRH) in a large group of volunteers (36 women, aged 18-35 yr, and 48 men, aged 18-35 yrs). In group A, 120 mg oral PD potentiated the GH response to GHRH in both men [area under the curve (AUC), 2579.3 +/- 264.5 vs. 806.2 +/- 99.7 micrograms/L.h; P < 0.00001] and women (AUC, 2273.2 +/- 248.7 vs. 792.6 +/- 72.7 micrograms/L.h; P < 0.00001). Similarly, in the group B, 60 mg oral PD potentiated the GH response to GHRH in both men (AUC, 1929.6 +/- 157.2 vs. 568.2 +/- 81.3 micrograms/L.h; P < 0.01) and in women (AUC, 1655.9 +/- 146.9 vs. 738.2 +/- 105.7 micrograms/L.h; P < 0.01). The GH responses to GHRH, both alone and after 120 and 60 mg oral PD, did not significantly differ in men and women. No sex-related difference was observed in the cholinergic side-effects (mild abdominal pain and muscle fasciculations) that occurred in nearly 30% of the subjects. In conclusion, our results clearly show that there is no sex-related difference in the potentiating effect of PD on GHRH-induced GH release, ruling out the suggestion that women have increased cholinergic activity, leading to reduced somatostatinergic tone.

Arginine but not pyridostigmine, a cholinesterase inhibitor, enhances the GHRH-induced GH rise in patients with anorexia nervosa.

Pirenzepine, a muscarinic antagonist probably acting via stimulation of hypothalamic somatostatin release, abolishes the growth hormone releasing hormone (GHRH)-stimulated growth hormone (GH) rise in normal subjects but only blunts it in patients with anorexia nervosa (AN). This finding suggested the existence in AN of an alteration of cholinergic system and/or somatostatinergic tone. To further investigate these mechanisms, in 11 AN women patients (age 18.8 +/- 0.9 years; BMI 13.4 +/- 0.4) we studied the GH response alone (1 microgram/Kg IV as a bolus at 0 min) and combined with pyridostigmine (PD, 120 mg orally, 60 min before GHRH administration), a cholinesterase inhibitor, or arginine (ARG 30 g infused over 30 min starting at 0 min), two compounds probably acting via inhibition of hypothalamic somatostatin (SS) release. The GH response to GHRH preceded by a previous (120 min before) neurohormone administration also was studied. All these tests also were performed in 20 normal age-matched women (age 22.0 +/- 1.8 yrs; BMI20.1 +/- 2.4). Basal serum GH levels were higher in AN patients than in normal volunteers (NV) (10.3 +/- 3.4 versus 2.8 +/- 0.3 microgram/L; p < 0.001), whereas plasma IGF-I levels were lower in AN patients than in NV (43.3 +/- 10.6 versus 172.4 +/- 13.9 micrograms/L; p < 0.00001). In AN patients, GHRH administration induced a GH rise higher, though not significantly, than that in NV [delta area under the curve (AUC) 1173.6 +/- 167.6 versus 834.6 +/- 188.1 micrograms/L/h]. The GH response to the second of two consecutive GHRH boluses was lower (p < 0.01) than that of the first one either in AN patients or in NV (67.6 +/- 27.4 and 53.1 +/- 25.7 micrograms/L/h, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Interactions of galanin and arginine on growth hormone, prolactin, and insulin secretion in man.

Galanin (GAL), a 29 amino acid neuropeptide, is known to increase both basal and growth hormone-releasing hormone (GHRH)-induced growth hormone (GH) secretion while not significantly increasing prolactin (PRL) secretion in man. GAL is also endowed with an inhibiting effect on glucose-stimulated insulin release in animals, but not in man. We studied the effect of GAL (80 pmol/kg/min infused over 60 minutes) on the arginine- (ARG, 30 g infused over 30 minutes) stimulated GH, PRL, insulin, and C-peptide secretion in eight healthy volunteers (age, 20 to 30 years). GAL induced an increase of GH (GAL v saline, area under curve [AUC], mean +/- SEM: 316.5 +/- 73.9 v 93.2 +/- 20.9 micrograms/L/h, P less than .05), but failed to modify both PRL and insulin secretion. GAL enhanced the ARG-induced stimulation of both GH (1,634.1 +/- 293.1 v 566.9 +/- 144.0 micrograms/L/h, P less than .02) and PRL secretion (1,541.9 +/- 248.8 v 1,023.8 +/- 158.7 micrograms/L/h, P less than .02). On the contrary, GAL blunted the ARG-stimulated insulin (816.3 +/- 87.7 v 1,322.7 +/- 240.9 mU/L/h, P less than .05), as well as C-peptide secretion (105.1 +/- 9.8 v 132.8 +/- 17.3 micrograms/L/h, P less than .02). ARG administration induced a transient increase of glucose levels (P less than .01 v baseline) followed by a significant decrease (P less than .05 v baseline). This latter effect was prevented by the coadministration of GAL. In conclusion, these results show that in man GAL potentiates the GH response to ARG, suggesting that these drugs act at the hypothalamic level, at least in part, via different mechanisms.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspergilloma: a series of 89 surgical cases.

BACKGROUND: Surgery for pleuropulmonary aspergilloma is reputed to be risky. We reviewed our results, focusing attention on the postoperative complications. METHODS: During a 20-year period, 87 patients were operated on for pulmonary (86) or pleural (3) aspergillomas. Seventy-two percent of patients were complaining of hemoptysis. Eighty-nine resections were performed because there were two bilateral cases. Seventy percent of aspergillomas had developed in cavitation sequelaes from tuberculosis disease. Thirty-four patients had severe respiratory insufficiency that allowed us to perform only lobectomy (18), segmentectomy (2), or cavernostomy (14). RESULTS: Thirty-seven lobectomies (five with associated segmentectomies), two bilobectomies, 21 segmentectomies, 10 pneumonectomies, and 17 cavernostomies were performed. Total blood loss exceeded 1,500 mL in 14 cases, and 71% of patients required blood transfusion. There were five postoperative deaths (5.7%), related to respiratory failure (2), infectious complication (1), pulmonary embolus (1), and cardiorythmic disorder (1). Incomplete reexpansions were frequently seen in patients undergoing lobectomies or segmentectomies. No death or major complications occurred in asymptomatic patients. During follow-up, none of the patients had recurrent hemoptysis. CONCLUSIONS: Surgical resection of aspergilloma is effective in preventing recurrence of hemoptysis. It has low risk in asymptomatic patients and in the absence of underlying pulmonary disease. Incomplete reexpansion is frequent after lobectomy and segmentectomy, especially when there is underlying lung disease. Cavernostomy is an effective treatment in high-risk patients. Long-term prognosis is mainly dependent on the general condition of patients.

Comparison of growth hormone-releasing effect of growth hormone-releasing hormone, clonidine and pyridostigmine in normal children and adolescents. GH-releasing effect of GHRH, clonidine and pyridostigmine.

The GHRH test has been proposed to replace conventional stimuli in the diagnosis of GH deficiency. However the reliability of GHRH in discriminating between normal and GH-deficient children is still uncertain. The aim of this study was to compare the GH-releasing effect of GHRH (1 microgram/kg i.v.) with that of two neuroactive drugs, clonidine (CLON, 150 micrograms/m2 orally), an alpha 2-receptor agonist, and pyridostigmine (PD, 60 mg orally), a cholinergic agonist that inhibits cholinesterases, in 23 children and adolescents with normal and familial short stature. The plasma GH peak (mean +/- SEM) after GHRH (20.3 +/- 2.5 ng/ml), CLON (17.0 +/- 2.1 ng/ml) and PD (14.9 +/- 1.5 ng/ml) did not significantly differ. According to the conventional limit (less than 10 ng/ml), a false negative response was present in 6, 5 and 6 subjects after GHRH, CLON and PD, respectively. In conclusion, GHRH, CLON and PD have a similar GH-releasing effect. A similar percentage of false negative responses was observed with all tests and this evidence reduces their diagnostic ability.

Results of surgical resection of stage IIIa (N2) non small cell lung cancer, according to the site of the mediastinal metastases.

Out of a series of 1563 consecutive patients submitted to thoracotomy for lung cancer between 1980 and 1990, 278 patients underwent a resection for a non small cell lung cancer (NSCLC) with mediastinal node metastases (N2). Selection of cases for surgery was carried out using CT from 1983 and mediastinoscopy for the patients with mediastinal lymph nodes larger than 1.5 cm from 1985: all patients with positive mediastinoscopy were excluded from thoracotomy, but 10 cases underwent a resection after neoadjuvant radio-chemotherapy. The surgical procedures were pneumonectomy (106), lobectomy (146) and atypical resection (8) with ipsilateral mediastinal lymphadenectomy. Resection was complete in 236 patients (84.8%) and incomplete in 42 patients (15.2%). Postoperative mortality was 3.2%. Almost all patients received radiotherapy after surgery. Actuarial 5-year survival was 13.7% for the entire group and 18.5% for the patients who underwent curative resection; no patients survived 5 years after palliative resection (p < 0.05). There were no differences with regard to prognosis according to the histology of the tumors and to surgical procedures. A better prognosis is associated with: completeness of resection, involvement of only one level, low T classification. Five-year survival rate of patients with metastases only in upper mediastinum was 25%; on the contrary 5-year survival rate of patients with metastases in the lymph nodes of the lower mediastinum was only 8% (p < 0.05). In our opinion better results among the patients with metastases in the upper mediastinum depends on the selection obtained with mediastinoscopy.(ABSTRACT TRUNCATED AT 250 WORDS)

[HRT: state of the art]. / HRT: lo stato dell'arte.

Hormone replacement therapy (HRT) in postmenopause represents the most advanced frontier of preventive medicine in a rapidly evolving society that aims to emphasise, today as in the past, the leading role of women. While modern medicine has extended the average life expectancy of women today, it is now the task to enhance the quality of these extra years. HRT prevents cardiovascular disease, osteoporosis, disorders relating to changes in pelvic connective tissue and genitourinary tissues, and it can also have a positive influence on the psycho-affective sphere and, perhaps, alterations in cognitive capacity. Cultural delays and alternate phases of optimism and alarm are not always backed by solid scientific knowledge. Epidemiological research over the past years has underlined the oncological risk of using estrogens, even if associated with progestin, without the necessary methodological clarity and efficacy. From the data reported in the international literature and on the basis of over ten years experience accumulated at Department B of Gynecology and Obstetrics of Turin University, it appears that the oncogenic risk in women taking HRT is not significantly higher if the indications are strictly respected and, when necessary, progestin is associated with estrogen.

[Congenital hepatic fibrosis in pregnancy]. / Su un caso di fibrosi epatica congenita in gravidanza.

The purpose of this study was to analyse the course of pregnancy of a 20-year-old woman suffering from congenital hepatic fibrosis (CHF), a genetic disease with recessive autosomic transmission, attributed to the group of hepato-nephro-pancreatic fibropolycystic familial diseases. This was the only time such a case had ever been encountered in a pregnancy in the history of Turin University's Obstetrics and Gynaecological Clinic. The case of a 20-year-old woman is considered. She was admitted to our observation at the Obstetrics and Gynaecological Department of Faculty "B" of the University of Turin, suffering from CHF, a primigravid in the eighth week of gestation. Haematochemical tests carried out on the patient showed a platelet deficiency without evident changes in liver and renal function. Objective examination revealed a slight hepatosplenomegaly confirmed by abdominal echotomography. The haematochemical examinations subsequently carried out confirmed thrombocytopenia due to hepatosplenic hyperhaemocataresis. In agreement with the will of the patient and her family, and after having heard the opinion of our hospital's anaesthetists and internists, a conservative approach was decided on and close monitoring of maternal and foetal conditions was planned, with hospitalisations scheduled for every fortnight. Together with the internists and anaesthetists, it was decided to allow the pregnancy to proceed as far as foetal maturity but not to term, to avoid problems relating to the excessive increase in uterine volume which would have led to pressure on the portal tree and so favoured haemorrhaging due to rupture of the oesophageal varices. Caesarean delivery was planned for the 37th week of gestation. The birth went according to plan and the foetus was a live, vital male with Apgar index of 9/9. The placenta presented normal characteristics and a weight of 590 g. No haemorrhagic complications were observed either in the course of surgery or in the postoperative phase, notwithstanding the preoperative finding of a platelet count of 64,000 platelets/ mm3. Although in our case neither the pregnancy nor the delivery constituted a serious danger for the life of the mother, possible obstetric complications are among the most serious encountered in obstetric pathology and can lead both to maternal death and to the intrauterine death of the foetus. For these reasons we believe it essential to provide correct, clear and adequate information about the risks involved for patients suffering from congenital hepatic fibrosis, especially if they are associated with renal polycystic disease, and who are admitted to our wards with the desire to programme a pregnancy.

[Results of surgical treatment of lung metastases from colorectal cancers]. / Résultats du traitement chirurgical des métastases pulmonaires des cancers colo-rectaux.

OBJECTIVE: The aim of this work was to determine the long term results and the prognostic factors after surgical resection of pulmonary metastases from colorectal cancers. METHODS: Clinical status after surgery and survival were studied in 101 consecutive patients undergoing lung resection for pulmonary metastases from colorectal carcinoma between 1970 and 1993. Prognostic factors were evaluated according to surgical design. Mean interval between colon resection and lung resection was 44 months. Fifty-nine patients had a solitary lesion, 17 had multiple unilateral lesions and 25 multiple bilateral lesions. Eighteen patients had undergone previous surgery for localized extrapulmonary metastases. A wedge resection was performed in 47 patients, lobectomy or bilobectomy in 40, pneumonectomy in 11 and biopsy in 3. RESULTS: There was no postoperative mortality and 5-year survival in complete resection was 21%; all patients with incomplete resection or biopsy died within 3 years. Significant prognostic factors were: complete resection, metachronous disease (vs synchronous metastases) and absence of lymph node involvement. The extent of the colorectal disease and the number of resected metastases did not influence prognosis. Survival for patients with resected extrapulmonary disease was not significantly different as compared with patients with only pulmonary metastases. Eleven patients had repeat pulmonary resections, 6 of these patients are currently alive, 3 of them more than 3 years after the second pulmonary resection. CONCLUSIONS: We conclude that resection of colorectal lung metastases is safe and effective, that resectable extrapulmonary disease does not contra-indicate pulmonary resection and that repeat thoracotomy is warranted in selected patients with recurrent lung metastases.

[Hamartochondroma of the lung. Apropos 11 cases]. / L'amartocondroma del polmone. A proposito di 11 osservazioni.

The authors take the opportunity of 11 cases of pulmonary hamartomas observed during the last 10 years, to specify the clinical and diagnostic problems and the therapeutic possibilities of this rare pulmonary neoplasm. The hamartochondroma is found mainly in the male sex, between the age of the fifth and sixth decades of life; the size of the neoplasm varies from 2 to 4 cm, rarely exceeding 10 cm. In 8 cases the operation was the simple enucleation of the hamartochondroma or its removal by atypical resection: in only one case, become of the conspicuous dimensions of the neoplasm, was it necessary to perform a typical lobectomy. The follow-up did not demonstrate any relapse, or the appearance of carcinoma of the lung in any of the cases under observation and surgically treated.

[Intrathoracic hemangiopericytoma localized in the mediastinum]. / L'emangiopericitoma intratoracico a localizzazione mediastinica.

The paper reports a case of intrathoracic hemangiopericytoma localised in mediastinum which was brought to the authors attention and treated surgically. Having analysed the tumour's macro- and microscopic histological and biological features and the most suitable methods of diagnosis, the authors stress that, in line with international literature, radical surgery extended to the surrounding tissues is the elective surgical treatment for hemangiopericytoma in a mediastinal site.

[Bilateral adrenal pheochromocytoma. A clinical case and review of the literature]. / Feocromocitoma surrenalico bilaterale. Caso clinico e revisione della letteratura.

The authors present a case of bilateral adrenal pheochromocytoma that occurred at their observation and surgically treated with a bilateral adrenalectomy. The authors review the literature in order to discuss the diagnostic and therapeutic option to treat these cases. They stress the importance of preoperative abdominal TC an MIBG scintigraphy and the importance of pre and intraoperative assessment to exclude extra adrenal localization of pheochromocytoma.

[Thoracic neurinoma: a case of a giant neurinoma]. / Il neurinoma endotoracico: a proposito di un caso di neurinoma gigante.

Having observed 6 cases of benign tumours deriving from nerve sheaths, one of which was of exceptional size (19 x 11 x 10 cm), with an endothoracic localization over the past 5 years, the Authors analyse the etiopathogenetic problems, anatomo-clinical symptoms and the possible methods of treating these endothoracic tumours. Neurinomas represent between 60 and 70% of mediastinal neurogenic tumours which account for 20% of all cancers of the mediastinum. Their typical localization is the posterior mediastinum, along the paravertebral grooves, and the dimensions of these tumours vary between 3 and 8 cm, although on rare occasions they reach 15 cm. In all cases except that of the giant neurinoma, surgery took the form of straightforward enucleation. Follow-up has not revealed recidivation in any of the cases operated.

[Pleuro-pericardial cysts. Case reports and clinical-diagnostic as well as therapeutic considerations]. / Le cisti pleuro-pericardiche. Contributo casistico e considerazioni clinico-diagnostiche e terapeutiche.

Three patients with pleuropericardial cysts are reported. The authors accoding to what exists in literature confirm the congenital origin of this relatively rare pathology. It is benign and rapresents 6-19% of all mediastinal neoplasms. This lesion is more common in adults and prefer IV-VI decade of life. Usually this cyst constitute a casual radiological report because most of these tumours are asymptomatic. In our experience only one case was characterized by dyspnea. The authors, besides, consider CT of great help in diagnosis of pleuropericadial cyst in view of its high specificity. Thoracoscopy, result very important to diagnosis and exeresis of this neoplasm when doubts no persist as to the true nature of the lesion. Surgical treatment of pleuropericadial cyst is the only therapy. In our experience thoracotomy was preferred with excellent results and no postoperative complications or recurrences.

[Spigelian hernia: apropos of two cases]. / L'ernia di Spigelio: a proposito di due casi.

Two observed cases of spigelian hernias in 54 years and 62 years old men leads to an analysis of the diagnostic clinical and therapeutic aspects of this rare abdominal pathology. It represents 1-2% of all abdominal hernias and can occur anywhere along the semicircular line of Douglas, but in 90% of cases its most frequent localization is from the level of the umbilicus to the inguinal area. Diagnosis can be difficult because of non-specificity of symptoms. Many times Spigelian hernia is masked by abdominal fat and the only symptom is pain. TAC plays a primary role in the diagnosis of spigelian hernia, infact with it, detailed characteristiques and location of the hernia, hernial content, other intra-abdominal pathology, are recognized. The only treatment of spigelian hernia is surgical; many times it is diagnostic and therapeutic. A pararectal skin incision permits an accurate exploration of the abdominal cavity and an cautious choice of aponeurosis to the plastic repair.

[Efficacy of continuous intercostal analgesia versus epidural analgesia on post-thoracotomy pain]. / Efficacia del blocco analgesico intercostale continuo versus l'analgesia epidurale nel dolore post-toracotomico.

The authors compare the efficacy of epidural morphine analgesia with continuous intercostal extrapleural block using bupivacaine 0.5% after thoracotomy. They affirm that antalgic treatment in thoracotomised patients is the most important factor in preventing the onset of major complications that may negatively influence the results of surgery. The efficacy of the analgesic techniques examined was evaluated using El-Baz's visual analogic scale of pain, through the analysis of spirometric values and on the incidence of postoperative complications. The authors demonstrate that the extrapleural continuous nerve block is a reliable method of post-thoracotomic analgesia.