Prevalence and incidence of osteoporotic fractures in patients on long-term glucocorticoid treatment for rheumatic diseases: the Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) study.

Osteoporosis and fractures are common and invalidating consequences of chronic glucorticoid (GC) treatment. Reliable information regarding the epidemiology of GC induced osteoporosis (GIOP) comes exclusively from the placebo group of randomized clinical trials while observational studies are generally lacking data on the real prevalence of vertebral fractures, GC dosage and primary diagnosis. The objective of this study was to evaluate the prevalence and incidence of osteoporotic fractures and to identify their major determinants (primary disease, GC dosage, bone mineral density, risk factors, specific treatment for GIOP) in a large cohort of consecutive patients aged >21 years, on chronic treatment with GC (≥5 mg prednisone - PN - equivalent) and attending rheumatology centers located all over Italy. Glucocorticoid Induced OsTeoporosis TOol (GIOTTO) is a national multicenter cross-sectional and longitudinal observational study. 553 patients suffering from Rheumatoid Arthritis (RA), Polymyalgia Rheumatica (PMR) and Connective Tissue Diseases (CTDs) and in chronic treatment with GCs were enrolled. Osteoporotic BMD values (T score <-2.5) were observed in 28%, 38% and 35% of patients with CTDs, PMR or RA at the lumbar spine, and in 18%, 29% and 26% at the femoral neck, respectively. Before GC treatment, prevalent clinical fractures were reported by 12%, 37% and 17% of patients with CTDs, PMR, or RA, respectively. New clinical fragility fractures during GC treatment were reported by 12%, 10% and 23% of CTDs, PMR and RA patients, respectively. Vertebral fractures were the prevailing type of fragility fracture. More than 30% of patients had recurrence of fracture. An average of 80% of patients were in supplementation with calcium and/or vitamin D during treatment with GCs. Respectively, 64%, 80%, and 72% of the CTDs, PMR and RA patients were on pharmacological treatment for GIOP, almost exclusively with bisphosphonates. The GIOTTO study might provide relevant contributions to clinical practice, in particular by highlighting and quantifying in real life the prevalence of GIOP and relative fractures, the frequency of the main risk factors, and the currently sub-optimal prevention. Moreover, these results emphasize the importance of the underlying rheumatic disease on the risk of GIOP associated fractures.

Epidemiologic and clinical profiles of bacterial myocarditis. Report of two cases and data from a pooled analysis.

We aimed to characterize the epidemiology, diagnostic peculiarities and outcome determinants of bacterial myocarditis. Two cases from our institution and literature reports were collected ending up with a total of 66 cases. In 37 (56%) patients, the diagnosis was confirmed by magnetic resonance and histopathological criteria. The other patients were classified as having possible myocarditis. Only occurrence of rhythm disturbances was associated with the specific diagnosis of myocarditis (p = 0.04). Thirty-two (48%) patients presented with severe sepsis that was associated with a worse prognosis. At multivariate analysis, left ventricular ejection fraction (LVEF) at admission and heart rhythm disturbances were associated with incomplete recovery (odds ratio (OR) 1.1, 95% (CI) 1.03-1.2, p = 0.004 and OR 6.6, 95% CI 1.35-32.5, p = 0.02, respectively). In summary, bacterial myocarditis is uncommon. Most commonly, it is secondary to septic dissemination of bacteria or to transient secondary myocardial toxicity.

Anomalous water dynamics in brain: a combined diffusion magnetic resonance imaging and neutron scattering investigation.

Water diffusion is an optimal tool for investigating the architecture of brain tissue on which modern medical diagnostic imaging techniques rely. However, intrinsic tissue heterogeneity causes systematic deviations from pure free-water diffusion behaviour. To date, numerous theoretical and empirical approaches have been proposed to explain the non-Gaussian profile of this process. The aim of this work is to shed light on the physics piloting water diffusion in brain tissue at the micrometre-to-atomic scale. Combined diffusion magnetic resonance imaging and first pioneering neutron scattering experiments on bovine brain tissue have been performed in order to probe diffusion distances up to macromolecular separation. The coexistence of free-like and confined water populations in brain tissue extracted from a bovine right hemisphere has been revealed at the micrometre and atomic scale. The results are relevant for improving the modelling of the physics driving intra- and extracellular water diffusion in brain, with evident benefit for the diffusion magnetic resonance imaging technique, nowadays widely used to diagnose, at the micrometre scale, brain diseases such as ischemia and tumours.

Extra-intracranial arterial bypass in typical carotid reversible ischaemic deficits: long-term follow-up in 100 patients.

The long-term follow-up of 100 consecutive patients who suffered from a reversible ischaemic attack (RIA) in the carotid territory and were submitted to extra-intracranial arterial bypass (EIAB) surgery in seven Italian Neurosurgical Centres is reported. The preoperative angiographic and clinical features, and the surgical complications are reported. The follow-up ranged from two to seven years with a mean of thirty-five months. In this period in the territory served by the bypass only two completed strokes and six RIAs occurred. Four patients died, only one for cerebral ischaemic problems. The results of the present series have been compared with those of the literature: they appeared consistent with other surgical series and clearly better than those of medical treated patients. The EIAB can then be considered a good therapeutic choice for the treatment of RIAs in carotid territory.

Long-term follow-up in 257 ICA occlusion: comparison between EIAB-treated and untreated patients.

The purpose of this paper is to estimate the real value of the Extra-Intracranial Arterial Bypass (EIAB) in preventing or reducing further and more catastrophic ischaemic events in patients suffering from an Internal Carotid Artery (ICA) occlusion. 257 patients, suffering from ICA occlusion, are considered retrospectively: 122 of them submitted to EIAB and 135 medically treated or untreated. In both groups, homogeneous by sex, age, neurological grading distribution and length of follow-up, the following parameters were considered: the incidence of ischaemic recurrences during the follow-up period; the characters of the recurrences with particular reference to the fatal stroke; the rate of ischaemic events per year. The comparison between the outcome in surgically treated patients and in "untreated" ones indicates that the EIAB can be effective in preventing or reducing the ischaemic recurrences and the frequency of fatal stroke in TIA-, RIND, or stroke-patients suffering from ICA occlusion.

Fatal septicaemia due to Listeria monocytogenes in a patient with systemic lupus erythematosus receiving cyclosporin and high prednisone doses.

Cyclosporin A is widely used in organ transplantation, preventing the rejection of multiple types of organ allografts. It is also being increasingly used as an immunosuppressive agent to treat various autoimmune diseases in patients refractory to more commonly used immunosuppressive therapy. Several trials are currently evaluating the utility of this drug associated with corticosteroids in the treatment of systemic lupus erythematosus. This case, describing a lethal septicaemia caused by Listeria monocytogenes in a patient receiving this treatment, seems to indicate that the use of these "cocktails" of immunosuppressive drugs should be particularly cautious to prevent fatal infectious complications.

Femoral nerve palsy secondary to anticoagulant induced iliacus hematoma. A case report.

A case of femoral neuropathy from iliac muscle hematoma occurring in a patient treated with urokinase, subcutaneous heparin and aspirin for myocardial infarction is reported. Diagnosis of this complication was suspected on the basis of clinical signs and on the fact that the patient had received anticoagulants. Computed tomography allowed direct and clear visualization of the hematoma. Anticoagulant suspension followed by an early surgical decompression seems to be the ideal treatment for this neuropathy; however, our patient died for a reinfarction after stopping heparinic administration. This may indicate that, in some patients "at risk", it is better to reduce rather than stop anticoagulant therapy.

[Infection and digestive bleeding: late complications of aortofemoral bypass surgery]. / L'infezione ed il sanguinamento digestivo, complicanze tardive dell'intervento di by-pass aorto-femorale.

Graft-enteric fistulas and (the most uncommon) graft-enteric erosions are feared complications of aortic reconstructive surgery and infection and hemorrhage are their major clinical manifestations. A case considered unusual due to the simultaneous presence of two graft-enteric erosions: duodenal and sigmoid is reported. The first erosion was revealed by endoscopy performed for gastrointestinal bleeding. The role played by infection and mechanical factors in the pathogenesis of these complications is then discussed.

[A rare case of recurrent meningitis: intranasal encephalocele]. / Una rara causa di meningiti recidivanti: l'encefalocele intranasale.

Intranasal meningoencephalocele is a rare malformation characterized by a protrusion of brain tissue and meninges out of the cranial cavity into the nose, through a discontinuity of the ethmoidal cribriform plate. It is a congenital anomaly but it may be also due to trauma or to chronic intracranial hypertension. It is clinically apparent as a small mass that may be confused with nasal polyp. A cerebrospinal fluid leakage may be present. In a few cases it gives no symptoms until adulthood, but usually recurrent meningitis may occur. A case of young woman with intranasal encephalomeningocele who suffered from 18 episodes of meningitis is reported. Nevertheless she is at present without neurological consequences.

[Acute gastric volvulus]. / Il volvolo gastrico acuto.

Gastric volvulus is an uncommon condition in which a torsion of the stomach results in acute or chronic gastrointestinal symptoms. We report a case of an intrathoracic organo-axial gastric volvulus secondary to a hiatal hernia. The patient died after surgery. Even though it was a surgical emergency, the patient was admitted to a Medical Department because she was regularly examined by the Digestive Endoscopy Unit for a hiatal hernia. The Authors emphasize the contribution of endoscopy to the preoperative recognition of this condition.

A localized pleuropulmonary lesion induced by long-term therapy with amiodarone.

Pulmonary toxicity is an important adverse effect of amiodarone therapy that usually manifests as an acute or chronic diffuse lung disease; in rare cases localized lesions have also been described. We observed a solitary mass localized in the left lung base and involving the adjacent pleura in a 69-year-old man who had been treated for 1 year with amiodarone (cumulative dose 52 g). Cytological and histological examination showed that the lesion consisted of fibrotic tissue and a massive macrophagic infiltration. Following suspension of amiodarone and surgical excision, there was a complete recovery and the mass did not relapse. We confirm that respiratory complaints can occur in patients treated by long-term amiodarone therapy and that lung involvement can manifest with a solitary localized (fibrotic) lesion.

Lytic bone lesions and polyarthritis associated with acne fulminans.

We describe a case of a male teenager, affected by acne fulminans. He had lytic bone lesions in both clavicles and arthritis of the right sacroiliac joint and spine. A bone scan showed increased uptake in these areas. Infection or a neoplastic disease was suspected but the cytological examination and the bacterial cultures of the material collected with a fine needle biopsy from the clavicular lesion were negative. The patient was treated with diclofenac and promptly recovered. Our report emphasizes that, although unusual, acne fulminans can be complicated by an erosive systemic arthritis and bone lesions. An immunological mechanism seems to be involved in this association.

Lymphocytic clusters in peripheral blood: an atypical morphologic pattern of chronic lymphocytic leukemia.

A case of chronic lymphocytic leukemia is described in which peripheral blood and bone marrow films showed lymphocytes arranged in aggregates resembling epithelial cell clusters. Due to this morphological conformation, automatic hemogram screening was not able to detect the presence of chronic lymphocytic leukemia. Correct interpretation of a typical histogram pattern led to the final diagnosis.

Recurrent bacterial meningitis occurring five years after closed head injury and caused by an intranasal post-traumatic meningo-encephalocele.

A case of atypical presentation of a post-traumatic intranasal meningo-encephalocele is described in a patient with a history of recurrent bacterial meningitis occurring 5 years after closed head injury. The usefulness of the CT and MRI findings in diagnostic evaluation of this lesion is emphasized.

Humoral response to subcutaneous, oral, and nasal immunotherapy for allergic rhinitis due to Dermatophagoides pteronyssinus.

We investigated variations in total IgE, and specific IgE, IgG, and IgG4 for Dermatophagoides pteronyssinus in 57 patients with perennial rhinitis due to house dust mite allergy in an open controlled study: 43 subjects received immunotherapy (17 subcutaneous, 14 sublingual, and 12 local immunotherapy) and 14 were controls. The results were compared with the clinical course to determine possible associations between serum and clinical changes. Subcutaneous, but not sublingual and nasal, immunotherapy induced a significant clinical benefit (P < .001). Specific antibody behavior in patients receiving subcutaneous immunotherapy was similar to literature reports. Specific IgE levels fell starting from the 6th month of therapy, and specific IgG and IgG4 levels rose significantly, but there was no correlation with the clinical course. The other two forms of immunotherapy did not induce significant specific antibody modifications. We conclude that the specific IgG4 rise induced by subcutaneous immunotherapy was the most important variation observed. This change, however, was not correlated with the clinical outcome.

[Acute rhabdomyolysis, myoglobinuria and renal insufficiency caused by ethanol: review of the literature and description of a clinical case with fatal outcome]. / Rabdomiolisi acuta, mioglobinuria ed insufficienza renale da etanolo: revisione della letteratura e descrizione di un caso clinico ad evoluzione infausta.

Several studies demonstrated that alcohol can induce both chronic and acute myopathy with myoglobinuria. Acute rhabdomyolysis is commonly followed by a renal failure (R.F.) of variable degree. The Authors report a case of rhabdomyolysis induced acute R.F. in a chronic alcoholic young man. The patient died in irreversible shock. Early diagnosis of the disease seems to be important, because early treatment can prevent acute myoglobinuric R.F.

Painless giant cell thyroiditis.

We describe an atypical case of subacute thyroiditis affecting a 50 year old patient with long lasting fever, weight loss, malaise and a high erythrocyte sedimentation rate. Cytological examination of the thyroid gland showed the classic granulomas with giant cells. However, the patient had neither painful enlargement of the gland nor thyrotoxicosis. This case, as well as others previously described, probably represents a new subtype of subacute thyroiditis, painless giant cell thyroiditis. The presence of painless giant cell thyroiditis should be considered in any patient with undiagnosed pyrexia, weight loss and elevated ESR.