A case of supracondylar humerus fracture with vascular impairment. Open it up?

Supracondylar humerus fracture is one of the most frequent fractures in childhood. A serious complication is an injury to the neurovascular structures which could potentially result in severe functional impairment. We are presenting the case of a 3-year-old girl with a supracondylar humerus fracture in our emergency department and highlight the diagnostic and therapeutic steps in managing this situation. Initially, the hand was well perfused but showed to be pulseless in the operating theater after preparation for surgery. After open reduction and internal pin fixation the neurovascular structures were explored and the brachial artery was repaired by means of a cephalic vein graft. On follow up the patient presented with normal hand function and without vascular or neurologic deficits. As concomitant vascular injuries after supracondylar humerus fractures are rare, it can be difficult to discriminate a pink pulseless hand from a patient with essential vascular injury. Our case also demonstrates the need for short-term reevaluation of the clinical status. When in doubt there should be no hesitation to perform open surgery and vascular repair.

Predictors of short-term survival after helicopter rescue.

The purpose of the present retrospective study was to identify easily obtainable predictors of short-term outcome for emergency victims treated by a physician-staffed helicopter emergency medical system (HEMS). The study was conducted at the HEMS unit 'Christophorus 1' based at Innsbruck, Austria. Outcomes for 2139 patients rescued in primary missions during a 3-year period from 1 January 1989 to 31 December 1991 were included in the study. The majority of missions were in response to sports accidents, although missions included a wide spectrum of emergencies. Data were obtained from the 'Christophorus 1' operation protocols and by written, personal, or telephone request from admitting hospitals. Eleven parameters selected from the HEMS flight logs were tested for their predictive value on survival following helicopter rescue. In a univariate analysis, the cause of the emergency, time at the scene, total duration of the emergency mission, patient age, patient gender, severity of the emergency using the National Advisory Committee of Aeronautics (NACA) scoring system, state of consciousness, respiratory status and patient circulatory status each had a statistically significant influence on survival up to 90 days following the emergency. Flight time to the scene and the original specialty of the additionally trained emergency physician had no significant influence on outcome. Multivariate analysis using the Cox proportional hazards model revealed that severity of the emergency by the seven-level NACA scale (P = 0.0001), initial respiratory status (P = 0.0001), time at the scene (P = 0.0108), patient age (P = 0.0047) and patient gender (P = 0.0477) were each independent predictors of short-term survival following physician-staffed helicopter rescue. We conclude that the parameters described above can be used in an initial predictive assessment by the flight physician and the admitting institution.

[Intracavitary echography with a 12.5 MHz microprobe: a new study method in the pathology of the urinary tract]. / Ecografia endocavitaria con microsonda rotante da 12.5 MHz: una nuova metodica di studio delle patologie dell'apparato urinario.

Endoluminal sonography performed with 12.5 MHz miniature transducer-containing catheters with diameter of 6 or 9 Fr., is a new technique for the study of urinary tract. We studied: U.S. scan of 10 corpes and 10 operatory specimens (bladders and kidneys) with anatomic measurement in vitro. U.S. scan of 20 patients "in vivo" with pathologies involving bladder and upper urinary tract. We studied the normal anatomy of bladder and ureter by U.S. and we detected the structures beyond the ureteral lumen as: vessels, lymph nodes, muscle. Our indications for the utility of this new U.S. technique are: Detection and staging of superficial T.C.C. of the bladder. Detection of dangerous vessels near the U.P.F before endopielotomy. Excretory tract minus (endoluminal ultrasound is helpful in differentiating such pelvic filling defects as blood clots, no opaque stones and transitional cell carcinoma).

[Pathology of urologic importance associated with acquired immunodeficiency syndrome]. / Patologia di interesse urologico associata a sindrome da immunodeficienza acquisita.

Infection by the HIV virus affects the urogenital system in a minor percentage of cases in comparison to other organs such as the lungs, the central nervous system and the haemolymphopoietic system. In recent years however, with the continued spread of the disease also urologists find themselves dealing with the various urogenital pathologies that are presented in seropositive or fully-blown Aids patients. The Authors present their experience and describe the problems correlated to the dealing with acquired immune deficiency syndrome patients that are affected with urogenital pathologies.

[Radical prostatectomy: comparison of technics]. / Prostatectomia radicale: tecniche a confronto.

From 1989 until today 46 patients aged 44-75 years underwent a radical prostatectomy two of whom transperineal and another 44 patients underwent a retropubical prostatectomy (twenty of whom with the nerve sparing technique). Based on our experience, the clinical stages that benefit from a radical prostatectomy as are as followed: T1b, T1c, T2a, T2b; T2c, in patients who present a good A.S.A., a remaining life-span of ten years is expected. Our preference, regarding the best access was clearly the traditional retropubical which allowed us on a preliminary bases a bilateral iliaco-otturatorial lymphoadenectomy with extemporaneus histological exams. Based on our experience we do not see an indication for a radical surgical intervention in the following with: P.S.A. higher than 60 ng./ml in patients with a clinical stage C. Positive abdominal-pelvical computer tomography for macrometastical lymph nodes. Positive bone scintigraphy. Patients over the age of 75 years.

Surgical classification of renal calculi.

A classification of renal calculi is presented. 'C' describes the morphology, size and topography of the stone in five descriptive categories; the letters 'P', 'S', 'M', 'I' indicate the pelvis, the superior, middle and inferior calices, respectively, and complete the topographic description. The letter 'E' stands for the excretory tract; the symbols + and - are added to indicate the presence or absence of dilatation and the small letters e and i indicate the intra- and extrarenal position of the pelvis. 'R' points out the number of surgical recurrences. In conclusion, the letter 'P' indicates the functional status of the parenchyma, and the numbers 1, 2, 3 refer to a normally functioning kidney; moderate renal insufficiency, or serious renal insufficiency. 'U' symbolizes a solitary anatomical or functional kidney.

[New surgical classification of renoureteral lithiasis]. / Nueva clasificación quirúrgica de la litiasis renoureteral.

The authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p", "s", "m", "i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize a stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters, "l", "i", "p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract: "+" and "-" indicate the presence or absence of dilatation; the small letters "e", "i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3 refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.

[Recurrence of acute lymphoid leukemia in the bladder: a rare cause of bilateral hydronephrosis]. / Recidiva di leucemia linfoide acuta a livello vescicale: una rara causa di idronefrosi bilaterale.

While the invasion of the bladder by neoplastic cells during acute lymphatic leukaemia in children has been reported by various authors, the leukaemic invasion of the bladder in adults is extremely rare. We report a case of recurrence of A.L.L. in the bladder presenting colicky symptomatology and obstruction of the excretory tracts.

Long-term results of intrarenal surgery for branched calculi: is such surgery still valid?

OBJECTIVE: To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy. PATIENTS AND METHODS: Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex surgery for large stones, requiring opening of the renal pelvis and a transparenchymal approach to the calices; 47 renal units were operated in 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abdominal plain X-ray (44 patients), intravenous urography (42) and isotopic renography with renal scintigraphy (five). Renal lithiasis was categorized and all patients underwent extended pyelolithotomy with a transparenchymal approach, achieved by partial nephrectomy (six patients), radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segmentotomy and reconstruction (2); 16 operations were performed under ischaemia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (42), IVU (34), isotopic renography (eight), renal ultrasonography (eight) and blood pressure measurement (44). The mean follow-up was 14.8 years. RESULTS: The major postoperative complications were; residual stones (six patients), fistula with ureteric stenosis (one, with a permanent nephrostomy), toxic temporary hepatic failure (one), femoral arterial embolism (one, resolved using a Fogarty catheter) and recurrent large stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 patients had recurrent stones and two underwent dialysis. In October 1996, the renal function of 47 renal units was stable or normal in 36 (77%), reduced in seven (15%) and lost in four (8%); 24 patients were hypertensive (12 preoperatively), nine have urinary tract infection, three are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units. CONCLUSIONS: Intrarenal surgery, conducted using modern anatomical guidelines, was an effective treatment for renal branched stones. The long-term results are satisfactory after appropriate correction of the urinary tract, with the consequent prevention of stasis and chronic infection. The definitive comparison between surgical and combined endoscopic/extracorporeal methods will only become clear when there is a comparable follow-up. Currently, surgery remains preferable in patients with giant calculi, a small pelvis and prevalent calyceal development.

[The EDAP LT and the M.P.L. 9000. Results of the treatment of reno-ureteral lithiasis]. / EDAP LT 01 e M.P.L. 9000. Risultati nella terapia della litiasi reno-ureterale.

The advantages and disadvantages of piezoelectric lithotripsy are discussed with specific analysis of the EDAP LT 01. A description of the EDAP LT 01 is included. Installation, accommodation, and maintenance features are discussed. The Dornier M.P.L. 9000 represents a third-generation lithotripter for both kidney and gallbladder stones with an ultrasound localization system tubules shock-wave coupling. The use of TH M.P.L. 9000 was limited by ultrasound-guided localization of kidney stones, upper ureteral calculi causing obstruction, and intramural lower ureteral stones.

MIB1 in colorectal carcinomas: its evaluation by three different methods reveals lack of prognostic significance.

Immunohistochemically detected MIB1 has been determined in a series of 106 colorectal carcinomas with three different evaluation methods (semiquantitative estimation, evaluation by image analysis, and cell count). Although the semiquantitative estimation correlated significantly with results obtained by image analysis (R = 0.8), both methods were only poorly associated with MIB1 counts (R = 0.5). Additionally, all three methods revealed no statistical correlation of MIB1 with the clinical outcome of the respective patients. Our results indicate a pronounced heterogeneity of MIB1 in colorectal adenocarcinoma, thus leading, irrespectively of the evaluation method used, to non-representative results with lack of clinical relevance.

[Complications and limitations of endoscopic therapy for urethral stenosis]. / Complicanze e limiti della terapia endoscopica delle stenosi dell'uretra.

Endoscopic treatment of urethral stenosis is not an alternative to surgical therapy but is an ideal therapeutical partner. The limits of endoscopic resection lie in the lack of anatomopathologican and clinical knowledge regarding the long-term maintenance of stability of the urethral lumen that in every case the internal urethrotomy manages to create. In fact internal urethrotomy is capable of almost totally eliminating the urethral stenosis but with a higher incidence of relapse, even in the short-term. The complications of endoscopic therapy of urethral stenosis are the usual local complications and of mild seriousness. Among the most frequently noted are the swelling and/or peno-scrotal suffusion by incorrect routes, and post-operative urethraemorrhagia. More rarely, but with serious effects, are purulent urethritis or sepsis. In our case list major complications such as priapism, cavernositis or septic shock were not noted. In conclusion endoscopic therapy of urethral stenosis is a simple technique, repeatable with low morbidity and is the best technique in the congenital 'ring'.

[Neoadjuvant chemotherapy using cisplatin (CDDP) and methotrexate (MTX) in carcinoma of the bladder]. / Chemioterapia neoadiuvante con cisplatino (CDDP) e methotrexate (MTX) nel carcinoma della vescica.

From June 1986 to November 1989, 7 patients (pts.) with transitional bladder cancer were treated with CDDP 70 mg/m2 i.v. on day 1 and MTX 40 mg/m2 i.v. on days 8 and 15. The initial stage was T2 N0 M0 (2), T2 N0 M0 (8), T4 N0 M0 (4) and T3-4 N+ M0 (3). The median age was 56 years. After a median number of two cycles (1-5) of CDDP-MTX, 3/17 pts. (17.6%) had a complete remission (CM), 9/17 pts. (53%) a partial response (PR) greater than 50%, 4/17 pts. (23.4%) a PR less than 50%, 1/17 pts. (6%) a stable disease. Nausea and vomiting occurred in almost all pts., 20% of pts. had grade 3 stomatitis, 35% of pts. had diarrhoea, 20% of pts. had conjunctivitis, 7% of pts. had a bone marrow depression and hair loss. One patient had severe renal and liver toxicity and grade 4 bone marrow suppression with sepsis, completely controlled after intensive care. The treatment after neoadjuvant chemotherapy was: radical cystectomy (11)- in one following radiotherapy -; partial resection + lymphoadenectomy (2); TUR (4) in 1 pt. with lymphoadenectomy. After a median follow-up of 28 months (6-36), 12/17, equivalent to 71% of pts. are disease free, 3/17 (17%) are alive with disease, 2/17 (12%) died. In conclusion the association of neoadjuvant CDDP-MTX can induce a high percentage of response, and can preserve bladder function in some patients. Further controlled trials and a longer follow-up are needed to better define the exact role of this combination in terms of disease free survival, total survival and quality of life.

[A new classification of reno-ureteral lithiasis]. / Nuova classificazione della litiasi reno-ureterale.

The Authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p, s, m, i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters "l, i, p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract; "+" and "-" indicate the presence or absence of dilatation, the small letters "e, i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3, refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.

[Prognostic parameters in extracorporeal lithotripsy]. / Parametri prognostici per la litotrissia extracorporea.

Extracorporeal lithotripsy consists of applying shock waves (electrohydraulic and piezoelectric) from outside the human body, which pass through the body tissues without damaging them breaking down the urinary calculi into particles which can then be automatically expulsed through the excretory tract. The object of this study is to analysis some of the important parameters which affect the success of the extracorporeal lithotripsy. These factors are as follows: 1) type of shock wave: electrohydraulic or piezoelectric, their action mechanism, methods of fragmenting the urolites; 2) the chemical composition of the calculi and its consequential resistance to the fragmented shock waves; 3) Patency, tone and peristalsis of the intra and extrarenal excretory tract for expulsing the urolite particles; 4) general conditions of the urinary apparatus. From the interaction of these 4 variables arise different clinical situations which must be evaluated before operating in order to develop the proper therapeutic subscription for a renal-urethral lithiasis. The current therapeutic procedures for renal-urethral lithiasis are as follows: electrohydraulic and piezoelectric extracorporeal lithotripsy; electrohydraulic waves or ultrasound percutaneous litholapaxy; operative urethroscope; traditional surgery; chemolysis.