[Epidural hematoma after removal of an epidural catheter]

Epidural hematoma is a rare but serious neurological complication of epidural anesthesia. We report the case of a 61-year-old man with squamous cell carcinoma of the lung who suffered an epidural hematoma after undergoing right double lobectomy. Before anesthetic induction an epidural catheter was inserted to the D5-D6 space for postoperative analgesia. Surgery was without noteworthy events and the patient was extubated in the operating room; 5,000 IU of low molecular weight heparin was injected subcutaneously every 24 hours and 5 mg of methadone was provided by epidural catheter every 8 hours. After removal of the catheter three days after surgery, lumbar back pain and hypoesthesia, and weakness in both legs appeared. Epidural hematoma was suspected and treatment with 30 mg.kg-1 of methylprednisolone i.v. was started. Nuclear magnetic resonance imaging of the lumbar spine confirmed the presence of a hematoma at D6-D8. Neurologic symptoms improved in the following hours and additional surgery was not required. The patient was released without neurological symptoms 10 days after lung surgery. We discuss the prevalence, etiology and treatment of epidural hematoma related to epidural anesthesia.

[Indication for spinal anesthesia for cesarean section in HELLP syndrome coagulopathy]

We describe the relation between coagulation and local-regional anesthesia in two women with HELLP syndrome who required emergency cesarean delivery. HELLP syndrome involves hemolysis, elevated liver enzyme levels and thrombopenia complicating the hypertension of pregnancy. Regional anesthesia presents advantages for mother and fetus in this context but also involves the risk of coagulopathy. In the first case we describe, coagulation was normal before surgery and epidural anesthesia was therefore prescribed. The initial epidural puncture was hemorrhagic and a second, higher puncture was made to insert the catheter. Shortly after surgery severe thrombopenia developed and lasted 24 hours; formation of an epidural hematoma caused by vascular lesion during puncture was suspected. The epidural catheter was left in place, and the patient was kept under observation and seen by a neurologist within the first 48 hours. Outcome was good. In the second patient, epidural puncture was contraindicated by the presence of preoperative coagulopathy, and the cesarean was performed without complications under intradural anesthesia provided with low doses of bupivacaine and fentanyl. The coagulopathy that accompanies HELLP syndrome should be assessed not only before taking the decision on anesthetic technique; as the condition can be progressive it can become most severe after the epidural puncture is performed, as shown by the first case we describe. The patient's condition must be watched closely until coagulation becomes normal. Removal of the epidural catheter must wait until coagulopathy is resolved. When coagulopathy is evident before surgery, intradural anesthesia is a safe option provided hemodynamic stability is assured, as demonstrated by the second case we report.

N-ethyl-tauroursodeoxycholic acid, a novel deconjugation-resistant bile salt analogue: effects of acute feeding in the rat

The purpose of this study was to investigate the physicochemical/biological properties and the effects of acute administration of N-ethyl-tauroursodeoxycholic acid in bile-fistula rats. In vitro determination of high-performance liquid chromatography mobility, octanol/ water partitioning, cholesterol solubilizing capacity, and sensitivity to enzyme deconjugation by bacteria and cholylglycine-hydroxylase were performed. In vivo determination of the following was also performed: (1) maximum secretory rate (SRmax) and choleretic/secretory properties during intravenous (IV) administration; (2) site/ extent of absorption, effects on bile flow, lipid secretion, and biotransformations after intraduodenal infusion. N-ethyl-tauroursodeoxycholate has a lipophilicity slightly higher than tauroursodeoxycholate, close to taurocholate, and similar cholesterol solubilizing capacity. Deconjugation of N-ethyl-tauroursodeoxycholate was 3.4 +/- 2.1% after 72 hours, that of tauroursodeoxycholate was 100% after 24 hours. During IV infusion of 300 nmol/min/ 100g, biliary secretion of N-ethyl-tauroursodeoxycholic and tauroursodeoxycholic acids averaged 185 +/- 76 (standard deviation) nmol/min/100 g and 221 +/- 77 nmol/min/ 100 g (not significant). Increasing infusion rates caused progressive enhancement of bile flow and bile salt secretion until the SRmax was reached (1,305 +/- 240 nmol/min/ 100 g for N-ethyl-tauroursodeoxycholic acid and 3,240 nmol/min/100 g for tauroursodeoxycholate). The two bile salts were similarly choleretic. IV feeding of N-ethyl-tauroursodeoxycholic promoted a greater lipid secretion than tauroursodeoxycholate. After intraduodenal feeding of 800 mumol, 38.8 +/- 14.0% and 43.4 +/- 12.4% of the two bile salts were recovered in bile. No unconjugated bile salts nor unusual metabolites were detected.(ABSTRACT TRUNCATED AT 250 WORDS)

Twelve-month omeprazole vs ranitidine in the treatment of Helicobacter pylori positive patients with healed duodenal ulcer

We evaluated the results of a 12-month treatment using different regimens of omeprazole at the dose of 20 mg daily (three day week-end treatments and every other day) and of 150 mg nocte of ranitidine on Helicobacter pylori status and on preventing duodenal ulcer relapses in 140 Helicobacter pylori positive patients with healed duodenal ulcer. Only every-other-day omeprazole suppresses Helicobacter pylori after 3 month therapy (p < 0.001), after 6 months (p < 0.001) and 12 months (p < 0.05). After 3 months (T1) no significant effectiveness was found in the prevention of ulcer relapses by omeprazole and ranitidine. After 6 months (T2) a significant reduction of relapses (p < 0.05) was recorded when comparing every- other-day omeprazole to the weekend regimen. After 12 months every-other-day omeprazole treatment significantly reduced the relapses compared with the week-end therapy (p = 0.05) and with ranitidine (p < 0.05).

[Levosulpiride versus domperidone in the treatment of functional dyspepsia]

Levosulpiride, a dopaminergic antagonist was compared in a double-blind randomized study with domperidone for treatment of functional dyspepsia in 50 patients divided into two groups of 25 subjects each. Group I received 25 mg levosulpiride 3 times daily, group II received 10 mg domperidone 3 times daily, all for 30 days. Periodic clinical examination at days 0, 7, 15, 30 showed symptomatic changes. Gallbladder and gastric emptying was studied by ultrasonography at the start and end of treatment. Both drugs had a positive influence on dyspeptic symptoms and on gastric and gallbladder emptying, but the latter parameters were improved significantly more effectively by levosulpiride. As to tolerability, there have been 3 drop-outs and a further 6 patients complained of sides effects that did not require suspension of treatment.

Octylonium bromide in the treatment of the irritable bowel syndrome: a clinical-functional study

We investigated the effect of octylonium bromide on a number of symptoms and functional aspects of the irritable bowel syndrome. Seventy-two patients complaining mainly of abdominal pain were studied in a double-blind trial (octylonium bromide 40 mg tid for 4 weeks or placebo). Clinical parameters were: abdominal pain, bloating and bowel frequency. Sigmoid manometry with simultaneous recording of the thresholds for distension and/or pain upon graded inflation of an endoluminal balloon was performed before and at the end of treatment. In contrast to placebo, octylonium bromide significantly reduced pain and bloating, and significantly increased (p < 0.02) the pain threshold throughout the treatment period. However, comparison with the placebo group failed to show any relevant differences. Neither treatment influenced the frequency of bowel movement. Sigmoid motility during distension was significantly reduced after octylonium bromide (p < 0.05), but it did not change after placebo. In conclusion, octylonium bromide is capable of reducing symptoms and motor reactivity of the sigmoid in patients with irritable bowel syndrome.

Clinical and functional evaluation of the efficacy of otilonium bromide: a multicenter study in Italy

Seventy-two patients complaining of abdominal pain were studied in a double blind trial with otilonium bromide (OB) (40 mg tid or placebo). In our patients we performed, before and after the treatment, a clinical evaluation (symptom variations) and functional studies (sigmoid manometry during bowel distension). As regards clinical parameters, otilonium bromide significantly reduced abdominal pain and bloating and significantly increased (p less than 0.02) the pain threshold. However the comparison with the placebo group did not show any difference between the two groups. Sigmoid motility during distension was significantly reduced (p less than 0.05) in OB group, whereas it did not change in the placebo group. We can conclude that, in irritable bowel syndrome (IBS) patients, OB is able to improve symptoms and to reduce stimulated motor activity of the sigmoid.

Non-ulcer dyspepsia

Non-ulcer dyspepsia (NUD) includes functional forms, related to secretory and/or motor disorders, but also refers to forms with gastritis and/or duodenitis (erosive or not, Helicobacter pylori positive or not), as well as to idiopathic forms. NUD pathophysiology is multifactorial. Secretory abnormalities, H. pylori infection and in particular digestive and interdigestive disorders of gastrointestinal motility are often detected in NUD patients, but psychological, social and environmental factors can be also involved in NUD pathogenesis. With regard to symptom genesis, there is still no convincing evidence as to whether and to what extent pathogenetic factors have a causal relationship with dyspeptic symptoms. Upper gastro-intestinal endoscopy with biopsies and abdominal ultrasonography must be performed in patients over 45 years complaining of sudden symptoms, in patients under 45 years suffering from symptoms suggestive of severe organic disease and in patients with unexplained worsening of chronic symptoms. Ex adjuvantibus therapy may be employed in the remainder of dyspeptics. Oligosymptomatic dyspepsia needs no pharmacological treatment and in most cases it is enough to advise modifications of dietary habits and life style. Many drugs are usually employed in the pharmacological treatment of severe NUD but only H2-antagonists, pirenzepine and prokinetics are reported to be more effective than placebo. Efficacy of therapy should be checked after 4 weeks of treatment. If no improvement occurs, combined or different therapy might be employed. Treatment should be checked again after 8 weeks: therapeutic failure at this time indicates the need for endoscopic examination.

The development of the sense of self in adolescence

This study attempts to clarify the sense of self that may underlie the adolescent's subjective experience of identity. The initial orientation was provided by descriptions of three different modes of experiencing identity derived from a reanalysis of Loevinger, Wessler, and Redmore's (1970) ego development categories. Our goal was to replicate by a more direct method the Loevinger-derived descriptions. Specifically, we looked at whether the various aspects of the pre-identity mode ("Social Role Identity") and of the early identity mode ("Identity Observed") would in fact form different clusters and whether these clusters would differentiate early and middle adolescent groups. Participants were 24 sixth graders and 24 high-school seniors, equally divided by sex. In individual interviews they were asked questions concerning the main characteristics of the Identity Observed Mode. Six self scales were constructed from subjects' responses. Our two major hypotheses were strongly supported: (a) The two age groups differed dramatically on each of the self scales; and (b) the six self scales highly correlated with each other. Moreover, clusters of responses could be constructed that model the a priori descriptions of identity modes and that sharply separate the two grades.

Ultrasonographic study of the Wirsung duct caliber after meal

The pancreatic duct or at least parts of this structure can be demonstrated today by sonography in 50-82% according to various authors. We have measured the caliber of the sonographically visualized pancreatic duct in 20 normal subjects after physiological stimulation with meal. The mean caliber of the duct markedly increased after meal. During dilatation a longer segment of duct is more clearly visualized. It is possible to document an increase of caliber of Wirsung duct "in vivo" as an evident sign of pancreatic secretion.

A controlled study of 20 mg famotidine nocte vs. 150 mg ranitidine nocte for the prevention of duodenal ulcer relapse

A 24-week, double-blind, randomized study at 13 centres compared the efficacy and safety of 20 mg famotidine nocte and 150 mg ranitidine h.s. for the prevention of duodenal ulcer recurrence. All participants had been successfully treated for an acute duodenal ulcer with 40 mg famotidine nocte. Patients were endoscoped at baseline and at 24 weeks, unless symptoms warranted earlier examination: of the 208 patients enrolled, 86 who received famotidine and 84 who received ranitidine met all protocol criteria and were considered evaluable. Intention to treat and per protocol analyses showed non-significant trends in favour of famotidine (P = 0.44 and 0.16, respectively). During the 24-week observation period, 16.3% of the famotidine group and 25% of the ranitidine group had an ulcer recurrence (95% CI of percentage difference -0.22 + 0.04). At 24 weeks, relief of day and night pain was reported by 81.2% and 91.8% of the famotidine-treated patients, respectively. The corresponding figures in the ranitidine group were 73.5% and 85.5%. No laboratory abnormalities related to the study-drugs were noted and only two drug related (possibly or probably) adverse experiences were reported, both in the famotidine group. The data from this study therefore, supports the conclusion that the efficacy of 20 mg famotidine nocte is comparable to that of ranitidine in preventing duodenal ulcer recurrence, with comparable tolerability for long-term therapy.

Misoprostol prevents NSAID-induced gastroduodenal lesions in patients with osteoarthritis and rheumatoid arthritis

The clinical use of nonsteroidal anti-inflammatory drugs (NSAIDs) is associated with significant adverse effects on the integrity of the gastrointestinal (GI) mucosa. A unique, double-blind, placebo-controlled, randomized, multicentre study investigated the prophylactic co-therapy with misoprostol, a novel PGE1 analog, for the prevention of the NSAID-induced gastric and duodenal mucosal lesions. The study also investigated whether the co-therapy with misoprostol could interfere with the anti-rheumatic action of the NSAIDs using detailed rheumatological assessments. Patients with osteoarthritis or rheumatoid arthritis had to be free of symptoms and significant erosive and/or haemorrhagic lesions of the upper GI tract. The patients were randomized to co-therapy with misoprostol or its matching placebo. Follow-up endoscopy and symptoms assessment were carried out within 4 weeks and compared to pre-study findings. Misoprostol significantly reduced (p less than 0.01) the incidence of erosive and/or haemorrhagic gastric and duodenal mucosal lesions. Misoprostol also reduced the proportion of patients with epigastric pain (p less than 0.01). Misoprostol was well tolerated and did not interfere with the anti-rheumatic activity of the administered NSAID. We conclude that misoprostol is safe and effective in the protection against NSAID-induced gastric and duodenal mucosal lesions and symptoms.

Common bile duct and sex, age and body mass index in normal humans: an ultrasonographic study

A probable relationship between Common Bile Duct (CBD) size and sex, age and Body Mass Index (BMI) was investigated in healthy volunteers. Real-time ultrasonography was employed to visualize gallbladder and CBD. No change of CBD size related to sex and BMI was found. A significant increase of CBD related to age was recorded.

Famotidine vs ranitidine h.s. in acute duodenal ulcer. A multicentre endoscopic trial

A double-blind, randomized, active drug-controlled study was conducted in order to evaluate the efficacy and safety of famotidine vs ranitidine h.s. in promoting the healing of acute duodenal ulcers. Two hundred and eighty patients participated in the trial and received either famotidine 40mg h.s. or ranitidine, 300mg h.s. The two groups were not significantly different with regard to sex and risk factors such as alcohol consumption and family history of peptic ulcer disease, while in the famotidine group, there was a slightly higher number of patients who smoked. Endoscopy was performed at the end of 4 and 6 weeks in 248 patients (128 in the famotidine group and 120 in the ranitidine group). The healing rate in those receiving famotidine was 73.4% at the end of 4 weeks and increased to 93% at the end of 6 weeks, while in the ranitidine group, the rate was 75.8% and 92.5% respectively. Day and night pain markedly reduced in both groups and therapy was generally well tolerated.

Omeprazole vs. ranitidine in short-term treatment of Helicobacter pylori positive duodenal ulcer patients

Forty-three patients with active duodenal ulcer and Helicobacter pylori positivity in gastric antrum were randomly assigned to either omeprazole treatment (20 mg once a day) or ranitidine treatment (300 mg once a day) for 28 days. Re-evaluation of the patients (clinical and endoscopic examination and assessments for H pylori detection) was repeated after 2 weeks and at the end of the treatment. Healing rates in the omeprazole group were 40% after 2 weeks and 90% after 4 weeks, in the ranitidine group ulcer healing was recorded in 20% of patients after 2 weeks and in 80% after 4 weeks. Differences between treatments at 2 and 4 weeks were not statistically significant. Clinical response (disappearance of ulcer-related symptoms) was better in the omeprazole group at 2 weeks (p less than 0.05) but not at 4 weeks. At the end of the trial H pylori positivity in gastric antrum disappeared in 95% of the patients treated with omeprazole and in 5% of the patients who received ranitidine (p less than 0.001). The results confirm the effectiveness of omeprazole in short-term treatment of duodenal ulcer and re-emphasize the powerful activity of the drug on H pylori infection.

[Tuberculosis of the breast. Report of a clinical case and review of the literature]

Tuberculosis of the breast is an uncommon disease and the correct diagnosis may be established only by histologic demonstration of granulomatous inflammatory infiltrates with central caseation. In fact, preoperative examination and mammography suggest carcinoma or sometimes bacterial abscess in most instances. Tuberculous mastitis was diagnosed in a 74-year-old woman. The case history and a review of the literature are presented. The Authors emphasize the role of excision of necrotic tissue and drainage, in combination with antimicrobial therapy, in the treatment of this pathology.

Rioprostil in the short-term treatment of duodenal ulcer: a multicentre double-blind trial vs. cimetidine

The efficacy and safety of the new prostaglandin E1 (PGE1) synthetic analogue, rioprostil, 300 micrograms b.d. and cimetidine, 400 mg b.d., on duodenal ulcer healing are compared in an international, multicentre, double-blind study. A total of 257 patients have entered the study; 243 are considered eligible for efficacy analysis and 207 for safety analysis. After 4 and 6 weeks of treatment, the endoscopic healing rates do not significantly differ between the two groups, being 55% and 83% respectively with rioprostil vs. 60% and 78% respectively with cimetidine. The major adverse effect attributable to rioprostil is diarrhoea, which was documented in 11% of patients compared with 1% of patients taking cimetidine. However, central nervous system complaints are twice as frequent in the cimetidine group. Monitoring of clinical laboratory tests show no significant abnormalities when compared with the baseline values during the administration of either drug. This study documents that rioprostil, at the dosage of 300 micrograms b.d., is as effective and safe as cimetidine in the short-term therapy of duodenal ulcer.