McKeown oesophagectomy and pulmonary wedge resection with a prone thoracoscopic and laparoscopic approach: a video report

In the past few years, minimally invasive oesophagectomy has become an increasingly popular approach for oesophagectomy showing advantages in terms of fewer postoperative complications, shorter hospital stay and faster recovery. We present the case of a 60-year-old man with a lesion of the distal third of the oesophagus and solid pulmonary nodule who underwent McKeown subtotal oesophagectomy by laparoscopic and thoracoscopic approach in prone position with concomitant thoracoscopic pulmonary wedge resection. The postoperative course was smooth, and the patient was discharged on postoperative day 10. The procedure is feasible and safe, and combines better respiratory postoperative outcomes even when associated with other diagnostic or therapeutic lung procedures.

Laparoscopic repair of a giant hiatal hernia after minimally invasive oesophagectomy

Minimally invasive oesophagectomy has become popular, but studies showed a higher rate of postoperative hiatus hernia compared with open oesophagectomy. Our video presents the laparoscopic biosynthetic mesh repair of a symptomatic giant hiatus hernia in a 71-year-old man who had undergone minimally invasive oesophagectomy one year earlier for distal adenocarcinoma of the oesophagus. The operative time was 120 minutes. The patient started oral intake on postoperative day one and was discharged on postoperative day three. Postoperative computed tomography at six months showed no signs of recurrence. In the setting of a symptomatic hiatus hernia post-minimally invasive oesophagectomy, we suggest an initial laparoscopic approach, because of its countless advantages.

Palliative care in the emergency department as seen by providers and users: a qualitative study

Background

Much effort has been made to explore how patients with advanced chronic illness and their families experience care when they attend the Emergency Department, and many studies have investigated how healthcare professionals perceive Palliative Care provision in the Emergency Department. Various models exist, but nonetheless incorporating palliative care into the Emergency Department remains challenging. Considering both healthcare professionals’ and users’ perspective on problems encountered in delivering and receiving appropriate palliative care within this context may provide important insight into meaningful targets for improvements in quality of care. Accordingly, this study aims at exploring issues in delivering palliative care in the Emergency Department from the perspective of both providers and users, as part of a larger project on the development and implementation of a quality improvement program in Italian Emergency Departments.

Methods

A qualitative study involving focus group interviews with Emergency Department professionals and semi-structured interviews with patients with palliative care needs in the Emergency Department and their relatives was conducted. Both datasets were analyzed using Thematic Analysis.

Results

Twenty-one healthcare professionals, 6 patients and 5 relatives participated in this study. Five themes were identified: 1) shared priorities in Emergency Department among healthcare professionals and patients, 2) the information provided by healthcare professionals and that desired by relatives, 3) perception of environment and time, 4) limitations and barriers to the continuity of care, and 5) the contrasting interpretations of giving and receiving palliative care.

Conclusions

This study provides insights into targets for changes in Italian Emergency Departments. Room for improvement relates to training for healthcare professionals on palliative care, the development of a shared care pathway for patients with palliative care needs, and the optimization of Emergency Department environment. These targets will be the basis for the development of a quality improvement program in Italian Emergency Departments.

Neurophysiology of the pelvic floor in clinical practice: a systematic literature review

Neurophysiological testing of the pelvic floor is recognized as an essential tool to identify pathophysiological mechanisms of pelvic floor disorders, support clinical diagnosis, and aid in therapeutic decisions. Nevertheless, the diagnostic value of these tests in specific neurological diseases of the pelvic floor is not completely clarified. Seeking to fill this gap, the members of the Neurophysiology of the Pelvic Floor Study Group of the Italian Clinical Neurophysiology Society performed a systematic review of the literature to gather available evidence for and against the utility of neurophysiological tests. Our findings confirm the utility of some tests in specific clinical conditions [e.g. concentric needle electromyography, evaluation of sacral reflexes and of pudendal somatosensory evoked potentials (pSEPs) in cauda equina and conus medullaris lesions, and evaluation of pSEPs and perineal sympathetic skin response in spinal cord lesions], and support their use in clinical practice. Other tests, particularly those not currently supported by high-level evidence, when employed in individual patients, should be evaluated in the overall clinical context, or otherwise used for research purposes.

Pisa syndrome in Parkinson's disease: electromyographic quantification of paraspinal and non-paraspinal muscle activity

Patients with Parkinson's disease (PD) and Pisa syndrome (PS) may present tonic dystonic or compensatory (i.e. acting against gravity) hyperactivity in the paraspinal and non-paraspinal muscles. Electromyographic (EMG) activity was measured in nine patients with PD and PS, three with PD without PS, and five healthy controls. Fine-wire intramuscular electrodes were inserted bilaterally into the iliocostalis lumborum (ICL), iliocostalis thoracis (ICT), gluteus medius (GM), and external oblique (EO) muscles. The root mean square (RMS) of the EMG signal was calculated and normalized for each muscle. In stance condition, side-to-side muscle activity comparisons showed a higher RMS only for the contralateral ICL in PD patients with PS (p=0.028). Moreover, with increasing degrees of lateral flexion, the activity of the EO and the ICL muscles progressively increased and decreased, respectively. The present data suggest that contralateral paraspinal muscle activity plays a crucial compensatory role and can be dysfunctional in PD patients with PS.

A modified spica-splint in postoperative early-motion management of skier's thumb lesion: a randomized clinical trial

BACKGROUND

Rupture of ulnar collateral ligament of the thumb (UCL) represents a frequent injury of the hand. Surgical repair is considered the gold standard but postoperative immobilization causes partial stiffness in a percentage of cases.

AIM

The aim of this paper was to assess the effectiveness of a postoperative functional hand-based splint for the thumb which allows immediate postoperative motion.

DESIGN

Randomized prospective clinical trial.

SETTING

The study was carried out at the Orthopedics and Hand Surgery Unit of The Catholic University School of Medicine, Rome, Italy.

POPULATION

Thirty consecutive patients, with a diagnosis of acute complete tear of the UCL, were selected to be treated surgically (predominantly men, mean age 39). Cases presenting associated injuries were not included.

METHODS

Patients were randomized postoperatively into 2 groups of 15 (one using the new splint and the other using a standard spica splint). After four weeks of splinting, clinical outpatient evaluations were carried on (at one, two, six, twelve months) on both groups to evaluate: joint stability; pain; pinch strength; range of motion; time lost from work; sessions of physiotherapy.

RESULTS

Immediate postoperative motion of the operated joint produced faster and better functional results. No cases of recurrence were recorded.

CONCLUSIONS

Surgical repair, combined with active metacarpophalangeal motion allowed by the new functional splint, was effective, safe and well tolerated.

CLINICAL REHABILITATION IMPACT

Enhancing the patients' function and reducing the time of functional recovery, the reported treatment presents potential advantages in the management of this frequent acute hand injury.

Abductor pollicis longus hemitendon looping around the first intermetacarpal ligament as interposition following trapeziectomy: a one-year follow-up study

BACKGROUND

Trapeziectomy and ligament reconstructions are favoured by surgeons concerned that telescoping of the thumb may reduce its function. However, theoretically ligamentoplasties are at risk to develop tendinosis or tendon rupture or trigger a complex regional pain syndrome type 1.

HYPOTHESIS

Authors tested the looping of a slip from the abductor pollicis longus (APL) tendon around the first intermetacarpal ligament. They intended to use a surgical treatment which does not require bone tunnelling or looping around a tendon. Their results support the hypothesis that this new technique is a valid addition among treatments for carpometacarpal arthritis.

PATIENTS AND METHODS

Forty-two patients were followed up to one year. Each patient had subjective assessment for: pain; function (DASH score); overall satisfaction. An objective assessment was used for: first web span angle; abduction and opposition; key pinch; grip strength. Tests were performed prior to surgery, then at three, six and 12 months. X-ray films were taken to monitor thumb height.

RESULTS

A substantial improvement in all these parameters was measured in all patients. X-ray films showed the mantainance of a physiological heigth after one year. We recorded one complication of keloid and two of temporary dysesthesia but no case of tendinosis, delayed rupture, or CRPS 1. Mean operative time was 27 minutes.

DISCUSSION

Simplification and search for a technique which avoids the looping around a tendon is why the authors undertook this study. Advantages are the small number of required steps, short time of surgery and comfortable postoperative rehab regimen for the patient. The technique provides a distal anchoring point (without bone tunnelling). It is quite respectful of anatomy and physiology, in minimizing the re-routing of functioning tendons. We propose it as an effective procedure both to expand the armamentarium for treating the thumb carpometacarpal joint osteoarthritis and/or to simplify the ligamentoplasties already in use.

‘Neurographic’ palmaris brevis sign in type II° ulnar neuropathy at wrist

OBJECTIVE

To investigate the source of an unusual and previously unreported volume conducted potential on motor nerve conduction studies. In a case of subacute ulnar neuropathy at wrist (UNW) selectively involving the deep motor branch, we recorded from the hypothenar eminence a large positive wave (2.5 ms-2 mV) preceding the negative takeoff of the delayed distal ulnar motor response.

METHODS

We performed multiple channels motor and sensory ulnar nerve (UN) conduction studies; these included selective electrical stimulation and anaesthetic block of UN branches and also selective recording of motor responses by single fibre needles; data were confirmed by an intraoperative neurophysiological study and correlated with MRI and surgical findings.

RESULTS

Detailed neurophysiological investigation demonstrated the generation of this waveform from the palmaris brevis (PB) muscle. MRI and surgical exploration documented a hypertrophy of this muscle.

CONCLUSIONS

In type II degrees UNW, depolarization of a spared palmaris brevis muscle may be recorded as a positive wave preceding the delayed abductor digiti minimi motor response.

SIGNIFICANCE

We underline the peculiar localizing value of this volume conducted 'meaningful artefact' in that particular setting. It actually represented an early neurographic analogue of what is known as the clinical 'Palmaris Brevis Sign' in long standing type II degrees UNW.

Symptoms and neurophysiological picture of carpal tunnel syndrome in pregnancy

OBJECTIVE

To evaluate the incidence of carpal tunnel syndrome (CTS) in pregnancy through a validated and multiperspective assessment of CTS.

METHODS

During 2000, the Italian CTS study group focussed on the occurrence of CTS in women during the final stages of pregnancy, enrolled in 7 Italian centers. In addition to the physician-centered and neurophysiologic traditional evaluations, we used a validated patient-oriented measurement to obtain more comprehensive and consistent data for severity of symptoms and functional impairment.

RESULTS

In our study, CTS was clinically diagnosed in more than half of women (62%). Neurophysiological evaluation provided diagnosis of CTS in around half of women (43% were positive in one hand at least). Our study provides evidence, reported here for the first time, of a correlation between edema and neurophysiological picture. Similarly, our study provides a correlation between validated patient-oriented measurement and edema. Moreover, a significant correlation between a negative trend (subjectively assessed) and smoking and alcohol consumption was observed.

CONCLUSIONS

Our observations confirm that the edema of the tissues in the carpal tunnel could induce a mechanical compression of the nerve. Moreover, our data suggest that smoking and alcohol consumption have a negative role in the evolution of the syndrome probably due to impairment of the microcirculation.

Isolated hypoglossal nerve palsy due to an anomalous vertebral artery course: report of two cases

The authors report two patients with isolated unilateral tongue atrophy. Magnetic resonance imaging (MRI) of the brain stem and angio-MRI demonstrated a dolichovertebral artery with an abnormal course compressing the medulla oblongata at the emergence of the hypoglossal rootlets. The semeiological observation of a sectorial and not uniform distribution of atrophy in the half-affected tongue is discussed in relation to the lesional site.

Pregnancy after heart transplant: update and case report

A literature review of 22 cases of pregnancy following cardiac transplantation up to 1995 and a case report are presented here. A 30 year old woman, gravida 3, para 1, contacted us for obstetric care at 8 weeks gestation, about 55 months after orthotopic cardiac transplantation. The transplant had been performed for a familial dilative cardiomyopathy, which had become manifest during her previous pregnancy. The course of the current gestation was uneventful. The patient's cardiovascular function was good throughout the pregnancy. Immunosuppressive therapy, the dose of which was increased during pregnancy, included cyclosporine and azathioprine. Because of an increase in the patient's plasma uric acid concentration and an initial rise in her blood pressure, despite therapy, a repeat Caesarean section was performed at 37 weeks gestation. A female baby weighing 2330 g, Apgar scores 7/9, was delivered. Mother and infant were discharged on postoperative day 15 and are doing well 14 months postpartum. Through a review of literature and our case, the issues and problems related to pregnancy after a heart transplant are discussed, in particular the maternal-fetal risks, management, therapy, delivery, neonatal problems and follow-up postpartum of mother and baby.

[Intrahepatic cholestasis in pregnancy]

Intrahepatic cholestasis of pregnancy (ICP) is a syndrome usually manifesting during the third trimester of pregnancy and disappearing after delivery. Multiple factors seem to be involved in pathogenesis of the syndrome; however, ICP appears to take place in women congenitally hypersensitive to estrogens. Typical is pruritus, which may be followed by jaundice and associated with other less common symptoms. The biochemical parameters are characteristically altered: an increase in the levels of aminotransferases (AST, ALT), total bile acids and alkaline phosphatase is observed; while serum GGT are normal. Maternal prognosis is benign. By contrast, a higher risk of acute fetal distress and prematurity has been reported. Various drugs are used in the treatment of ICP. We present the case of a patient treated with S-adenosyl-L-methionine (SaMe). SaMe therapy has proved to be effective in improving the altered biochemical parameters, whose normalization was obtained before delivery.

The pineal gland and reproduction

The hormonal activity of the pineal gland is influenced by both the dark-light cycle and the seasonal cycle, causing it to play an important role in the neuroendocrine control of reproductive physiology. This is especially evident in seasonally breeding animals, in which reproductive function is clearly influenced by seasonal variations in the duration of night and day. Humans are not seasonal breeders. Nevertheless, seasonal fluctuations have been described in human reproduction, and the pineal gland also appears to exert an important role in the neuroendocrine regulation of human reproductive physiology. There is evidence that the epiphysis is involved in the control of sexual maturation. In rats, the maternal pineal appears to influence the gonadal and genital development and function of offspring; this hypothesis has yet to be confirmed in humans. The pineal apparently influences human reproductive function not only at the hypothalamic-pituitary level, by inhibition of the hypothalamic pulsatile secretion of gonadotrophin-releasing hormone, but also at the gonadal level, where melatonin receptors have also been found. In addition, melatonin is reported to increase serum prolactin concentrations in both rats and humans. It has been suggested that melatonin is involved in the control of menstrual cyclicity.

[Fetal lesions due to the bistoury during cesarean section: a study of 58 cases. The 5-year case records of 3117 cesarean sections at the Institutes of Clinical Obstetrics and Gynecology of the University of Rome La Sapienza]

In the present article the authors have carried out a statistical investigation on data relative to the caesarean sections performed in the Departments of Obstetrics and Gynaecology of the University of Rome "La Sapienza" since 1986 to 1990. Particular object of this study is to evaluate data regarding fetal bistoury lesions incidentally caused while performing the incision of the uterine wall during a caesarean section. To our knowledge, this topic has never been taken into account by the world's literature, nevertheless it is important also for its legal and insurance implications. Throughout the mentioned period 13787 deliveries occurred, 3117 of which were caesarean sections: this is equal to a frequency of 22.6%, with an increase rate of 37.5% during the whole 5 years time. 58 cases of fetal bistoury lesions have been found to occur since 1986 to 1990: this equal to 1.8% of all the performed caesarean sections. Even if their gravity was usually scarce, and only 7 cases needed a specific treatment, 25.8% of these lesions involved areas such as forehead, cheek bone, cheek, mostly related to possible aesthetic damages with their connected legal consequences. In order to evaluate what factors can contribute to the occurrence of these lesions and taking account of the large number of factors that may be involved (such as conditions at which the operation is performed, skill and experience of the surgeon etc.), the authors focus their attention to those which, for their clinical significance and possibility of detection, suit more than others such a statistical investigation.(ABSTRACT TRUNCATED AT 250 WORDS)

[The emotive and cognitive reactions in temporary pharmacological menopause]

The authors have attempted to evaluate the extent to which menopausal crisis is linked to hypoestrogenism and the extent to which it is linked to the socioenvironmental context in which it takes place. The study analyses emotional and cognitive aspects in a group of women in temporary menopause which was pharmacologically induced for therapeutic purposes. The study was carried out in 30 patients suffering from benign gynecological pathologies receiving ovarian steroidogenesis-blocking treatment. Treatment consisted of a subcutaneous administration of a Gn-Rh analog every 28 days for 6 months. After having collected information regarding the symptoms that appeared following the administration of therapy, the authors evaluated the emotive (anxiety and depression) and cognitive (short-term memory and concentration) conditions of patients using psychometric reactives performed during the first check-up, and then repeated at the 3rd, 5th and 7th control visit: the State-Trait-Anxiety-Inventory to assess trait anxiety and state anxiety; scale D of the Minnesota Multiphasic Personality Inventory to assess depression; the sub-test for memory of figures from Wechsler-Bellevue Intelligence Scale to evaluate short-term memory; the Toulouse-Pieron reactive to evaluate attention and concentration. The results obtained were analysed statistically using Student's t-test and Pearson's coefficient. An analysis of the data shows that, after the first doses of the drug stress trends to diminish from the high levels recorded at the first visit, stabilising at normal values throughout treatment. Like anxiety and depression, concentration and memory do not show marked variations.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute puerperal uterine inversion: a report of 3 cases and an analysis of 358 cases in the literature]

Acute puerperal uterine inversion is a rare but very feared obstetrical complication. It determines an almost immediate shock and serious metrorrhagia. It is a "glove-finger" introflexion of parietes uteri which takes place during the third stage of labor or during the first hours of puerperium. It can be distinguished in inversion of I, II or III degree according to the zone concerned by the introflexion: only the fundus of the uterus, all the corpus emerging in the vagina or the entirety of the uterus coming out from the vulvar orifice. The research carried out in the archives of the Department Obstetrics and Gynaecology of the University of Rome "La Sapienza" has showed, for the 20 years 1968-1988, 3 cases of uterine inversion out of a total of 69,677 childbirths. The uterine inversion was immediately diagnosed and in all the 3 cases a method of replacement by central taxis was practiced. In 2 cases, despite the packed tamponade, there was a recidivist or persistent uterine inversion of 1 degree, and in both cases a surgical reduction by laparatomy was practiced. In 1 of the 2 cases a hysterectomy was needed because of the persisting metratonia and metrorrhagia. The III case was treated with a manual replacement, a uterus massage from outside keeping the organ, with fist inside the cavity, in forced anteflexion in order to reach a good contractile activity. In 2 of the 3 cases the placental stage was operative, manual in 1 case and with fundal pressure applied abdominally in the other. We have found and analysed, in the international literature, 358 cases described from 1939 to 1989. The homogeneous data have been grouped in 21 tables for an easier visualization. Frequency varies from 1 out of 1,200 childbirths to 1 out of 57,393 childbirths. The medium value has been 1 out of 5,903 in the period from 1939 to 1989. The most significant data emerging from the analysis of the 358 cases of uterine inversion concern the placental stage. This was spontaneous in a number of cases equivalent to 28.9%; the number of fundal pressure applied abdominally was up to 30.9%; tractions over funicle up to 22.3%; manual delivery of the placenta up to 17.9%. Eighty-nine percent of cases were diagnosed by simple inspection, whilst for the resting ones an exploration was needed. For most of the cases the treatment was immediate (77%) especially by means of manual reduction vaginally (88%). Hysterectomy was needed for 14 cases that is up to 4.24%.(ABSTRACT TRUNCATED AT 400 WORDS)

[Directions of future research on GnGH analogs in the treatment of endometriosis and uterine fibromyoma]

A variety of new data on the biology, pathophysiology and metabolic changes occurring in leiomyomas and in the ectopic endometrium have opened new avenues for research in a neglected area, that of benign proliferations of the female reproductive tract. In addition, the availability of potent inhibitors of ovarian function which, like the super-agonist analogues of GnRH, have no hormonal activity (oestrogenic, progestogenic or androgenic) has allowed for the first time to evaluate the effect of oestrogen deprivation on endometriosis and uterine fibrosis. The results, although impressive, are only temporary: in both cases hypoestrogenism produces an important relief of symptoms, but--once treatment is discontinued--both conditions usually continue to evolve. For this reason, much remains to be done to optimize Gn-RH analogue utilization. In the case of endometriosis, there seem to be three main areas for future research: pain, infertility and the possibility of modifying its natural history. In addition, the role of combined, medico-surgical therapy remains to be established, especially in the case of severe disease. In the treatment of fibrosis, analogues can be utilized as pre-treatment before conservative or demolitive surgery, or as an alternative to hysterectomy. The role of analogues as a pre-surgical adjuvant has probably been overemphasized and it is time to carry out well controlled studies to narrow down indications. At present they include: severe anemia caused by chronic heavy uterine bleeding, and the need to minimize intraoperative blood loss. Much remains to be done before analogues can become a real alternative to surgery. To date no single sequential therapeutic regimen has been identified which is capable of prolonging the beneficial effects of agonists without their well known negative consequences. Temporary results can be obtained interrupting analogue therapy and substituting it with the administration of a progestogen. Finally, analogue administration can be prolonged by associating an oestrogen-progestogen sequential combination as in HRT. In all of these instances, what are urgently needed are well controlled randomized clinical trials.

Further considerations on the changing face of pneumonia in Marche Region (central Adriatic coast of Italy)

The present paper provides a more detailed review of some themes already discussed in previous papers concerning the changing face of pneumonia in an area of the central Adriatic coast of Italy, including an ex novo examination of the correlations between radiological findings and serological groups not previously reported. The discussion concentrates particularly on some questions raised by the research, such as the apparent rarity of pneumococcus, the elevated number of seronegatives appearing as atypical pneumonia, the high percentage of "bacterial-type" cases occurring among the viral-like, and the therapeutic problem.

[Pregnancy in HIV positive women: psycho-emotional aspects. Study of 16 cases]

The aim of this study was to analyse the day-to-day life of HIV-positive women during pregnancy and to assess the emotions deriving from their relations with the baby during the first few months of life. The study was carried out on a group of 16 HIV-positive women aged between 19 and 37 years old (mean age 27.3 years) who underwent a guided interview using a questionnaire. The questionnaire, which was mainly based on questions requiring a free answer, focused on four main areas: 1) the woman's reaction to HIV-positive status; 2) the influence of HIV-positive status on relations with her partner and surroundings; 3) the interaction between pregnancy and the HIV-positive status; 4) the relation between mother and children after birth and during the first few months of life. 56.25% of the women interviewed had become infected by intravenous drug injection, 25% through heterosexual relationships and 12.5% through blood transfusions. The cause was unspecified in 6.25%. The women had been aware of their HIV-positive status for between one and four years. Their reactions to HIV-positive status were predominantly denial, condemnation, and depression accompanied by a sense of death, anxiety and of being different. Relations between couples were influenced in a variety of ways by the new situation: 4 women reported a diminished frequency of sexual relations, one women reported reduced libido, 10 women did not notice changes in sexual relations and one woman did not reply.(ABSTRACT TRUNCATED AT 250 WORDS)

Sequential Gn-RH superagonist and medroxyprogesterone acetate treatment of uterine leiomyomata

A group of 48 women with symptomatic leiomyomata were treated during 6 months with the short-acting Gn-RH superagonist analog buserelin. The first (group C) was followed up for an additional six months of no medication. The second (group M) was treated for 6 additional months with medroxyprogesterone acetate (MPA) at doses decreasing from 200 to 25 mg/day. Buserelin therapy significantly decreased uterine size (P less than 0.001) in all patients, the average final volume being 48.5% of the original (from 262 +/- 147 ml to 127 +/- 85.4 ml). In group C there was a significant (P less than 0.001) re-growth during the post-treatment observation period (from 120 +/- 81.0 ml to 198 +/- 77.2 ml); a significant (P less than 0.01) re-growth was also observed in group M during MPA medication (from 132 +/- 77.2 ml to 170 +/- 96.0 ml). The agonist had also a marked effect on fibroids: on average they decreased from 75.1 +/- 74.3 ml to 24.7 +/- 23.3 ml (P less than 0.025). In group C during the post-buserelin period of observation without treatment, there was a significant re-growth from 23.7 +/- 21.6 ml to 47.7 +/- 27.5 ml (P less than 0.001), whereas in group M treatment with MPA prevented any significant re-growth (from 25.6 +/- 24.8 to 30.6 +/- 32.9 ml; P greater than 0.3).

[The new aspect of pneumonia in an area of the Middle Adriatic]

The present work reports the findings of a ten-year, research, the aim of which is to outline current views of pneumonia in a zone of the Middle Adriatic (USL 17-Regione Marche). The study confirmed, in its entirety, a lesser aggressiveness and loss of the "seasonal feature" of today's pneumonias. The high incidence of Atypical Pneumonia (AP) due to viral-like microorganisms (mycoplasma, chlamydia, coxiella, legionella) and an even higher one of unknown etiology is reported. After having analysed the most likely reasons for such a change and its various implications, the authors conclude that this type of research should be extended in order to trace a map of the more common infectious agents in single geographical zones, as an indispensable premise for a more concrete etiological diagnosis and for a more rational choice of the antibiotic.

[Emergency ambulatory treatment of dysfunctional metrorrhagia in adolescents]

The authors compared the therapeutic efficacy of oestrogen-progestogen combinations with pure progestagen in the urgent treatment of adolescent metrorrhagia. Two groups of adolescents were studied whose haemorrhages were attributed exclusively to disfunction. Every medicine was evaluated as to: 1) effectiveness in completely spotting haemorrhage, 2) any persistence of bleeding, 3) side effects. The therapy was given during 2 consecutive menstrual cycles. Results following treatment with oestrogen-progestogen combinations were favourable, even though side effects were more noticeable.

[Destructive cesarean section: hysterectomy for obstetric reasons and post-abortive hysterectomy. Analysis of 35 cases]

The Authors examined surgical case studies for the 20-year period from February 1968 to February 1988 concerning hysterectomies performed for obstetric reasons at the "La Sapienza" University of Rome, Obstetrics and Gynaecology Department; these numbered 35 out of 69,677 births. They also considered hysterectomies carried out during caesarean sections, during birth or the postpartum period, during the puerperium and after miscarriage. They also analyzed reasons for the action taken, the type of operation, the length of the gestation period, the mother's age, and transfusions given.

[Medium term treatment and prophylaxis of dysfunctional metrorrhagia in adolescence]

The authors compared the therapeutic effectiveness of these different pharmacological methods of preventing dysfunctional menometrorrhagia in adolescents, which were: 1) chorionic gonadotropin, 2) cyclofenil, 3) ovariostatics. Therapy was given during 2 menstrual cycles, and effects were evaluated both during the treatment and for the succeeding 2 cycles. Parameters followed were: a) clinical recovery, b) persistence of spotting, c) effectiveness in inducing ovulation. The results were equally good both in treatment with ovariostatics and ovulation inducers. The latter proved however, more effective during follow-up. Side-effects were very rare, so much so that, in no case was it necessary to suspend treatment.

[Use of low-dose danazol in adenosis of the breast]

Mammary adenosis is a very common affliction which, it has been calculated, affects between 7 and 15% of women of child-bearing age. The Authors report the results obtained during treatment of this condition with danazol in those different dosages (50, 100 and 200 mg per day). Results were evaluated at 3 and 6 months during therapy, and then 4 months after suspension of the treatment. Effects were evaluated in terms of changes in the symptomatic pain and in the actual clinical record. Side effects were also examined in terms of age and obstetric history. The therapy produced good results with all those dosages used. The lowest dosage gave the most favourable long-term effects, also in terms of the scarsity of side-effects.

[Hysterectomy in obstetrics. Analysis and comparison of a group of cases from the Italian and the international literature (536 cases)]

The Authors made a comparison between the frequency of obstetric hysterectomies carried out at the "La Sapienza" University Obstetrics and Gynaecology Departments and of those reported in international publications regarding Great Britain, USA, Australia, Saudi Arabia and Libya. Data obtained covered the 462 hysterectomies effected out of the 442,174 births from 1972 to 1895. Results were compared as under: general frequency per number of births, reasons for surgery, type of operation carried out, age of the patient, gestation period, obstetrical history and complications.

PCB and other organochlorine compounds in blood of women with or without miscarriage: a hypothesis of correlation

Polychlorobiphenyls (PCBs) have been shown to affect reproduction in experimental animals and in human beings following intoxication. The concentrations of PCBs and other organochlorine compounds were determined in blood samples from 120 women hospitalized for miscarriages and 120 full-term pregnancy controls. The average PCB hematic level (reported as Fenclor 54) was higher in women with miscarriages than in control women. No differences were detected as far as the hematic concentrations of hexachlorobenzene and DDT compounds were concerned. The reproductive history of each woman was assessed together with confounding variables on the phenomenon of miscarriage and the factors regarding environmental exposure and food intake. Food consumption did not indicate diet as the main source of PCB intake.

[Antiemetic protocol in oncohematologic polychemotherapy]

Authors, in an open and preliminary study, evaluate the beneficial effects on chemotherapy-induced nausea and vomiting of an association of three antiemetic drugs parenterally administered. Twenty-six patients receiving chemotherapy for Lymphomas (195 cycles) were treated with: Chlorpheniramine maleate 10 mg IM 45' before, Sulpiride 200 mg in normal saline 100 ml, at XXX gtt/m', 20' before, and 6-Methyl-Prednisolone 500 mg IV over 2'-3' immediately before chemotherapy. Patients were evaluated for emesis over 48 hours after chemotherapy: they were interviewed on nausea, vomiting and other possible side-effects. The antiemetic activity observed was: complete response in 73.1% (19/26); partial response 27.9% (7/26). Failure of response was never observed. 166/195 cycles were well tolerated. Our results demonstrate the antiemetic efficacy of this antiemetic regimen. Further studies should investigate its use in randomized trials.

[A small epidemic focus of pulmonitis caused by Legionella]

A mini-epidemic consisting of 5 cases of Legionnaire's disease treated during september 1983 is reported. These patients shared many of the symptoms distinguishing the most common form of this disease in its severe or very severe form and some characteristic features of this case series are emphasised. It was impossible to trace the source of the outbreak, in spite of the fact that the mini-epidemic took place in an open situation. It is underlined that diagnosis is mainly clinical. The Legionella pneumophila bacteria should always be considered as one of the causal agents of bronchopneumonia, particularly when the following conditions are fulfilled: a) the disease takes the form of a confined, out-of-season, mini-epidemic; b) it is accompanied by multisystemic symptomatology and/or much greater involvement of general conditions that is usually to be expected in normal cases of bronchopneumonia. Since the disease is often fatal, erythromycin or rifampicin treatment should be started upon the slightest suspicion of contagion.

[Role and importance of antidepressants in general medicine. Bibliographic review and case contribution]

Starting from the consideration that communications relating to antidepressant drugs are chiefly reported by psychiatrists and that such reports deal with cases that we don't find in general practice, or at least marginally, the authors go on considering again their material consisting of 944 patients treated with antidepressants alone or associated with tranquilizers and/or with neuroplegic sedatives, hoping to gather usefull informations for a better definition of the role of these drugs in this large nosographic area. The authors could, therefore, by that way: confirm the high incidence of psychosomatic disorders among all the professional areas concerned with general practice; confirm the clear prevalence of the less symptomatic forms; verify in a high percentage of cases the coexistence of an organic disorder in way of progress or in outcome; confirm the double role of these drugs, diagnostic (ex-juvantibus) and therapeutical; suggest a third role of nosographic nature.

[Irritable colon and psychosomatic disease]

The authors, after having considered the close likeness between the collateral clinical picture described by others in regard to the irritable colon syndrome and the outstanding one pointed out by them in many cases of psychosomatic disorders, have analyzed again a large number of personal cases diagnosed as "psychosomatic" in order to find possible relations between these two unwholesome conditions. At the end of their examination, after having ascertained that the "Irritable colon" has not to be considered an isolated disease but a syndrome caused by many factors, hinged on a predisposing condition likely of constitutional nature, the authors remark how it may nest in the folds of a psychosomatic disorder and sometimes be its outbreaking feature. The authors by this way, don't want to conclude identifying the I.C. with a psychosomatic disorder and suggest that in such cases one may take this syndrome as the main manifestation of a condition marked by an impairment of the digestive tract motility inside a psychosomatic disorder with a somatic expression of this apparatus.

[Psychosomatic disorders considered from an internist viewpoint. I. Nosographic aspects and diagnostic problems]

After a brief introduction regarding the nosography of psychosomatic disorders and the main reasons that have little by little discouraged non-psychiatric physicians to deal with this type of pathology, considering its high incidence among all the areas of general practice, the Authors go on discussing the diagnostic problems and pointing out the most important aspects concerned with these. The Authors conclude by warning not to over-value the effects obtained with an antidepressant especially when it is set up only on the basis of the ex-juvantibus principle. The Authors also invite their colleagues general practitioners to take greater care in the fight for prevention and treatment of these disorders, side by side with the psychiatrist.

[Psychosomatic disorders considered from an internist viewpoint. II. Problems of drug therapy]

Following a previous communication concerning some of the principal diagnostic and differential diagnostic questions regarding psychosomatic pathology, with the present note the authors wish to review the most common therapeutic problems related to these disorders. The text has been subdivided into two parts. In the first part it has been adjusted the approach to the pharmacological treatment of these disorders, following principally the authors' experience, and, in the second, have been analyzed some of the most common prejudices that have taken shape around this therapeutic praxis and that have contributed so much to handicap the diffusion of antidepressants in general practice. The authors conclude providing some clues both to those who, encouraged by the reading of this paper, should feel persuaded to deal with psychosomatic disorders from the general practitioners' point of view and to those who, for any reason, should not feel to tackle this task.

[Secretory lymphomas]

After a short introduction regarding the concept of "secreting" lymphoma and the most recent theories about the dynamics of normal and pathologic lymphocytes, resulting from the actual immunologic advancements and designed in order do give an explanation of some of the problems concerned with these diseases, such as "classification", "transmutation" of one type of lymphoma into another and the lymphoma/leukemia question, the authors go on describing few personal cases taken as examples. Finally, upon having pointed out that following now a day's whole population screening there is an always more increasing number of asymptomatic "secreting" lymphomas, casually diagnosed, the authors call the general practitioners' attention on the most common clinical and laboratory features that should lead to suspect a lymphoma of this type.