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OBJECTIVE: Human brucellosis is a zoonosis with an extremely wide spectrum of clinical manifestations. Focal splenic involvement is very uncommon, particularly in the pediatric age group, during the illness' acute phase. CASE REPORT: A 4-year-old boy, already receiving third-generation cephalosporin treatment, was transferred from a local hospital to the University Pediatric Department for fever, anemia, increased inflammation index, and multiple, hyper-echogenic splenic lesions on abdominal ultrasound. Initial diagnostic laboratory investigations for Brucella infection, including the Widal-Wright test, were found to be negative. However, further diagnostic laboratory analysis using the chemiluminescent immunoassay was positive for Brucella IgM antibodies. Treatment with rifampicin at a dose of 150 mg/Kg/twice daily and co-trimethoprim at a dose of 80 mg/Kg/twice daily was started and continued for 7 weeks. IgM antibodies were undetectable after 2 weeks of treatment, and after 6 weeks of treatment, abdominal ultrasound documented a reduction of the diameter of the major splenic infiltrate from 1 to 0.5 cm. At 3 and 5 months of follow-up, re-evaluation of the abdominal lesions displayed complete resolution of the splenic lesions and a complete clinical recovery. CONCLUSIONS: The present case and a literature review are presented in this study since a standard diagnostic laboratory evaluation for brucellosis may miss the diagnosis, and in suspected cases, the laboratory analysis should be extended. Splenic abscesses are known to be rare in brucellosis, but the diagnosis should be considered in children with severe focal lesions, as specific antibiotic treatment may result in complete clinical recovery.

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Surgery for impacted third molar is often characterized, in the postoperative period, by pain, trismus and swelling. The study evaluates temperature variations of mucosa and skin after application of ice packs, in three different modalities, to the region overlying the surgical site. The goal was to identify any correlation between variations of temperature and postoperative clinical symptoms. For this purpose we selected 54 patients programmed for impacted third molar surgery. The patients were divided into three groups of 18. Time and frequency of application of the ice pack varied in the three groups; 5'/30' (group 1); 10'/60' (group 2); 20'/60' (group 3). During the four hours following surgery, temperatures of mucosa and of skin at the surgical site were measured with high-precision thermocouples, maximum response 5". The results indicate that application of an ice pack for 5'/30' or for 10'/60' controls the temperature of the mucosa post-surgery more effectively, and that the duration of surgery appears not to influence temperature variations. In the postoperative phase we recommend a rational application of ice packs appropriate to the constitution of each patient.

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BACKGROUND: Several longitudinal studies report that allergic sensitization increases with age from childhood to adulthood. OBJECTIVE: To evaluate whether an age-dependent tendency to become sensitized to new classes of allergens is present in atopic children, we studied retrospectively the changes in allergic sensitization in 165 asthmatic patients, monosensitized (ie, sensitized to only one class of allergens) in the first survey. METHODS: All the children (18 months to 8 years at enrollment), attended our outpatient clinics twice, at time intervals ranging from 2 to 10 years. On each visit, sensitization to house dust mites, pollens, animal danders, and molds was determined by skin prick test. RESULTS: We found that 43.6% (n = 72) of the patients became polysensitized on the second survey. According to age on first survey, the patients were further divided into two age groups: (1) group 1 = 18 months to < 5 years old (n = 98) and (2) group 2 = 5 to 8 years (n = 67). The transition from monosensitization to polysensitization observed in the entire population was present in both groups: 47 (47.9%) of the 98 children in group 1 and 25 (37.3%) of the 67 children in group 2 showed to be sensitized to more classes of allergens, as compared with first survey. Both in the whole population and in the two age subgroups, the changes in the frequency of monosensitization between the two evaluations were time-dependent (P < .05, each Chi(2)). Finally, to investigate whether monosensitization to a specific class of allergens could favor the development of polysensitization, we evaluated the frequency of polysensitization in the second survey in patients originally monosensitized to house dust mites or to pollens. We found that of the 130 patients originally monosensitized to house dust mites, 59 became polysensitized (45.4%), while of the 28 patients originally monosensitized to pollens, 9 became polysensitized (32.1%) (P > . 1). Similar results were obtained when patients were divided into age groups. CONCLUSION: These data demonstrate that (1) monosensitized children are likely to become polysensitized and (2) house dust mite sensitization and, at a lower degree, pollen sensitization, apparently seem to play a "triggering" role in the development of polysensitization, since a high proportion of children originally monosensitized to house dust mites or to pollens became polysensitized.

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BACKGROUND: The impacted third molar is often excised in the absence of clear signs of disease. On this basis and taking also into account the usual surgical hazard, an analysis of the post-surgical behavior of 100 patients that had undergone excision of the impacted third molar, is made. METHODS: All patients were observed and treated by the same surgeon and were divided into two distinct groups based on the position and depth of the tooth in the bone as observed by orthopantomography. In the first group of patients, bone fenestration was carried out by the use of mallet and gouge and the tooth was excised without odontotomy. In contrast, in patients of the second group, odontotomy always preceded tooth excision. Patients of both groups were analyzed for several different parameters including age, sex, the reason for surgery, tooth position according to Pell and Gregory, the length of excision and, finally, swelling and the reduced mouth opening that occur after surgery. RESULTS AND CONCLUSIONS: Data reported indicate non-proportional results between the two groups; there is no apparent relation between post-surgical swelling and mouth opening, the latter being always present and very pronounced.

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The study was designed to investigate the effect of creatine monohydrate ingestion (20 g daily for 5 days) on performance in 45 s maximal continuous jumping and in all-out treadmill running at 20 km x h(-1), (inclination 5 degrees, duration approximately 60s). The participants were qualified sprinters and jumpers. The effect of creatine was compared with placebo in a double-blind design. Creatine (Cr) supplementation led to a significant enhancement of performance capacity in the jumping test by 7% during the first 15 s and by 12% during the second 15 s of the exercise. The positive effect of Cr supplementation was not observed in the last third of the continuous jumping exercise, when the contribution of anaerobic metabolism was decreasing. The time of intensive running up to exhaustion improved by 13%. The results show that Cr supplementation helps to prolong the time during which the maximal rate of power output could be maintained.

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

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

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The authors performed a color Doppler ultrasound examination of both renal and interlobar arteries of 15 pregnant women affected by pregnancy-induced hypertension. The pulsatility index (PI), the resistance index (RI) and the systolic/diastolic ratio (S/D) values were compared with those of 15 healthy pregnant women of the same gestational age and with those of 15 nonpregnant healthy women. The authors found a significant difference (p < 0.0001) for all parameters investigated in renal and interlobar arteries between healthy pregnant women and the other two groups. No difference was found between patients with pregnancy-induced hypertension and nonpregnant healthy women. In conclusion, color Doppler ultrasound examination of both renal and interlobar arteries seems to be important for understanding the etiopathogenesis of pregnancy-induced hypertension.

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In order to test the possibility for rapid responses of blood hormone levels in short-term supramaximal exercises, serum concentrations of corticotropin (ACTH), cortisol (C), total testosterone (tT), free testosterone (fT), growth hormone (GH), thyrotropin (TSH), free thyroxine (fT4), free triiodothyronine (fT3), prolactin (PRL), insulin-like growth factor (IGF-I), and sex hormone-binding globulin (SHBG) were determined by RIA procedures in blood samples obtained before and immediately after a 60-s period of consecutive vertical jumps (Bosco test). The study subjects were 16 Italian professional soccer players. Immediately after exercise, significant increases (p < 0.05) were found in the concentrations of ACTH (by 39%), C (by 14%), TSH (by 20%), fT3 (by 28%), fT4 (by 30%), tT (by 12%), fT (by 13%), and SHBG (by 21%). Significant changes were not detected in the blood levels of GH, IGF-I and PRL. Most pronounced testosterone responses were typical for persons of high jumping performance (the increase of serum tT correlated with average power output, r = 0.61 and jumping height, r = 0.66). The larger the drop in power output during 60-s jumping, the higher was the thyroid response: the difference in jumping height between the first and last 15-s period correlated with increases in TSH (r = 0.52) and in fT4, (r = 0.55). In conclusion, the obtained results indicate that in intense exercise, causing the rapid development of fatigue, rapid increases in serum levels of hormones of the pituitary-adrenocortical, pituitary-gonadal and pituitary-thyroid systems occur.

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Between January 1989 and December 1994 we accomplished 130 CT-guided transthoracic fine needle aspirations (FNA) in 120 patients. Ten patients underwent a second FNA because of the negativity and doubts of the first. Diagnosis was targeted in 114 (95%) patients and 89% showed cytological evidence of malignancy. FNA-CT guided is reliable in the diagnosis of lung cancer, but less accurate in excluding diagnosis of malignancy. In our experience FNA had an accuracy with regard to lung cancer, of 92%. Sensitivity and specificity were respectively 93.8% and 100%. There were 6 false negative and 9 very negative. All patients should have bronchoscopy rather than FNA as the initial diagnostic procedure and perform it only in the absence of endobronchial lesions and malignant cells obtained with cytologic sputum or fiber bronchoscopy. In our experience 91 patients have lung cancer and thoracotomy was performed in 21% with confirm of diagnosis. FNA offers several advantages over other diagnostic procedures used in the evaluation of patients with intra-thoracic nodules and masses. The uses of small needles (20-22 gauge) and CT-guide has practically eliminated the risk of major haemorrhage. Deep and superficial lesions of the lung may be approached safely with FNA-CT guided and complications are no fatalities. Pneumothorax occurred in our experience in 5 cases and no occurred a chest drainage.

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An observed case of carcinoid tumor of the large-bowel in a 68-year-old woman leads to an analysis of the clinical-diagnostic and therapeutic aspects of this rare gastrointestinal tumour. Carcinoid tumour represents 0.8-1.5% of malignant digestive tumours, in 6% of cases it is localized in large-bowel and in 2-3% in cecal-bowel. In our experience there is no specific symptoms and diagnosis was based on postoperative histopathologic analysis. Right hemicolectomy with lymphadenectomy performed and the operative specimen included a 7 cm diameter tumour, which had narrowed the lumen by 80% and infiltrated ileocecal valve. Carcinoid tumour presents considerable problems of diagnosis because symptoms are aspecific. Diagnosis is possible only in patients with high urinary levels of 5-HIAA, in presence of carcinoid syndrome and by endoscopic biopsy when tumour infiltrated gastrointestinal mucosa. False negative cases are frequent in small carcinoids ( < 2 cm) because the tumour tissues are covered by integral mucosa. C.T., ultrasonography and angiography play a primary role in the diagnosis of this tumour but octreotide scintigraphy is very important for tumour and metastases localization in consequence of its ability to demonstrate somatostatin receptor positive tumours. Radical surgery is the only treatment in very little carcinoids to prevent metastases risk. Determinant risk factors are: primary size, localization, serosal penetration. In patients with any of these risk factors, resection with regional lymphadenectomy is recommended. Other prognostic factors include histologic differentiation, the presence of macroscopic residual disease after initial surgery and level of 5-HIAA in urine. We think that neither adjuvant chemotherapy, or radiotherapy may play a significant role in this neoplasm. Many authors report considerable unsuccessful with this treatment and it is used mainly for palliation. At present, the medical treatment of inoperable gastrointestinal carcinoid consist in association with interferon alpha and octreotide. During this treatment the size of the tumour is stable: reduction of symptoms and 5-HIAA urinary levels are noted.

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

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

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BACKGROUND: Bradykinin is a potent vasoactive peptide which has been proposed as an important inflammatory mediator in asthma since it provokes potent bronchoconstriction in asthmatic subjects. Little is known at present about the potential role of lung peptidases in modulating bradykinin-induced airway dysfunction in vivo in man. The change in bronchial reactivity to bradykinin was therefore investigated after treatment with inhaled phosphoramidon, a potent neutral endopeptidase (NEP) inhibitor, in a double blind, placebo controlled, randomised study of 10 asthmatic subjects. METHODS: Subjects attended on six separate occasions at the same time of day during which concentration-response studies with inhaled bradykinin and histamine were carried out, without treatment and after each test drug. Subjects received nebulised phosphoramidon sodium salt (10(-5) M, 3 ml) or matched placebo for 5-7 minutes using an Inspiron Mini-neb nebuliser 5 minutes before the bronchoprovocation test with bradykinin or histamine. Agonists were administered in increasing concentrations as an aerosol generated from a starting volume of 3 ml in a nebuliser driven by compressed air at 8 1/min. Changes in airway calibre were measured as forced expiratory volume in one second (FEV1) and responsiveness as the provocative concentration causing a 20% fall in FEV1 (PC20). RESULTS: Phosphoramidon administration caused a transient fall in FEV1 from baseline, FEV1 values decreasing 6.3% and 5.3% on the bradykinin and histamine study days, respectively. When compared with placebo, phosphoramidon elicited a small enhancement of the airways response to bradykinin, the geometric mean PC20 value (range) decreasing from 0.281 (0.015-5.575) to 0.136 (0.006-2.061) mg/ml. In contrast, NEP blockade failed to alter the airways response to a subsequent inhalation with histamine, the geometric mean (range) PC20 histamine value of 1.65 (0.17-10.52) mg/ml after placebo being no different from that of 1.58 (0.09-15.21) mg/ml obtained after phosphoramidon. CONCLUSIONS: The small increase in bronchial reactivity to bradykinin after phosphoramidon exposure suggests that endogenous airway NEP may play a modulatory role in the airways response to inflammatory peptides in human asthma.

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Neurokinin A (NKA) elicits a potent contractile effect in asthmatic airways. Its mechanism of action in bronchial asthma is still unknown. Recent work supports the view that NKA may stimulate mediator release from mast cells. To investigate the relative contribution of mast cell degranulation to the action of NKA, a randomized, double-blind study has been undertaken, to evaluate the effect of a potent and selective histamine H1-receptor antagonist, terfenadine (180 mg q.d., for three days), on bronchoconstriction provoked by inhaled NKA in six asthmatic subjects. Bronchial provocation tests with histamine were included in this study as control challenge. In the subjects studied, oral terfenadine, when compared to placebo, significantly increased the geometric mean (range) provocation dose of inhaled histamine required to reduce forced expiratory volume in one second (FEV1) by 20% of baseline (PD20) from 0.05 (0.03-0.08) mg (0.16 (0.10-0.26) mumol) to 1.19 (0.63-2.04) mg (3.88 (2.05-6.64) mumol). However, terfenadine failed to increase the airway responsiveness to NKA in all of the subjects studied, the geometric mean (range) PD15 NKA value being 0.94 (0.47-2.49) micrograms (8.36 (4.14-21.9 nmol) and 0.75 (0.48-1.59) micrograms (6.62 (4.23-14.0) nmol) after placebo and terfenadine, respectively. We conclude that NKA is a potent bronchoconstrictor agonist in asthma, being approximately 19 times more potent than histamine in molar terms. In this study on a small number of subjects, pharmacological intervention with oral terfenadine failed to achieve significant protection of the airways against the constrictor effect of NKA.(ABSTRACT TRUNCATED AT 250 WORDS)

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An observed case of leiomyosarcoma of the stomach in a 67 year old man leads to an analysis of the diagnostic, clinical and therapeutical aspects of this myoid tumour in the digestive tract representing 50-60% of cases. Symptoms are aspecific and gastric bleeding is the most common sign (50%). leiomyosarcoma always presents considerable problems of diagnosis and represents the most important among the various examined diagnostic investigations but it is maintained that surgery many times plays a primary role in the diagnosis of this tumour. The accuracy of gastrofiberoscopic biopsy is limited by frequent false-negative cases. False negative cases are obtained because the tumour tissues are usually covered by gastric mucosa and so the biopsy with standard forceps is too small and too superficial. The ultrasonographic finding of a gastric leiomyosarcoma is variegated, in fact it can be hyperechoic or hypoechoic. Frequently we can see echo-free spaces due to liquefactive necrosis and in such a case, an echogenic rim is demonstrable. According to our experience ultrasonography is very important in post-operative follow-up. The TC study can be considered superior to the other diagnostic investigations, in fact with it, detailed characteristics and location of the tumour, invasivity, metastatic dissemination, are recognized. It is still controversial the criterium concerning the diagnosis of malignant smooth muscle tumour of the gastrointestinal tract. We believe that number of mitoses (having five or more mitotic figures x 10 high-power fields), cellularity, pleomorphism, atypicality, together with macroscopic aspects (size, bleeding, ulcerations, necrosis, invasivity) are the most reliable indicators of malignancy.(ABSTRACT TRUNCATED AT 250 WORDS)

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

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