Pneumomediastinum, subcutaneous emphysema and pneumorrhachis in asthmatic children

Pneumomediastinum (PM), subcutaneous emphysema (SE) and pneumorrhachis (also known as epidural air (EDA) or epidural emphysema) are very rare findings in children. PM is defined as the passage of air from intra-alveolar space to interstitium and, later, to the mediastinum. From the mediastinum, the air may catch up subcutaneous tissue (usually of the neck) and/or epidural space via the cervical fascial planes and neural foramina, forming respectively SE and EDA. The PM can be divided in spontaneous (or idiopathic) and secondary PM. Only few studies have evaluated the exact incidence of PM and its complications in children, and to define the correct diagnostic work up, treatment and outpatient follow-up. We report the case of a 9-year-old child with undiagnosed asthma that, during severe asthmatic flare secondary to acute infection of high airway, developed PM, SE and EDA.

West Nile Virus Surveillance in the Lombardy Region, Northern Italy

In 2013, the circulation of West Nile virus (WNV) was detected in the Lombardy region and the following year a surveillance programme was activated with the aim of early identification of the viral distribution in mosquitoes and wild birds. A total of 50 959 Culex spp. mosquitoes grouped in six hundred and forty-seven pools as well as 1400 birds were screened by RT-PCR for the presence of West Nile virus leading to the identification of the viral genome in 32 mosquito pools and 13 wild birds. The surveillance was able to detect the WNV circulation on an average of 42 days (CI 95% 29.98-53.86; Student's t-distribution) before the occurrence of human West Nile disease (WND) cases in the same area. These results demonstrate the presence of WNV in the Lombardy region and confirm entomological and wild birds surveillance as an effective measure for the early identification of WNV circulation in infected areas, thus providing a useful and cost-effective tool for the public health authorities in the application of measures to prevent human infection.

Evaluation of Humoral Response and Protective Efficacy of an Inactivated Vaccine Against Peste des Petits Ruminants Virus in Goats

Four goats were inoculated with an inactivated peste des petits ruminants virus (PPRV) vaccine. Three unvaccinated goats were kept as controls. After 36 days, the four goats were revaccinated. The immune response was monitored by virus neutralization test showing that two doses of the vaccine were able to stimulate strong immune response in all the vaccinated animals. The vaccinated goat and the controls were challenged with virulent PPRV intranasally. After PPRV challenge, the three control goats showed fever, viremia and virus excretion through mucosal surfaces, whereas the vaccinated goats were fully protected against PPRV infection and replication.

Successful HLA haploidentical myeloablative stem cell transplantation for aggressive hepatosplenic alpha/beta (αβ) T-cell lymphoma

Hepatosplenic T cell lymphoma (HSTCL) is a type of hematologic neoplasia with a poor prognosis and a high frequency of refractoriness to conventional chemotherapy. The results obtained by high dose chemotherapy followed by autologous stem cells transplantation seem to be a more effective option but still unsatisfactory. Also the role of allogeneic stem cell transplantation is still unclear, although the few cases reported on the literature would seem to show good results in overall survival rates.

In this paper, we reported the patient׳s medical history affected by a αβ variant of hepatosplenic T cell successfully rescued with a haploidentical transplant.

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Hepatosplenic T-cell lymphoma is associated with a poor prognosis.

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Allogeneic stem cell transplantation has a role in treatment of refractory lymphoma.

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The haploidentical SCT may offer a strategy in patients without a matched donor.

Development and Preliminary Evaluation of a New Real-Time RT-PCR Assay For Detection of Peste des petits Ruminants Virus Genome

A duplex real-time reverse transcription-polymerase chain reaction (qRT-PCR) assay was developed for a simple and rapid diagnosis of Peste des petits ruminants (PPR). qRT-PCR primers and TaqMan probe were designed on a conserved region of nucleocapsid protein (Np) of PPR virus (PPRV) genome. An in vitro transcript of the target region was constructed and tested to determine analytical sensitivity. Commercial heterologous Armored RNA(®) was used as an internal positive control (IPC) for either RNA isolation or RT-PCR steps. The detection limit of the newly designed duplex real-time RT-PCR (qRT-PCR PPR_Np) was approximately 20 copies/μl with a 95% probability. No amplification signals were recorded when the qRT-PCR PPR_Np was applied to viruses closely related or clinically similar to PPRV- or to PPR-negative blood samples. A preliminary evaluation of the diagnostic performance was carried out by testing a group of 43 clinical specimens collected from distinct geographic areas of Africa and Middle East. qRT-PCR PPR_Np showed higher sensitivity than the conventional gel-based RT-PCR assays, which have been used as reference standards. Internal positive control made it possible to identify the occurrence of 5 false-negative results caused by the amplification failure, thus improving the accuracy of PPRV detection.

Schmallenberg virus in Italy: a retrospective survey in Culicoides stored during the bluetongue Italian surveillance program

Following the first case of Schmallenberg (SBV) in northern Italy in February 2012, virus detection was conducted on midges collected during the national entomological surveillance program for bluetongue (BT). Six cattle farms, within a radius of 50 km from the SBV case, were selected for a 12 month study, aiming to determine when the virus entered the area, if it was capable of overwintering, and the possible role played by each species of the Obsoletus complex in disseminating the infection. A total of 33,724 Culicoides were collected at the six sites between June 2011 and June 2012. Species belonging to the Obsoletus Complex were the most abundant (94.44%) and, within the complex, Culicoides obsoletus was the most prevalent species in the studying area (65.4%). Nearly 7000 Culicoides midges were screened, either in pools or individually, for SBV by real-time RT-PCR. Viral genome was detected in six pools of the Obsoletus complex, collected at three sites between September and November 2011, and in a single parous female of C. obsoletus, collected in May 2012. As a result of the BT surveillance program in Italy it was possible to demonstrate, retrospectively, that SBV has circulated in at least three Italian provinces since early September 2011, nearly 5 months prior and as far as 40 km away from the first detected case. Similarly, the survey confirmed the presence of SBV in the vector population 3 months after the outbreak, following a cold winter during which the blacklight traps failed to catch active adult midges.

Bluetongue serotype 2 and 9 modified live vaccine viruses as causative agents of abortion in livestock: a retrospective analysis in Italy

The recent outbreak caused by Schmallenberg virus, which affected sheep, goats and cattle in Europe, highlighted the importance of having a robust surveillance plan capable of monitoring abortions and malformations in the livestock offspring. In this context, bluetongue viruses (BTVs) represented and represent one of the major threats to the European livestock industry. Aiming to improve the understanding on BTV cross placental transmission and serotype involvement, in this retrospective study foetal spleens and/or brains of 663 ovines, 429 bovines, 155 goats and 17 buffaloes were tested for the presence of BTV by virus isolation. BTV vaccine strains were isolated from 31 foetuses (2.4%; 95% CI: 1.7-3.4%): 24 (3.6%; 95% CI: 2.4-5.3%) from ovine foetal tissues; 6 (1.4%; 95% CI: 0.6-3.0%) from bovine foetal tissues and 1 (0.6%; 95% CI: 0.2-3.5%) from the spleen of a caprine foetus. All foetuses were from animals vaccinated with either BTV-2 or BTV-2, and BTV-9 modified live vaccines (MLVs) produced by Onderstepoort Biological Products (OBP), South Africa. Among the 31 isolated vaccine strains, serotype 9 (n = 28) was more frequently isolated (P < 0.05) than serotype 2 (n = 3). In two cases infectious vaccine strains were found in the foetal tissues 2 months after the vaccine administration. Other pathogens known to be causative agents of abortion in ruminants were not detected nor isolated. This study demonstrates, for the first time, that BTV-2 and BTV-9 vaccine strains are able to cross the placental barrier of sheep, cattle and goats. BTV-2 and BTV-9 vaccine strains are able to infect foetuses and cause abortions or malformations depending on the period of pregnancy at the time of vaccination.

Predictors of attack severity and duration in multiple sclerosis: a prospective study

Objective:

To evaluate predictors of severity and duration of early Multiple Sclerosis (MS) attacks.

Methods:

We analyzed 248 attacks in 95 patients in a prospective study. Severity: the difference between the EDSS score at the day of maximum worsening and the EDSS score before the onset of the attack. Duration: the time between the date of onset of the first symptom and the date of maximum improvement of the last symptom.

Results:

The number of involved Functional Systems (FS), FS type (brainstem and pyramidal), and total attack duration were linked to severity. Number of FS involved, FS type (sphincteric and sensory), and severity of the attack were related to duration. Neither severity nor duration were correlated to other predictors: gender, age and season at attack onset, speed of onset, infections in the preceding month, age at first attack, season of birth and first attack, CSF examination, first brain MRI, recovery from the first attack. In the multivariate analysis, the Odds Ratio (OR) and Confidence Intervals (CI) for severe attacks was 3.6, 1.7-7.7 for involvement of pyramidal FS, 2.6, 1.2-6.0 for brainstem and 2.5, 1.2-5.3 for long attack duration. Sphincteric (4.4; 1.7-11.0) and sensory FS (1.8; 1.0-3.2) were the only variables explaining duration. The probability of a second moderate/severe or long attack was not influenced by severity or duration of the first.

Conclusion:

FS are predictive of severity and duration of early MS attacks. Severity and duration of the first attack do not predict severity and duration of the second.

Epizootic heamorragic disease

Epizootic haemorrhagic disease (EHD) is an infectious non-contagious viral disease transmitted by insects of the genus Culicoides which affects wild and domestic ruminants. The causative agent, the epizootic haemorrhagic disease virus (EHDV), belongs to the family Reoviridae, genus Orbivirus and shares many morphological and structural characteristics with the other members of the genus such as bluetongue, African horse sickness and equine encephalosis viruses. In recent years EHD outbreaks have been reported in countries bordering the European Union. They caused disease in cattle and severe repercussion on the livestock industry of the affected countries. In the light of recent European bluetongue epizootic these events pose an increasing threat to the European Union. This review includes the most recent information regarding the virus and the disease as well as tools for its diagnosis and control. It is our conviction that more attention should be drawn to both EHDV and the disease itself in order to fulfil all these gaps and not to be unprepared in case future possible incursions.

Progressive multifocal leucoencephalopathy after autologous bone marrow transplantation: a treatment option

A patient with multiple myeloma was treated with high-dose chemotherapy followed by two autologous bone marrow transplantations (ABMTs). Nine months after the second ABMT the patient complained of severe left hemiparesis, paraesthesias, left homonymous visual field defects and gait ataxia. She was diagnosed with progressive multifocal leucoencephalopathy (PML) confirmed by detection of JC virus (JCV) DNA and prescribed cidofovir every other week and mirtazapine daily. Her symptoms and signs remained stable and after 6 months the JCV DNA was undetectable in the cerebrospinal fluid. Repeated MRI scans demonstrated the stabilisation of demyelinating lesion volume; after more than 2 years of follow-up the patient's neurological examination does not show significant variations. Combination of cidofovir and mirtazapine may be helpful in the treatment of PML in HIV-negative patients.

Re-emergence of West Nile virus in Italy

In August 2008, West Nile disease re-emerged in Italy. The infection is affecting the North Eastern regions and, as of November 2008, has caused 33 clinical cases and five fatalities in horses. Until now, no deaths have been reported in birds. Mosquitoes, blood, serum and tissue samples, from horses and birds, within and around the outbreak area, have been collected and tested by various methods both serologically and virologically. West Nile virus strains have been isolated from blood samples of one horse and one donkey and from pools of brain, kidneys, heart and spleen of a pigeon and three magpies. When compared to the strain isolated during the 1998 Tuscany outbreak, the 255 bp sequence of the genome region coding for the envelope (E) protein of the isolated WNV strains, exhibited a 98.8% and 100% similarity at nucleotide and amino-acid level respectively.

[Lung cancer with bronchial stenosis due to foreign body and Entoameba gingivalis infection]

Oral cavity infection by protozoarian agents may lead to pathologies such as stomatitis and gengivitis. An higher incidence has been reported in immunocompromised patients and in patients with dental disorders. Entoameba gingivalis localizes into oral cavity and in particular into interstitial and interdental spaces. Infection propagation to bronchial or lung parenchyma represents a complication. In this report the Authors, starting from a recently treated case, discuss on the incidence, complications and surgical management of lung infection by Entoameba gingivalis.

Do simple ventilation and gas exchange measurements predict early successful weaning from respiratory support in unselected general intensive care patients?

BACKGROUND

The value of respiratory variables as weaning predictors in the intensive care unit (ICU) is controversial. We evaluated the ability of tidal volume (Vt(exp)), respiratory rate (f), minute volume (MV(exp)), rapid shallow breathing index (f/Vt), inspired-expired oxygen concentration difference [(I-E)O(2)], and end-tidal carbon dioxide concentration (Pe'(co(2))) at the end of a weaning trial to predict early weaning outcomes.

METHODS

Seventy-three patients who required >24 h of mechanical ventilation were studied. A controlled pressure support weaning trial was undertaken until 5 cm H(2)O continuous positive airway pressure or predefined criteria were reached. The ability of data from the last 5 min of the trial to predict whether a predefined endpoint indicating discontinuation of ventilator support within the next 24 h was evaluated.

RESULTS

Pre-test probability for achieving the outcome was 44% in the cohort (n=32). Non-achievers were older, had higher APACHE II and organ failure scores before the trial, and higher baseline arterial H(+) concentrations. The Vt, MV, f, and f/Vt had no predictive power using a range of cut-off values or from receiver operating characteristic (ROC) analysis. The [I-E]O(2) and Pe'(co(2)) had weak discriminatory power [area under the ROC curve: [I-E]O(2) 0.64 (P=0.03); Pe'(co(2)) 0.63 (P=0.05)]. Using best cut-off values for [I-E]O(2) of 5.6% and Pe'(co(2)) of 5.1 kPa, positive and negative likelihood ratios were 2 and 0.5, respectively, which only changed the pre- to post-test probability by about 20%.

CONCLUSIONS

In unselected ICU patients, respiratory variables predict early weaning from mechanical ventilation poorly.

Clinical evaluation and treatment of acute asthma exacerbations in children

This update on treatment of asthma exacerbations in children is the result of an Italian Pediatric Society Task-force, made up of a panel of experts working in 2007-2008. The aim is to give clear indications on the use of the drugs most employed in children, grading the quality of evidence and the strength of recommendations. Suggestions on their limits due to unlicensed and off-label use are reported. The level of evidence and the strength of recommendations for different therapeutic approaches demonstrate that frequently the use of drugs in children is extrapolated from the experience in adults and that more studies are required to endorse the correct use of different drugs in asthmatic children.

West Nile virus transmission in 2008 in north-eastern Italy

After 10 years, West Nile virus (WNV) re-emerged in Italy in August 2008. As on 31 December 2008, the infection affected eight Provinces in three Regions (Emilia Romagna, Veneto, Lombardy), where a total of 794 cases of WNV infection in 251 equine stables were detected on the basis of the clinical signs and as a result of a serological screening in horses living in the area. Only 4.0% (32/794) of the serologically positive animals showed clinical signs, and the 32 clinical cases were reported in 18 different farms. The observed case-fatality rate was 15.6% (5/32). The confirmed clinical cases were detected from end August to mid October. Significant levels of positivity by RT-PCR were also observed in magpies (Pica pica) (9.1%, 95% confidence levels: 6.1-13.4%), carrion crows (Corvus corone) (7.4%, 95% confidence levels: 3.6-14.4%) and rock pigeons (Columba livia) (12.9%, 95% confidence levels: 7.6-21.2%).

First human case of Usutu virus neuroinvasive infection, Italy, August-September 2009

We report the first worldwide case of Usutu virus (USUV) neuroinvasive infection in a patient with diffuse large B cell lymphoma who presented with fever and neurological symptoms and was diagnosed with meningoencephalitits. The cerebrospinal fluid was positive for USUV, and USUV was also demonstrated in serum and plasma samples by RT-PCR and sequencing. Partial sequences of the premembrane and NS5 regions of the viral genome were similar to the USUV Vienna and Budapest isolates.

First human case of Usutu virus neuroinvasive infection, Italy, August-September 2009

We report the first worldwide case of Usutu virus (USUV) neuroinvasive infection in a patient with diffuse large B cell lymphoma who presented with fever and neurological symptoms and was diagnosed with meningoencephalitits. The cerebrospinal fluid was positive for USUV, and USUV was also demonstrated in serum and plasma samples by RT-PCR and sequencing. Partial sequences of the premembrane and NS5 regions of the viral genome were similar to the USUV Vienna and Budapest isolates.

Resection and end-to-end anastomosis for ascending aortic aneurysm: surgical technique

Treatment of ascending aortic aneurysm, without involvement of aortic sinuses of Valsalva, is usually treated by tube graft interposition. Nowadays, many alternative techniques were described. The technique of resection and end-to-end anastomosis has been already described both by our group and by other authors as well. This report will focus on some surgical details of this technique based on a ten-year-experience. The preoperative study of candidates amenable to undergo this technique has to be completed by a computed tomography-scan of thoracic aorta. The ideal candidate has an elongated aorta in the antero-lateral wall. As a consequence, the heart is usually displaced inferiorly and toward a more horizontal plane. The aortotomy is done circumferentially one and half cm above the aortic commissures. A wide wedge resection of the aortic wall is performed. The resected aortic wall is wider in the anterior part than in the posterior. A very accurate hemostasis of the fat tissue close to the pulmonary artery is achieved by diathermy. The amount of wedge resection is mainly dictated by the elongation of the aortic wall. In authors' experience it usually ranges between 4 and 6 cm anteriorly and 1 cm posteriorly. The suture of the two stumps is performed by a running suture. The technique described has extensively been used; up today 136 patients undergo. According to authors' opinion this technique can be a useful alternative to the tube graft interposition in selected patients.

Mesenchymal stem cell transplantation in amyotrophic lateral sclerosis: A Phase I clinical trial

Amyotrophic Lateral Sclerosis (ALS) is a devastating incurable disease. Stem-cell-based therapies represent a new possible strategy for ALS clinical research. The objectives of this Phase 1 clinical study were to assess the feasibility and toxicity of mesenchymal stem cell transplantation and to test the impact of a cell therapy in ALS patients. The trial was approved and monitored by the National Institute of Health and by the Ethics Committees of all participating Institutions. Autologous MSCs were isolated from bone marrow, expanded in vitro and analyzed according to GMP conditions. Expanded MSCs were suspended in the autologous cerebrospinal fluid (CSF) and directly transplanted into the spinal cord at a high thoracic level with a surgical procedure. Ten ALS patients were enrolled and regularly monitored before and after transplantation by clinical, psychological, neuroradiological and neurophysiological assessments. There was no immediate or delayed transplant-related toxicity. Clinical, laboratory, and radiographic evaluations of the patients showed no serious transplant-related adverse events. Magnetic resonance images (MRI) showed no structural changes (including tumor formation) in either the brain or the spinal cord. However the lack of post mortem material prevents any definitive conclusion about the vitality of the MSCs after transplantation. In conclusion, this study confirms that MSC transplantation into the spinal cord of ALS patients is safe and that MSCs might have a clinical use for future ALS cell based clinical trials.

[Pneumotorax and cannabis]

AIM

After having read the articles by Treasure and Beshay about the particular incidence of spontaneous pneumothorax (SP) in patients with daily consumption of Cannabis the authors took a strictly control of these subjects reviewing their personal experience in the treatment of this condition. In particular, the prevalence of SP has been evaluated through genomic assay of monocorial twins. The strong impact of the inflammatory phenomena that have always supported the emphysema burning is 10 time higher among worldwide population and patients with SP.

METHODS

In order to determine the real incidence of spontaneous pneumothorax in patients with proved daily assumption of Cannabis a retrospective analysis of patients with history of Cannabis drug abuse has been performed. In the period from January 2002 and June 2007,12 consecutive patients with SP and history of Cannabis abuse were enrolled. Selection criteria were: 1) age <16 years; 2) single-sided spontaneous pneumothorax; 3) history of daily Cannabis assumption. Patients with previous thoracic surgery/trauma and positive anamnesis for other drug assumption (ODA), snorkelling or work exposition to pollutions were excluded. In order to avoid the clinical overlapping of pathology and clinical symptoms due to other factors, patients with pleural effusion and documented similar episodes were excluded. This series focused on particular on twins. In all the patients an endopleuric drainage tube was inserted, and 3 patients underwent toracostomy.

RESULTS

No operatory mortality and/or complications were observed.

CONCLUSIONS

The role of the thoracic surgeon is important to sensitize on the problem of the circulation of light drugs among young people and their effects on the lung activity.

Health-related quality of life measures and psychiatric comorbidity in patients with migraine

BACKGROUND AND PURPOSE

The identification of factors associated to health-related quality of life (HRQoL) measures in patients with migraine has major implications in terms of prognosis and treatment. This study aimed at investigating associations between HRQoL and comorbid mood and anxiety disorders.

METHODS

Consecutive adult outpatients with a diagnosis of migraine with or without aura were assessed using the Mini International Neuropsychiatric Interview (M.I.N.I.) Plus version 5.0.0 and the Migraine-Specific Quality-of-Life Questionnaire (MSQ).

RESULTS

Data of 112 patients (82 females), 69 without aura, mean age 41.2 +/- 13.3 years were analyzed. According to the M.I.N.I., 50% patients had a lifetime or current DSM-IV diagnosis of mood or anxiety disorder. There was no between-groups difference in MSQ total and subscale scores in relation to the presence/absence of psychiatric comorbidity, independently whether that was current or lifetime. In the group of subjects with psychiatric disorders, age at onset of migraine correlated with MSQ-total (rho = -0.407 P = 0.002), and subscale scores (Role Function-Restrictive, rho = -0.397, P = 0.002; Emotional Function, rho = -0.487, P < 0.001).

CONCLUSIONS

Our findings suggest that current and/or lifetime psychiatric comorbidities are not associated with HRQoL measures in patients with migraine. However, patients with migraine and psychiatric comorbidities may represent a specific subgroup deserving particular attention for targeted interventions.

Chronic transverse sternal fracture. Role of CT scan and repair by an alternative use of the Synthes-Titanium Sternal Fixation System

Chest wall fractures, including injuries of the sternum, usually heal spontaneously without specific treatment. However sometimes, they need surgical treatment. To treat these patients the selection criteria often are subjective in spite of many surgical devices for sternal osteosynthesis are available nowadays. One of the most recent device is the Synthes-Titanium Sternal Fixing System, usually used to treat post-sternotomy dehiscence. We describe the case of a 67-year-old man with previous history of chest trauma presenting to our institution with chronic transverse sternal fracture. We describe the pre-operative study, stressing the particular role of the CT scan and a surgical approach by an alternative use of the Synthes.

Misunderstood cardiac involvement with heart impairment in traumatic sternal fracture: an enzyme-guided evaluation

BACKGROUND

Isolated sternal fractures occur more and more frequently in traffic road accidents in particular after the introduction of the seat-belt law. This study sets out to assess by laboratory parameters the incidence and consequences of pericardial and myocardial involvement in sternal injury.

PATIENTS AND METHODS

Between June 1997 and March 2007, 50 consecutive patients were admitted to our Thoracic Surgical Unit with acute traumatic sternal fractures. X-ray, CT scan, standard 12-lead electrocardiogram (ECG) and echocardiographic evaluation were obtained in all patients. (28 males, 22 females), with displaced and undisplaced fractures. The patients were hospitalised for cardiorespiratory monitoring, pain control and physiotherapy. Oxygen implementation was performed to obtain an arterial saturation above 96%. Supplementary investigations or therapeutic interventions were assessed if clinically indicated.

RESULTS

Our data, according to literature, show that sternal trauma must be careful evaluated by monitoring of vital parameters. In our collection we have no mortality with complex comorbidity. The interparametric relation between laboratory values and cardiac involvement was not significant anyway . The prolonged CK-MB peak level in a large number of patients is related with cardiac impairment.

CONCLUSIONS

Our results suggest that in traumatic sternal fractures enzymatic activity of CK-MB, echocardiographic investigation and careful monitoring for the first 96 hours are necessary. The cardiac compliance is inadequate in polytrauma patients and can lead to cardiac impairment.

Surgical treatment of pericardial cyst through median sternotomy

Pericardial cysts are an uncommon benign congenital anomaly in the middle mediastinum. They are thought to result from failure of fusion of one of the mesenchymal lacunae that form the pericardial sac. The authors present the case of a 77-year-old-man with a large pericardial cyst, treated by surgical resection trough a median sternotomy. They analyze the different diagnostic alternatives and the various management options in this pathology. In the reported case the authors used a surgical resection trough a median sternotomy, to facilitate the exposure of all of the cyst, extending around the great vessels area, and on the other side of the chest.

Acute renal failure and cardiac surgery

Acute renal failure (ARF) is s a major complication after cardiac surgery and its prevalence still remains high. Even minor changes in serum creatinine are related to an increase morbidity and mortality. Recently two consensus conferences have suggested new diagnostic criteria to define acute kidney injury and risk scores to better identify patients who will probably develop ARF after cardiac surgery. In fact a prompt recognition of high risk patients could allow a more aggressive therapy at a reversible stage of an incoming ARF. To date prophylactic strategies of renal function preservation during surgery include the avoidance of nephrotoxic insult and the prevention or correction of renal hypoperfusion. Although there are still no pharmacological agents able to prevent the perioperative ARF, several trials are investigating new pharmacological approaches. When prophylactic strategies fail and severe ARF occurs, renal replacement therapy becomes mandatory. The timing and the kind of renal replacement therapy remain an open issue. Further randomized case-control studies with adequate statistical power are needed to have more conclusive data. Aim of this paper is to start from the acute renal injury physiopathology to analyze the most common prophylactic and pharmacological strategies.

Phylogenetic analysis of West Nile virus isolated in Italy in 2008

In Italy the first occurrence of West Nile virus (WNV) infection was reported in Tuscany region during the late summer of 1998. In August 2008, the WNV infection re-emerged in Italy, in areas surrounding the Po river delta, and involving three regions Lombardy, Emilia Romagna and Veneto. WNV was isolated from blood and organs samples of one horse, one donkey, one pigeon (Columba livia) and three magpies (Pica pica). The phylogenetic analysis of the isolates, conducted on 255 bp in the region coding for the E protein, indicates that these isolates belong to the lineage I among the European strains. According to the analysis, both the 1998 and 2008 Italian strains as well as isolates from Romania, Russia, Senegal and Kenya fell in the same sub-cluster.

Phylogenetic analysis of West Nile virus isolated in Italy in 2008

In Italy the first occurrence of West Nile virus (WNV) infection was reported in Tuscany region during the late summer of 1998. In August 2008, the WNV infection re-emerged in Italy, in areas surrounding the Po river delta, and involving three regions Lombardy, Emilia Romagna and Veneto. WNV was isolated from blood and organs samples of one horse, one donkey, one pigeon (Columba livia) and three magpies (Pica pica). The phylogenetic analysis of the isolates, conducted on 255 bp in the region coding for the E protein, indicates that these isolates belong to the lineage I among the European strains. According to the analysis, both the 1998 and 2008 Italian strains as well as isolates from Romania, Russia, Senegal and Kenya fell in the same sub-cluster.

[Thoracic trauma: incidence, social and economic costs, educational opportunities. Experience on the last eight years of Thoracic Surgical Unit of Messina University]

The Authors, after extensive introduction on the incidence, etiology, classification, pathophysiology, possible complications, diagnosis and treatment of thoracic trauma, relate their experience on the last eight years, stressing the diagnostic and therapeutic strategy in management of trauma simple and complicated and assessing finally serious social impact of these pathologies and the educational opportunities provided.

Endovascular repair of aortic lesions associated to video-assisted thoracoscopy surgery after chest trauma

AIM

Trauma of the thoracic aorta for blunt trauma shows a very high incidence of mortality. Hospital mortality rate after aortic open surgery is between 15% and 30%. Endovascular management represents an alternative treatment Associated lesions are usually seen in those critical patients. Hemothorax may be present. The authors propose a combined treatment of endovascular repair for the aortic lesion and video-assisted thoracoscopy surgery (VATS) for the treatment of chest bleeding complications.

METHODS

The authors report a series of three patients with post-traumatic aortic lesion and hemothorax. In two patients endovascular procedure was first performed, followed by VATS, few days later, for retained hemothorax. In the third patient the two procedures were performed at the same time because of the patient's critical conditions.

RESULTS

There was technical success of stent-graft placement in all the treated cases. No postoperative mortality. No postoperative paraplegia. No VATS converted to thoracotomy. The postoperative follow-up time range between 10 and 19 months.

CONCLUSION

Considering the relatively short procedural time and minimally invasive approach of both techniques, the concomitant use of them may represent an alternative to standard open surgery in cases of thoracic aorta lesions associated with hemothorax. Those procedures may be performed sequentially or together in emergency cases with intra-thoracic more active bleeding to exclude or to treat intra thoracic bleeding.

Measuring the level and content of consciousness during epileptic seizures: the Ictal Consciousness Inventory

Ictal alterations of the level of general awareness and subjective content of consciousness play a pivotal role in the clinical phenomenology of epilepsy, and reflect the pathological involvement of different neurobiological substrates. However, no self-reported measures have been proposed for patients experiencing altered conscious states during seizures. This study describes the development and validation of a new scale for the quantitative assessment of the level and content of ictal consciousness, the Ictal Consciousness Inventory (ICI). The ICI is a 20-item questionnaire generated on the basis of interviews with patients, literature review, and consultation with experts. It was tested on a sample of 110 patients attending three different epilepsy clinics in Northern Italy, who also completed standardized clinical scales. Standard psychometric methods were used to demonstrate that this scale satisfies criteria for acceptability, reliability, and validity. The ICI is proposed as a user-friendly and clinically sound instrument for the measurement of ictal alterations of consciousness in patients with epilepsy.