Evaluation and management of the sexually assaulted woman

The evaluation and management of the sexually assaulted woman is a challenging task that emergency physicians frequently face. The physician must assume dual roles as advocate for the patient and as an agent of the government. While caring for the immediate physical and emotional well being of the victim, the physician also must be diligent in the forensic evaluation and evidence collection. To receive quality care, the victim should receive a thorough history and physical examination with appropriate diagnosis and treatment of injuries, a thorough evidentiary examination, counseling and treatment for prevention of pregnancy and STDs, provisions for initial and ongoing mental health evaluation, and appropriate follow-up. To provide this high quality care, the physician must be familiar with the process of the evidentiary examination, have knowledge of the current recommendations for pregnancy and STD prophylaxis. and have thorough knowledge of the community resources that are available.

Vaginal bleeding in the first 20 weeks of pregnancy

The first and foremost diagnosis to exclude in the pregnant patient presenting with vaginal bleeding is ectopic pregnancy. Once ectopic pregnancy is ruled out, miscarriage should be considered as a clinical spectrum. Its management is directed according to the integrity of the internal cervical os and patient hemodynamic status. Treatment with anti-D immune globulin is warranted for all Rh-negative patients. Urgent obstetric consultation is necessary for most miscarriage presentations.

An unusual association of malignant melanoma and small cell lung cancer: case report. An eleven-year-follow-up

The authors report the case of a patient affected by malignant melanoma and small cell lung cancer. After having underlined the rareness of this pathological association, reviewing the most recent literature, the description of the clinical case aims at opening a discussion on how the surgical treatment performed, associated to chemotherapy, brought to an unhoped-for success, also helped by an unexpected combination of events that were absolutely out of any protocol. Eleven years later, at the present follow-up, the patient shows a complete remission of both diseases.

[Periareolar subcutaneous quadrantectomy: a new approach in breast cancer surgery]

Plastic and oncological breast surgery are becoming more and more closer as one surgical treatment. The term "oncoplastic surgery" refers to the use of plastic surgery techniques in breast cancer surgery, in order to avoid and to correct the adverse aesthetic findings. The care of cosmetic sequelae of breast cancer surgery has reached an important therapeutic role for psychological consequences of disease and because of the higher patients expectations of a good aesthetic result. Considering the concept of oncoplastic surgery, since 1999 the Authors began to use a periareloar approach in the breast conserving therapy (BCT), associated to axillary dissection performed through the same periareolar incision. This technique, original from the oncological point of view, is not different from the traditional quadrantectomy in the extension of the glandular resection, while the skin may be preserved in according to the conventional protocols of BCT. Oncological and aesthetic results have proved to be safe and satisfactory.

Use of mesh to repair the submuscolar pocket in breast reconstruction: a new possible technique

The reconstruction of the female breast after mastectomy has become a crucial part of primary breast cancer therapy. Setting of an implant is possible only in case of locally abounding soft tissue coverage and when no radiation has before performed. It is necessary a complete integrity of the submuscolar pocket and good blood supply of the skin to avoid failure of the procedure. In Author's experience, started since 1994, an immediate breast reconstruction after mastectomy is performed using gel-silicon implants directly when it was possible or setting first an expander. In six cases the condition of major pectoralis muscle after mastectomy was so foul that an immediate breast reconstruction with prosthesis was not realizable. However, the Authors tried a new technique using polypropylene mesh sutured on the major pectoralis muscle to cover the muscle partially destroyed. Preliminary data from the 6 pts seems to be encouraging.

[Randomized prospective study of early removal of drainage in breast cancer surgery]

Axillary seroma is absolutely the most frequent complication of breast cancer surgery. The Authors have accrued 100 consecutive breast cancer patients in a randomized study in order to compare seroma incidence by removing drains on 2nd postoperative day (1st arm) versus 3rd postoperative day (2nd arm); 48 patients were accrued in the first arm and 52 in the second. All patients received a standard axillary dissection. Two suction drains were placed. A compressive medication was applied after surgery. Patients started physiotherapy on the 1st postoperative day. The overall seroma prevalence was 21%. We have 8/48 (16%) seromas in the 1st group and 13/52 (25%) in the 2nd. No significant differences were registered between two arms. Clinical seroma was treated by needle aspiration and medication with a steroid. Conclusions coming out from this study are: 1) early drains removal doesn't increase seroma rate; 2) axillary clearance has to be performed removing en bloc the fatty tissue respecting surgical plains; 3) apply a compressive bandaging; 4) early arm physiotherapy; 5) medication with steroid may reduce the fluid formation.

Surgery in Italy

During the past 15 years, surgery in Italy has undergone significant developments in health care services at the teaching and organizational levels. In 1987, the new teaching regulations of medical and surgical schools came into force with the introduction of integrated courses that converge into educational and training areas with precise objectives. For more than a decade, postgraduate schools have had a common guideline throughout the European community--becoming real "residencies." Surgical activity is provided by university hospital facilities and hospitals with a business administration that is completely autonomous as far as organization, income, management, technique, and accounts are concerned. Research guidelines for future developments are mainly addressed toward optimization of organization and use of the most recent technology. The widespread application of day surgery and video-assisted surgery substantiates this evolution of surgery in Italy.

Children creating language: how Nicaraguan sign language acquired a spatial grammar

It has long been postulated that language is not purely learned, but arises from an interaction between environmental exposure and innate abilities. The innate component becomes more evident in rare situations in which the environment is markedly impoverished. The present study investigated the language production of a generation of deaf Nicaraguans who had not been exposed to a developed language. We examined the changing use of early linguistic structures (specifically, spatial modulations) in a sign language that has emerged since the Nicaraguan group first came together: In tinder two decades, sequential cohorts of learners systematized the grammar of this new sign language. We examined whether the systematicity being added to the language stems from children or adults: our results indicate that such changes originate in children aged 10 and younger Thus, sequential cohorts of interacting young children collectively: possess the capacity not only to learn, but also to create, language.

Oa1 knock-out: new insights on the pathogenesis of ocular albinism type 1

Ocular albinism type I (OA1) is an X-linked disorder characterized by severe reduction of visual acuity, strabismus, photophobia and nystagmus. Ophthalmologic examination reveals hypopigmentation of the retina, foveal hypoplasia and iris translucency. Microscopic examination of both retinal pigment epithelium (RPE) and skin melanocytes shows the presence of large pigment granules called giant melanosomes or macromelanosomes. In this study, we have generated and characterized Oa1-deficient mice by gene targeting (KO). The KO males are viable, fertile and phenotypically indistinguishable from the wild-type littermates. Ophthalmologic examination shows hypopigmentation of the ocular fundus in mutant animals compared with wild-type. Analysis of the retinofugal pathway reveals a reduction in the size of the uncrossed pathway, demonstrating a misrouting of the optic fibres at the chiasm, as observed in OA1 patients. Microscopic examination of the RPE shows the presence of giant melanosomes comparable with those described in OA1 patients. Ultrastructural analysis of the RPE cells, suggests that the giant melanosomes may form by abnormal growth of single melanosomes, rather than the fusion of several, shedding light on the pathogenesis of ocular albinism.

The use of the Valtrac ring in the upper and lower gastrointestinal tract, for single, double, and triple anastomoses: a report of 50 cases

The Valtrac biofragmentable anastomotic ring (V-BAR) technique has been widely used in clinical practice, particularly in anastomoses of the colon. The success of this method encouraged some surgeons to use it also in anastomosis of the small intestine. We are convinced that the method can be used successfully also in anastomosis of the small intestine and the upper gastrointestinal tract, particularly in cases of technically difficult and high-risk anastomoses. Between 1995 and 1998, we used the V-BAR in 35 patients, performing a total of 50 anastomoses. In 13 patients a double anastomosis was created in the same operation, and in one patient a triple anastomosis was created. In all we performed one end-to-end esophagojejunostomy, one gastrojejunostomy, six gastroileostomies, two duodenojejunal anastomoses, 13 end-to-end duodenoileostomies, one jejuno-jejunal anastomosis, 18 end-to-side ileoileal anastomoses, one ileocolic anastomosis, and seven colocolic anastomoses. Follow-up at between 2 and 36 months showed good overall results with regard to resumption of intestinal transit and canalization, even in those cases in which a double and triple suture was performed using the Valtrac ring. In our experience, the V-BAR can be used in upper gastrointestinal surgery with excellent results. Compared with manual sutures, the ring allows better and faster resumption of transit and canalization.

Identification and characterization of YME1L1, a novel paraplegin-related gene

A gene responsible for an autosomal recessive form of hereditary spastic paraplegia (SPG7) was recently identified. This gene encodes paraplegin, a mitochondrial protein highly homologous to the yeast mitochondrial AAA proteases Afg3p, Rca1p, and Yme1p, which have both proteolytic and chaperone-like activities at the inner mitochondrial membrane. By screening the expressed sequence tag database, we identified and characterized a novel human gene, YME1L1 (YME1L1-like1, HGMW-approved symbol). This gene encodes a predicted protein of 716 amino acids highly similar to all mitochondrial AAA proteases and in particular to yeast Yme1p. Expression and immunofluorescence studies revealed that YME1L1 and paraplegin share a similar expression pattern and the same subcellular localization in the mitochondrial compartment. YME1L1 may represent a candidate gene for other forms of hereditary spastic paraplegia and possibly for other neurodegenerative disorders.

The measurement of the pressure-volume curves with computerized methods

The authors analyze the physiological basis, technical aspects and clinical usefulness of several methods for pressure-volume curves determinations in mechanically ventilatory, acute respiratory failure patients.

[Preliminary results of biliopancreatic diversion in the treatment of morbid obesity. Clinical considerations on 69 patients with a 3-year follow-up]

BACKGROUND AND AIMS

The aim of this study was to evaluate the results obtained using Scopinaro's biliopancreatic diversion technique (AHS-BPD) in the surgical treatment of morbid obesity.

METHODS

A retrospective study was carried out in 69 patients with a follow-up ranging between 6-44 months. All patients were operated and monitored by the Obesity Surgery Centre operating in Sardinia since february 1995 at the Department of Emergency Surgery of Sassari University. All the patients were severely obese with a mean BMI of 51.58 and, in the majority of cases, presented associated metabolic diseases with the following incidence: type 2 diabetes in 40.57%, arterial hypertension in 36.23%, severe alteration of lipid status in 52.17%; in overall terms, a plurimetabolic syndrome was present in 24.63% of cases. All patients underwent biliopancreatic diversion using Scopinaro's classic technique (AHS-BPD). Controls were carried out at set intervals (1-3-6-12-18 and 24 months) to evaluate weight loss and the metabolic effects of surgery in terms of the lipid, glucose and protein status.

RESULTS

Results were good, as confirmed by the marked weight loss (BMI after 24 months: 30) and the normalisation of cholesterol and glycemia. No major reductions were observed in proteinemia and albuminemia levels.

CONCLUSIONS

In the light of these results, the authors affirm that Scopinaro's technique is a valid solution for the treatment of morbid obesity. Its relatively invasive nature is justified by the results obtained in terms of weight control and its effect on associated metabolic diseases.

Somatic cell hybrids for high-density mapping of chromosome 2 breakpoints in radiation-induced myeloid leukemia cell lines from inbred mice

Chromosome 2 (chr 2) deletions are recurrent abnormalities in acute myeloid leukemia (AML) induced by ionizing radiation in the mouse. The localization of deletion sites has proven extremely useful in providing information on the molecular mechanisms of leukemogenesis. The models available for the study of AML are mostly represented by inbred mouse strains, in which the molecular resolution of breakpoints is problematic. In this study, we have examined five leukemic cell lines exhibiting hemizygous chr 2 loss, derived from CBA, C3H, or (C57BLxCBA/H) F1 mice in which AML had been induced by a whole-body dose of radiation. By application of a somatic cell hybridization technique, we have generated interspecific cell hybrids retaining the deleted murine chr 2 homologue. This strategy permitted a very detailed genetic analysis allowing the utilization of any genetic marker on chr 2 without a requirement for polymorphism. Somatic cell hybrid clones were subjected to a high-density polymerase chain reaction-based microsatellite screening using 62-106 informative markers for each cell line. Detailed maps accurately defining chr 2 breakpoints were obtained. The identification of critical breakpoint markers allowed the construction of partial yeast artificial chromosome contigs across chr 2 breakpoints. These maps represent an essential resource for cloning of the breakpoint regions.

Emergency department evaluation and treatment of pelvic fractures

Pelvic fractures are associated with a high morbidity and mortality rate. This article reviews the anatomy of the pelvis, discusses fracture patterns commonly seen in patients with an injured pelvis, and proposes a new method of classifying pelvic fractures based on potential associated injuries. Finally, algorithms for the management of hemodynamically stable and unstable patients with pelvic fractures are presented.

Application of a computerised method to measure static pressure volume curve in acute respiratory distress syndrome

OBJECTIVE

To assess the safety and the bedside feasibility of a new computerised method to record the static pressure-volume curves (Pst/V) of the respiratory system.

DESIGN

The Pst/V curves were recorded in 13 medical patients with the acute respiratory distress syndrome (ARDS). During the Pst/V curve tracing the following parameters were recorded: time required for the recording and the automatic analysis of the Pst/V curve and modifications in electrocardiograms, blood pressure, and arterial oxygen saturation (SaO(2)).

SETTING

The study was performed in the intensive care unit of the University of Naples "Federico II".

RESULTS

No statistically significant modifications in heart rate (HR, b min(-1)), blood pressure (BP, mmHg), and SaO(2) were observed between conditions at baseline (HR 97.2 +/- 17.7; BP 65.4 +/- 9.3; SaO(2) 93.6 +/- 2.0), during the recording (HR 99.8 +/- 19.5; BP 66.2 +/- 11.6; SaO(2) 93.7 +/- 2.4), and 2 min after the procedure (HR 98.2 +/- 17.8; BP 65.2 +/- 11.7; SaO(2) 93.7 +/- 1.9). The Pst/V curves were recorded in 8.38 +/- 1. 19 min and fully analysed in 2.69 +/- 0.85 min. Mean value of static compliance was 41.1 +/- 12.7 ml cmH(2)O(-1). A lower inflection point was found in ten patients (mean value 9.2 +/- 1.9 cmH(2)O).

CONCLUSIONS

In ARDS patients, the present new computerised method gave valuable data to ordinary intensivists and was shown to be safe, easy, and fast.

[Total thyroidectomy in surgical treatment of euthyroid goiter]

BACKGROUND AND AIMS

The aim of this study was to compare the experiences and results achieved by a single surgeon using total thyroidectomy and partial exeresis in the treatment of uni- and multinodular euthyroid goiter.

METHODS

The results of two groups of operations performed at two different periods were analysed: a more recent group (1995-97) in which management tended to prefer total thyroidectomy, and a retrospective group (1984-1994) in which a more conservative attitude was adopted to benign thyroid pathology.

RESULTS

An analysis of the results and complications in each group showed that there were no statistically significant differences between the percentage of recurrent and parathyroid lesions during total thyroidectomy and partial exeresis. In practice, the risk of these lesions is higher during redo surgery for cancer and/or recurrence. The recidivation of goitrogenic pathology is high, amounting to around 29% of total cases. The most significant findings, however, which further justifies the use of total thyroidectomy is the increasingly frequent observation of "occult carcinomas" within the benign pathology, registered in the retrospective group (13.27%) and in the more recent one (12.35%).

CONCLUSIONS

On the basis of this analysis, the authors confirm their support for the use of total thyroidectomy on principle as the correct and rational treatment for euthyroid goiter, and reserve the use of conservative treatment for single nodular lesions where it is possible to perform a correct hemithyroidectomy and isthmectomy following the patient's informed choice.

[Follow-up chest radiography in surgical breast cancer patients]

PURPOSE

We investigated to what extent the diagnostic findings of chest radiography can improve prognosis and treatment in surgical breast cancer patients. We also reviewed the literature and our personal findings to choose the optimal follow-up frequency to meet therapeutical and management needs, including radiation protection.

MATERIAL AND METHODS

We retrospectively reviewed 1556 chest radiographs of 195 surgical patients with M0 breast cancer performed January 1990 to December 1996. Patient's history and clinical data were accurately reviewed to investigate the relation between protocol type and results. The maximalist or intensive protocol featured 3 chest radiographs a year, even in the absence of any specific signs; the results were reviewed in terms of early diagnosis and prolongation of life.

RESULTS

Only 13% of the examinations had been performed following a specific clinical indication, while 87% had been performed for a generic referral. Recurrences were found in 0.6% only of the latter examinations, which means that radiography provided no diagnostic improvement or important change in treatment in as much as 99.4% of cases. In 1997 radiographic follow-up was made triannual instead of biannual as it used to be.

DISCUSSION AND CONCLUSIONS

In the absence of specific clinical indications, chest radiography can be performed in the two projections once a year. More aggressive protocols requiring more frequent examinations are not justified, as the patient's life expectancy is not increased. Yearly examinations permit to meet economic and management needs, with a better use of time, staff and materials. Moreover, the clinical-diagnostic yield is not affected by the skipping of unselected examinations. Finally, another pro is the technical thoroughness of the examination with orthogonal projections and the possibility to use ionizing radiations, which improves the management of clinical risks. Maximum radiologist-oncologist cooperation in clinical practice can improve both diagnostic efficiency and treatment efficacy, by reducing the population dose and rationalizing the use of human, instrumental, structural and financial resources.

A case of primary hydatidosis of the thyroid gland

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

A case of primary hydatidosis of the thyroid gland

A 54-year-old woman presented with an expansive mass in the anterior cervical region (front of the neck) with abscess. Laboratory tests and thyroid profile proved normal. Surgical exploration revealed a hydatid cyst in the left lobe of the thyroid gland with parasitic metastasis of the left lateral cervical lymph node chain. Postoperative examination of the nodule showed it to be a solitary primary thyroid hydatid cyst.

Mass casualty triage knowledge of military medical personnel

During battlefield and mass casualty incidents, triage has been traditionally performed by many different personnel, including medics, nurses, dentists, and physicians. The objective of this study was to determine which military medical providers are most knowledgeable in mass casualty triage. The design was a prospective, written, timed, case-based examination of triage knowledge. Participants were volunteers from the active duty medical (physician), dental, nursing, and enlisted corps of the three military services. Subjects completed a 16-minute written examination consisting of seven cases in each of three simulated mass casualty scenarios: combat; nuclear, biological, and chemical; and humanitarian. Tests were taken anonymously, although demographic data on medical specialty, training, and experience were collected. Participants were instructed to classify the cases using the NATO categories of immediate, delayed, minimal, or expectant. Scores were tabulated according to two grading scales: an absolute scale of number correct, and a weighted scale amplifying gross misclassifications. Median scores between groups were tested pairwise using the Kruskal-Wallis one-way analysis of variance with p < or = 0.05. Statistically significant differences were noted between the highest and lowest scoring groups in each scenario. Our conclusion is that among the subject groups tested, physicians were best at mass casualty triage. Dentists, nurses, and medics scored progressively less well on our examination.

Orally administered ranitidine plasma concentrations before and after biliopancreatic diversion in morbidly obese patients

BACKGROUND

Patients undergoing biliopancreatic diversion (BPD) may develop gastric ulcers, particularly within the first postoperative year. The prophylactic use of antisecretory compounds at the usual therapeutic doses, mainly conventional H2-receptor antagonists such as ranitidine, may reduce the incidence of this complication, which occurs in approximately 5% of patients after BPD.

METHODS

The authors measured the plasma concentrations of ranitidine (300 mg orally) in obese patients, before and 8 months after BPD, and in control subjects of normal weight. The study included 11 obese patients undergoing BPD (age 45+/-14 years; preoperative and postoperative weights 124+/-21 and 92+/-11 kg) and 10 normal-weight subjects (age 37+/-13 years, weight 67+/-9 kg).

RESULTS

Postoperative ranitidine plasma concentrations showed only minor differences from preoperative levels, with slightly higher maximum concentrations occurring sooner. The mean area under the curve was on the average 30% higher than preoperatively. All parameters, however, were similar to those in control subjects.

CONCLUSIONS

BPD per se does not greatly affect the pharmacokinetic behavior of ranitidine, and therefore a conventional dosage regimen appears adequate for the prophylaxis and therapy of gastric ulcers associated with this operation.

[Normal value of the tracheal bifurcation angle and correlation with left atrial volume]

PURPOSE

We evaluated the mean value and the variability range of the tracheal bifurcation angle by patient gender, age, height, weight, build, body area and max transverse diameter of the chest under normal conditions. We also evaluated tracheal bifurcation angle changes in orthostatism and recumbency, as well as in the different respiratory phases. Finally, we investigated the statistical correlation between the tracheal bifurcation angle value and the left atrial volume, to eventually derive either value from the other.

MATERIAL AND METHODS

We reviewed 700 high-voltage radiographs of the chest performed in 500 patients with normal echocardiographic findings from 1986 to 1990. To analyze the relationships with the left atrium, 100 patients with echocardiographically enlarged atrium were submitted to high-voltage radiography. The tracheal bifurcation angle was measured directly.

RESULTS

Mediastinal radiographs nearly always depict the trachea and extraparenchymal bronchi adequately. The tracheal bifurcation angle should be measured continuing and joining the upper and lower parabronchial contours. A 4-degree deviation is accepted between the upper or interbronchial and lower or carinal angles since the angles formed by parallel segments have the same value. Under normal conditions the absolute mean value of the tracheal bifurcation angle was 79.7 degrees and the range 37-105 degrees.

DISCUSSION AND CONCLUSIONS

In normal patients the mean value of the tracheal bifurcation angle: is independent of age and gender; depends on build; is related to the max transverse diameter of the chest and to body area; exhibits no major radiographic changes in orthostatism versus recumbency; exhibits no major radiographic changes in expiration versus inspiration; is correlated with left atrial volume, but the value is not statistically significant.