[History of the sacral epidural block]

Blockade of the sacral plexus is associated with an interesting chapter in the history of anesthesia. Use of this technique peaked in the difficult early decades of the twentieth century, a time when inhaled anesthesia was in decline and regional and local techniques were gaining ground as alternatives. This article analyzes the history of sacral epidural anesthesia, in particular the Spanish contribution. Names like Salvador Gil Vernet, Manuel Usandizaga, José Botella, Santiago Dexeus, José Miguel Martínez and José Estella should be remembered for the important pioneering roles these anesthetists played in research and clinical practice. Although Spanish surgeons were not enthusiastic about the sacral plexus block, the Spanish history of the technique has been similar to that seen in other countries: at first there was a certain degree of enthusiasm, later the technique was nearly forgotten, and finally interest has returned in recent years, initially in obstetric analgesia and more recently in pediatrics.

[Intravenous urography is died. Long live the computerized tomography!]

Very important changes have happened in the field of the genitourinary image during the last half of the 20th century, so that for most of the historical intravenous urography indications, nowadays the computerized tomography (CT) is technique of choice. The aim of this report is to perform an update in the correct use of the imaging techniques in the adult-related most frequent urological pathology, including: urolithiasis, haematuria, infections, tumours, surgery follow-up and pyelectasis, specially focused in CT. A brief historical review of the urological imaging techniques is performed, emphasizing the physical principles. In the second part, the role played by plain X-ray, ultrasound, CT and MR in the different urological pathologies are reviewed, discussing the sensibility and specificity of each technique. A brief reflection is finally carried out over of the radiation doses.

Changes in concentrations of cortisol and melatonin in plasma, expression of synaptophysin, and ultrastructural properties of pinealocytes in goat kids in situations of stress due to early weaning: the effect of melatonin

AIM

To analyse the changes in some histo-physiological parameters of the pineal gland of goat kids in situations of stress due to early weaning, and the effect of exogenous treatment with melatonin.

METHODS

Twenty-four 6-day-old Verata goat kids were used; 12 suckled their dams throughout the study (non-weaned groups), and the other 12 were removed from their dams and fed a milk replacer (weaned groups). Six goat kids in each group were treated with melatonin, and the other six with double-distilled pyrogen-free water (Day 0). On Days 28-29, blood samples were collected at 0600, 1000, 1400, 1800, 2200, 0200 and 0600 hours, to determine concentrations of cortisol and melatonin in plasma. On Days 29 and 30, six animals per group (three at 1400 and three at 0200 hours, respectively) were subject to euthanasia and the weight of their pineal glands determined. The structural immunocytochemistry, morphometric analysis, ultrastructural analysis and immunotransmission electron microscopy of the pineal glands were established.

RESULTS

Concentrations of cortisol in plasma were significantly higher in weaned than in non-weaned goat kids (p<0.05), and treatment with melatonin reduced the concentrations in weaned kids (p<0.05). Concentrations of melatonin in plasma showed a similar pattern in the four groups, with peak values at 0200 and troughs at 1400 hours. Mean concentrations of melatonin in plasma in weaned goat kids were significantly lower than those in the other groups (p<0.05). In weaned goat kids not treated with melatonin, the weight and volume of the pineal gland, and number of pinealocytes, were significantly lower when compared with those from non-weaned kids (p<0.05). Quantitative ultrastructural analysis of pinealocytes showed the relative volume of mitochondria, rough endoplasmic reticulum and Golgi complex was significantly lower in weaned than non-weaned goat kids (p<0.05); treatment with melatonin significantly increased these parameters in weaned kids.

CONCLUSIONS

Taken together, these results indicate that treatment with melatonin in goat kids in situations of stress due to premature weaning could play an important role in the improvement of histo-physiological function of the pineal gland.

Italian consensus statement on paediatric HIV infection

The objective of this document is to identify and reinforce current recommendations concerning the management of HIV infection in infants and children in the context of good resource availability. All recommendations were graded according to the strength and quality of the evidence and were voted on by the 57 participants attending the first Italian Consensus on Paediatric HIV, held in Siracusa in 2008. Paediatricians and HIV/AIDS care specialists were requested to agree on different statements summarizing key issues in the management of paediatric HIV. The comprehensive approach on preventing mother-to-child transmission (PMTCT) has clearly reduced the number of children acquiring the infection in Italy. Although further reduction of MTCT should be attempted, efforts to personalize intervention to specific cases are now required in order to optimise the treatment and care of HIV-infected children. The prompt initiation of treatment and careful selection of first-line regimen, taking into consideration potency and tolerance, remain central. In addition, opportunistic infection prevention, adherence to treatment, and long-term psychosocial consequences are becoming increasingly relevant in the era of effective antiretroviral combination therapies (ART). The increasing proportion of infected children achieving adulthood highlights the need for multidisciplinary strategies to facilitate transition to adult care and maintain strategies specific to perinatally acquired HIV infection.

Perioperative evaluation of primary hemostasis in patients undergoing mitral valve repair

INTRODUCTION

No data exist on the prevalence of primary hemostatic defects and acquired von Willebrand disease in mitral valve prolapse with severe regurgitation.

METHODS

Primary hemostasis was evaluated by PFA-100, von Willebrand Factor Antigen (vWF:Ag) and Ristocetin cofactor (vWF:RiCof) assays in a prospective observational trial. Sixty-five consecutive patients with mitral regurgitation (study group) or aortic stenosis (control group) who were operated for mitral valve repair or aortic valve replacement were enrolled in the study.

RESULTS

There were no differences in Closure Time in the two groups at all time points. The concentration of plasma vWF: Ag was within normal limits in all patients preoperatively; after surgery, a significant increase was observed in both groups from baseline (199 +/- 144 mcg/dL vs. 295 +/-141 mcg/dL in the study group, p=0.002; 243 +/- 141 mcg/dLl vs 338 +/- 154 mcg/dL in the control group, p=0.009). The ratio of vWF:RiCof to vWF:Ag was slightly decreased preoperatively in both groups (ratio= 0.91) and showed a marked increase in the postoperative period (ratio=0.22) as, probably, new hemostatically effective large multimeric forms of vWF were released.

CONCLUSIONS

Patients who present for surgery with a valvular pathology with high shear stress have some degree of primary hemostasis defect; nevertheless, the potent stimulus of surgery and the correction of the underlying disease allow quick restoration of vWF activity and normalization of PFA-100.

Surgical management of hereditary colorectal cancer: surgery based on molecular analysis and family history

The importance of colorectal cancer (CRC) is increasing. A proportion show a hereditary component, as in Lynch syndrome and Familial Adenomatous Polyposis, and a recently defined entity as well, namely, Familial Colorectal Cancer type X. The high probability to develop CRC in these groups may, at the time of recognition, change surgical management, including its timing or even the surgical technique. In some cases prophylactic surgery can play an important role. The possibility of using tools that allow recognition of the aforementioned syndromes, including microsatellite instability, immunohistochemistry for DNA mismatch repair system proteins, and especially their mutations, is on the basis of therapeutic strategies that differ from those employed in sporadic CRC cases.

Heterogeneity among methicillin-resistant Staphylococcus aureus from Italian pig finishing holdings

A survey for methicillin-resistant Staphylococcus aureus (MRSA) in finishing pig holdings was carried out in Italy in 2008. MRSA isolates were characterised by spa-, MLST-, SCCmec- and antimicrobial susceptibility typing. A prevalence of 38% (45/118, 95% CI 29.4-46.9%) positive holdings was observed. Eleven different spa-types were found among 102 MRSA isolates, clustering in lineages associated with farm animals (ST398, ST9, ST(CC)97 in 36 holdings) and humans (ST1, 7 holdings). Nine (7.6%) holdings were positive for two, three or four different and unrelated spa-types in various combinations. ST398 was the most prevalent lineage (33 positive holdings). The most prevalent spa-type was t899 (ST398), detected in 22 positive holdings. Three novel spa-types (t4794 of ST9; t4795 of ST97; t4838 of ST398) were detected. Ten holdings were positive for spa-type t1730, that proved to be a new single-locus variant of ST97, within the CC97 (ST1476). The most prevalent SCCmec was Type V (79 isolates), while Type IVb was found in 10 isolates. None of the isolates was positive for Panton-Valentine Leukocidin, while most of the t127 and t1730 isolates, one t4794, one t4795, and one t2922 were positive for LukE-LukD genes. All 64 antimicrobial susceptibility tested isolates were resistant to tetracyclines, with high resistance rates to trimethoprim (68.8%), erythromycin (60.9%), and ciprofloxacin (35.4%). All t127, ST1 isolates were resistant to tetracycline-ciprofloxacin-erythromycin. This survey provides the first report of MRSA ST1 and ST(CC)97 among pigs and the first report of MRSA ST9 from pigs in Europe. The presence of human-associated CA-MRSA (t127, ST1, SCCmec type V) in 6% holdings surveyed can represent an additional MRSA reservoir for infections in humans.

Prevalence and concentration of Verotoxigenic Escherichia coli O157:H7 in adult sheep at slaughter from Italy

A 1-year study on the animal-level prevalence and concentration of Escherichia coli O157 in adult sheep at slaughter was performed, to collect qualitative and quantitative information on the diffusion of the pathogen in adult sheep from Italy. A total 533 samples were collected, with a similar distribution in the four seasons. For prevalence estimates, a simple random sampling technique was used. An immuno-magnetic separation technique was used for sample screening, with enumeration of the pathogen in positive samples, along with molecular and serological identification of isolates. An overall prevalence of 7.1% (38/ 533, 95% CI 4.9-9.3%) was observed for fully virulent E. coli O157. A wide interval of VTEC O157 per gram was observed (< 100 to 6 x 10(5) CFU g(-1)), with 28.9% (11/38) of positive samples > or = 1 x 10(3) CFU g(-1), set as the threshold for those animals defined 'active shedders' for the purpose of the study. Eight per cent (3/38) of animals shed > 1 x 10(4) g(-1) VTEC O157, which represents > 96% of the total VTEC O157 bacteria cultured from all animals tested. The prevalence estimate of active shedders was therefore 2.1% (95% CI 0.9-3.3%). Most (34/38, 89.5%) of the positive animals were found in summer (July-September). Prevalence and concentrations of virulent VTEC O157 obtained in this study contribute to the demonstration that adult sheep represent a relevant source of environmental contamination from virulent VTEC O157, as well as a source of VTEC O157 contamination for food of ovine origin (meat and dairy products), especially during warm months.

[Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly]

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

Treatment of anaerobic sludge digester effluents by the CANON process in an air pulsing SBR

The CANON (Completely Autotrophic Nitrogen removal Over Nitrite) process was successfully developed in an air pulsing reactor type SBR fed with the supernatant from an anaerobic sludge digester and operated at moderately low temperatures (18-24 degrees C). The SBR was started up as a nitrifying reactor, lowering progressively the dissolved oxygen concentration until reaching partial nitrification. Afterwards, an inoculation with sludge containing Anammox biomass was carried out. Nitrogen volumetric removal rates of 0.25 g NL(-1)d(-1) due to Anammox activity were measured 35 d after inoculation even though the inoculum constituted only 8% (w/w) of the biomass present in the reactor and it was poorly enriched in Anammox bacteria. The maximal nitrogen removal rate was of 0.45 g NL(-1)d(-1). By working at a dissolved oxygen concentration of 0.5 mg L(-1) in the bulk liquid, nitrogen removal percentages up to 85% were achieved. The reactor presented good biomass retention capacity allowing the accumulation of 4.5 g VSS L(-1). The biomass was composed by ammonia oxidizing bacteria (AOB) forming fluffy structures and granules with an average diameter of 1.6mm. These granules were composed by Anammox bacteria located in internal anoxic layers surrounded by an external aerobic layer where AOB were placed.

Spontaneous chronic subdural hematoma in a young adult

Chronic subdural hematoma (CSDH) is a common pathology in the elderly but very rare in young adults. When CSDH occurs in this age group, severe head injury or some promotive factors are usually present. This article reports the case of a 29-year-old female presented at our Emergency Department with a few days' history of progressive frontal headache. Computed tomography scan of the head showed a right frontal CSDH. Only a decreased level of consciousness without focal deficits was present at clinical examination and her medical history was negative for trauma or promotive factors. Blood count showed a mild sideropenic anemia while coagulation tests were normal. No vascular malformations were shown at digital subtraction angiography. The patient underwent craniotomic evacuation. After surgery, the patient showed a full neurological recovery. Spontaneous CSDH in young adults is very rare. In the worldwide literature, many cases of non-traumatic CSDH are reported, but a promotive factor is generally present. We described a case of spontaneous CSDH, whose etiology remains unknown.