Chronobiology of acute pancreatitis in a single Italian centre

OBJECTIVE

Seasonal variation may occur in many different diseases hence influencing awareness in clinical practice. This study aimed to establish seasonal variations of acute pancreatitis by using a validated chronobiological analysis.

PATIENTS AND METHODS

All cases of acute pancreatitis consecutively observed in fifteen years, i.e., from January 2003 to December 2017, at St. Anna University Hospital of Ferrara, Italy, were included in this study. Accurate statistical and logistic regression analyses were applied to our database.

RESULTS

A total number of 1883 consecutive cases of acute pancreatitis were observed. A significant peak was identified in the summer period (p=0.014). Patient stratification, according to age, showed that elderly people had an increased incidence of acute pancreatitis in autumn and summer (being the biliary stone disease the main cause, p=0.011) vs. other seasons (p=0.003). Mortality occurred more prominently in males vs. females, although the latter gender was more prone to acute pancreatitis (p=0.017).

CONCLUSIONS

In a single centre of Northern East of Italy, we demonstrated that acute pancreatitis had a clear seasonal variation with a prominent incidence during summer. Various associated factors could contribute to this chronobiological pattern, including gender, age, and biliary stone disease.

Potenzialità delle sequenze fat suppression e del gadolinio nello studio RM della patologia degenerativa lombare

Le lombalgie e lombosciatalgie risultano estremamente frequenti nella popolazione. Il dolore viene attribuito solitamente alla patologia degenerativa discale, particolarmente alle ernie discali, ma le strutture della colonna potenzialmente in grado di determinare dolore sono numerose: dischi, osso, tendini, legamenti, faccette articolari, muscoli.

L'esame RM deve pertanto valutare con attenzione non soltanto il complesso somato-discale, ma anche gli elementi posteriori della colonna. Le sequenze T2 Fat-suppressed ed eventualmente T1 Fat-suppressed dopo somministrazione di mdc, nella nostra esperienza risultano di elevata capacità diagnostica nella patologia degenerativa della colonna, in particolare nel caso in cui l'esame RM convenzionale non mostri una chiara causa del dolore.

A EuroPrevall review of factors affecting incidence of peanut allergy: priorities for research and policy

Peanuts are extensively cultivated around the world, providing a foodstuff that is both cheap to produce and nutritious. However, allergy to peanuts is of growing global concern, particularly given the severity of peanut-allergic reactions, which can include anaphylaxis and death. Consequently, it is important to understand the factors related to the prevalence of peanut allergy in order to inform efforts to ameliorate or pre-empt the condition. In this article we review evidence for the relevance of factors hypothesized to have some association with allergy prevalence, including both genetic and environmental factors. Although our analysis does indicate some empirical support for the importance of a number of factors, the key finding is that there are significant data gaps in the literature that undermine our ability to provide firm conclusions. We highlight these gaps, indicating questions that need to be addressed by future research.

[Aortic intramural hematoma: aspects with spiral computerized tomography]

PURPOSE

To evaluate the signs of aortic intramural hematoma with helical CT and the diagnostic role of this technique in patients with this condition.

MATERIAL AND METHODS

We reviewed the CT findings of 396 patients submitted to emergency examinations for suspected aortic dissection from 1995 to 1999. Only 18 patients (6 women and 12 men) had CT signs of aortic intramural hematoma. Helical CT studies were carried out with the following parameters: slice thickness 10 mm, reconstruction index 10, feed 1.5 mm, conventional algorithm with minimum values of 130 kV and 125 mA. All patients were examined with dynamic contrast-enhanced CT, before and after a power injection of 130 mL ionic contrast material. We studied: hematoma localization and longitudinal extension; thickness and density of aortic wall; presence and location of intimal calcifications; integrity of intimal wall; hemomediastinum and/or hemothorax.

RESULTS

Aortic wall thickening appeared as a high density crescent-shaped area at baseline CT and had low density on enhanced images in all patients. Thickening was eccentric in 14/18 patients and concentric in 4/18 only; it always exceeded 4 mm. We found some intimal calcifications in 8 patients and hemothorax and/or hemomediastinum in 9 patients. A patient with type A hematoma died of cardiac tamponade a few hours after CT diagnosis. Six patients (5 type B and 1 type A) underwent anti-hypertensive treatment and radiological follow-up. Eleven patients (6 type A and 5 type B) underwent prosthesis replacement and 5 of them (3 type A and 2 type B) died of postoperative complications. In the 5 type B patients surgery was performed because of treatment-resistant pain and of the onset of ischemic complications to abdominal organs caused by involvement of the main collateral branches of the aorta. One patient with type A hematoma was submitted to drug treatment because it was judged unresectable.

DISCUSSION AND CONCLUSIONS

Intramural hematoma of the aorta is a distinct pathological entity, which should not be confused with aortic dissection. The imaging techniques (TEE, CT, MRI) have an important role in the final diagnosis of aortic hematoma. Presently Helical CT and MR angiography are the main tools in the early diagnosis of this condition before the development of complications. In our experience helical CT, before and after the administration of contrast material, was accurate in identifying the hematoma localization and extension.

[Pulmonary sequestration in the adult. Diagnostic contribution of angiography]

PURPOSE

The diagnosis of pulmonary sequestration is based on demonstration of mal-developed lung tissue, feeding on abnormal systemic level. We investigate the role of angiography in the diagnosis of pulmonary sequestration in adult patients.

MATERIAL AND METHODS

1987 to 1998 we examined 9 patients with suspected pulmonary sequestration who were subsequently submitted to surgery. The patients were 3 women and men; 6 of them were symptomatic and 3 asymptomatic. Six patients were examined with CT of chest and upper abdomen, thoracoabdominal aortography and selective arteriography of the abnormal vessel; one patient also submitted to left angiopneumography. One patient underwent bronchography and another one MRI.

RESULTS

An unquestionable diagnosis was made in 8 cases, namely 6 of intralobar and 2 of extralobar sequestration, and confirmed surgically. The only questionable case was diagnosed at histology as extralobar pulmonary sequestration atypically fed by thin branches from the left diaphragmatic artery.

CONCLUSIONS

Angiography demonstrated the abnormal arterial feeding typical of pulmonary sequestration in all cases but one. The evidence of venous drainage was the key sign to diagnose extra-versus intralobar sequestration. Therefore we conclude that angiography remains an essential tool in the diagnosis of pulmonary sequestration, notwithstanding the great potentials of Helical CT of MR angiography.

[Echography of the supraspinatus tendon: forced passive adduction maneuver]

INTRODUCTION

Imaging methods are essential for a correct diagnostic approach and treatment planning in patients with a painful shoulder. More than any other, the supraspinatus tendon is often involved in impingement syndrome and sonography (US) is now the procedure of choice for the first assessment of rotator cuff tears. We suggest a supraspinatus tendon passive stress maneuver drawing the tendon out from underneath the acromion and showing a longer portion of the tendon that would otherwise be masked by the acromion.

MATERIAL AND METHODS

Twenty normal subjects (10 men and 10 women, aged 20 to 46 years, mean age: 32 years) and two patients with shoulder pain underwent shoulder US with real time equipment and a 7.5 MHz linear array transducer. US images were acquired with the subjects allowed to rest with their arm in neutral position and during supraspinatus tendon passive adduction stress maneuver (with the arm first abducted by placing a plastic cylinder device under the armpit, then submitted to passive forced adduction). All US scans were performed along the longitudinal axis of the tendon. The length of the supraspinatus tendon was measured from its insertion on the greater tuberosity of the humerus to the lateral edge of the acromion. Measurements were made in neutral position and during the stress maneuver and, for each subject, the increased length of the displayed portion was obtained as the difference between the two measurements.

RESULTS AND CONCLUSIONS

In neutral position at rest, the displayed portion of the supraspinatus tendon was 21 mm long on the average (range: 11 to 31 mm). The average increase, namely the tendon portion recovered from the acromial acoustic shadow, was 4.5 mm (range: 2 to 10 mm). In two patients the stress maneuver permitted better visualization of tendon tear, which finding was confirmed at MRI. The results of our study so far seem to suggest that the passive adduction stress maneuver permits to visualize a longer portion of the supraspinatus tendon without affecting its anatomical alignment and could thus be useful in US studies of the rotator cuff.

Evidence for an independent role of metabolic acidosis on nutritional status in haemodialysis patients

BACKGROUND

Malnutrition in haemodialysis (HD) patients has been referred to underdialysis with low protein intake, and to acidosis. However, the separate effects of underdialysis and acidosis on nutrition have not been clearly demonstrated. To evaluate the role of the dialysis dose and of metabolic acidosis on nutrition, we measured the predialysis serum HCO3, pH, serum albumin, PCRn, Kt/V, and BMI in 81 uraemic patients on maintenance bicarbonate HD for 93+/-80 months. Patients with chronic liver diseases, malignancies, and cachexia were excluded.

RESULTS

Mean age was 59+/-17 years, Kt/V was 1.29+/-0.21, PCRn 1.06+/-0.22 g/kg/day, serum albumin 4.07+/-0.28 g/dl, BMI 23+/-4 kg/m2, HCO3 21.1+/-1.9 mmol/l, pH 7.36+/-0.04. Serum albumin showed a significant direct correlation with: PCRn (P=0.001), HCO3 (P=0.001), pH (P=0.002), but no correlation with Kt/V and BMI. Serum HCO3 correlated inversely with PCRn (P=0.027). Multiple regression analysis confirmed the significant role of serum bicarbonate and age, but not of Kt/V, on serum albumin concentrations. The role of PCRn appeared to be marginal compared to serum bicarbonate in determining serum albumin levels. Dividing patients into two groups, serum albumin was 3.96+/-0.22 g/dl with HCO3 < or = 20 mmol/l and 4.18+/-0.31 g/dl in those with serum HCO3 > or = 23 mmol/l (P=0.002). PCRn in the same groups was respectively 1.14+/-0.24 g/kg/day and 1.01+/-0.23 g/kg/day (P=0.03). Most importantly, serum albumin levels did not appear to be affected by the dialysis dose, with Kt/V ranging from 0.90 to 1.88.

CONCLUSIONS

In HD patients with adequate Kt/V, metabolic acidosis exerts a detrimental effect on serum albumin concentrations partially independently of the protein intake, as evaluated by PCRn. In the presence of moderate to severe metabolic acidosis, PCRn does not reflect the real dietary protein intake of the patients, probably as a result of increased catabolism of endogenous proteins. For this reason PCRn should be considered with caution as an estimate of the dietary protein intake in HD patients in the presence of metabolic acidosis.

[The echographic assessment of traumatic rib lesions]

INTRODUCTION

Conventional frontal radiography is mandatory in trauma patients and usually sufficient to detect rib fractures, even though the alignment of bone fragments or projection difficulties may sometimes hinder their depiction. Therefore, there exists moderate disagreement between clinically suspected rib fractures and radiographic findings.

MATERIALS AND METHODS

We report our personal experience with US in the detection of rib conditions (fractures and bruises), missed at preliminary radiography. Five symptomatic patients with suspected rib fractures underwent radiographic and US studies. All patients were examined with a real time unit (RT 2800, GE Medical Systems, Milwaukee, USA) with a 7.5 MHz linear probe.

RESULTS AND CONCLUSION

US demonstrated rib fractures in 4 patients with negative radiographic findings and a parosteal hematoma in one patient. We conclude that US can detect the rib fractures missed at conventional radiography and show rib cartilage conditions, costochondral dislocations and parosteal hematomas. Therefore we suggest the routine use of this technique in all chest trauma patients, as a useful complement to frontal radiographs, for both management and forensic purposes.

Blood volume changes during three different profiles of dialysate sodium variation with similar intradialytic sodium balances in chronic hemodialyzed patients

The aim of this study was to evaluate the effects on blood volume (BV) preservation of three different profiles of dialysate sodium variation with similar intradialytic sodium balances. Ten uremic patients aged 50 +/- 11 years receiving regular bicarbonate hemodialysis for 49 +/- 57 months were studied. Each patient underwent three hemodialysis treatments with different modalities of dialysate sodium profiles: constant sodium hemodialysis (CHD), high-low sodium hemodialysis (H-LHD), and low-high sodium hemodialysis (L-HHD). In CHD, the dialysate sodium concentration was 141 mEq/L and did not change during treatment. In H-LHD and L-HHD, the dialysate sodium concentration at the start of dialysis was 160 mEq/L and 133 mEq/L, respectively, and remained constant for 60 minutes. At this time, a single-step break point of variation of dialysate sodium concentration occurred. The dialysate sodium concentration changed according to a model aimed to keep identical the amount of dialysate sodium exchanged in the three different dialysis procedures. The duration of hemodialysis, the blood flow rate, the dialysate flow rate, and the dialysis membrane were the same for all three different hemodialysis modalities. The ultrafiltration rate was kept constant during treatment. Total dialysate collection and intradialytic sodium balance were calculated for each hemodialysis session. Blood pressure and heart rate were monitored at 10-minute intervals; percent reductions of BV (%R-BV) were continuously monitored by an online optical reflection method (Hemoscan; Hospal-Dasco, Medolla, Italy). The results have shown a lower intradialytic %R-BV with H-LHD compared with L-HHD and CHD. No differences in total ultrafiltration rate, systolic and diastolic blood pressures, and heart rate were observed among the three different dialysis procedures. The total dialysate sodium collected and the intradialytic sodium balances were very similar among the three different dialysis procedures, confirming the accuracy of the precision of the sodium model used. The H-LHD sodium profile may be a useful tool in the prevention of excessive %R-BV and of dialysis intolerance episodes.

A prospective comparison of bicarbonate dialysis, hemodiafiltration, and acetate-free biofiltration in the elderly

Hemodiafiltration (HDF) and more recently acetate-free biofiltration (AFB) have shown good blood purification and cardiovascular stability in young and middle-aged hemodialysis patients. It is not clear if this is also valid for elderly patients. Twelve patients aged more than 70 years (mean age +/- SD, 76 +/- 4 years) on regular dialysis for at least 5 months were treated with bicarbonate dialysis (BD), HDF, or AFB in a randomized sequence and prospectively followed for 6 months (72 dialysis sessions/patient) for each procedure. The dialysis solution (containing bicarbonate), blood flow rate, and dialysate flow rate were the same with all the methods. During HDF and AFB solutions containing bicarbonate at a concentration of 27 to 30 mEq/L and 145 mEq/L, respectively, were infused postdilution at a rate of 66 +/- 7 mL/min and 2.81 +/- 0.12 L/hr, respectively. During the period of observation we evaluated the number of intradialytic hypotensions, the episodes of nausea, vomiting, headache (dialysis intolerance), body weight, the interdialysis weight gain, the duration of the dialysis session, the number of hospitalizations/patient, and the length of hospitalization/patient. At the end of each observation period we determined: Kt/V, protein catabolic rate, acid base balance, serum creatinine, serum calcium, serum phosphorus, alkaline phosphatases, and serum intact parathyroid hormone. After the switch from BD to either HDF or AFB, the results have shown a significant reduction of dialysis hypotension episodes (18 percent on BD, 14 percent on HDF, and 13 percent on AFB; BD v HDF, P = 0.001; BD v AFB, P = 0.0001; and HDF v AFB, P = NS) and of dialysis intolerance (3.3 percent on BD, 1.3 percent on HDF, and 1.1 percent on AFB; BD v HDF, P = 0.021; BD v AFB, P = 0.019; and HDF v AFB, P = NS). Kt/V improved significantly after the switch from BD to either HDF or AFB (1.17 +/- 0.06 on BD, 1.32 +/- 0.12 on HDF, and 1.32 +/- 0.13 on AFB; BD v HDF, P = 0.021; BD v AFB, P = 0.003; HDF v AFB, P = NS). Protein catabolic rate also improved in HDF and AFB compared with BD (0.90 +/- 0.12 on BD, 1.03 +/- 0.15 on HDF, and 1.04 +/- 0.14 on AFB; BD v HDF, P = 0.001; BD v AFB, P = 0.009; and HDF v AFB, P = NS). AFB showed a better correction of acidosis compared either with BD or HDF (serum bicarbonate, 20.3 +/- 1.1 mEq/L on BD, 20.8 +/- 2.2 mEqL on HDF, and 22.2 +/- 2.4 mEq/L on AFB; BD v HDF, P = NS; BD v AFB, P = 0.01; and HDF v AFB, P = 0.030). The other parameters observed did not differ. In conclusion HDF and AFB show a better dialysis efficiency and a better hemodynamic tolerance compared with BD. This fact is associated with an improvement in protein intake as assessed by kinetic criteria. Acetate-free biofiltration has the further advantage of a better control of the acid-base balance compared with BD and HDF. HDF and AFB are useful dialytic options to traditional BD hemodialysis even in patients older than 70 years.

A six-year comparison of patient and technique survivals in CAPD and HD

Comparisons of patient and technique survival were made for 120 CAPD and 139 HD patients undergoing dialysis between January 1981 and December 1986. Cox's proportional hazard regression model was used to compare patient and technique survival, with an adjustment for pre-treatment prognostic differences. Only the patients' first treatments were considered. The CAPD patients were 10 years older, on the average, than the HD patients and had more complicated conditions (58% with 3 or more co-existing risk factors vs. 35%). Overall patient survival between CAPD and HD did not differ (P = 0.2694). However, when adjusted for patient age, sex and other comorbid complicating conditions, CAPD patients over the age of 66 had a significantly lower risk of death than their HD counterparts (P less than 0.05). There were no differences in the adjusted patient survival for patients aged 30 to 66. Four pre-treatment prognostic factors had statistically significant adverse effects on patient survival: age, diabetes, malignancy and peripheral vascular disease. Survival of the HD technique, when unadjusted, was better than survival of CAPD (P = 0.0457). Even after adjustment for sex and age, this difference was still very nearly significant (P = 0.0656). No risk factors were found to be significantly associated with technique survival. Based on patient and technique survival, CAPD would appear to be an excellent alternative to HD and may be the preferred treatment for high risk patients over the age of 66.