Gastroschisis: deferred closure with releasing incisions. A case report

Primary defect closure is the surgical treatment of choice in gastroschisis. When this is not feasible, a silo is required to progressively reduce the organs and perform a deferred closure of the wall. We present the case of a newborn with gastroschisis that required the use of a silo. Once the silo had been created, the distance between borders did not allow the defect to be closed, so decision was made to conduct releasing aponeurotic incisions for mobilization purposes.Progression was uneventful, and enteral nutrition was initiated at 24 days of life. Total enteral total nutrition was achieved at 40 days of life. He received parenteral nutrition for 36 days. He was discharged at 59 days of life. Abdominal wall treatment through releasing incisions allows prostheses to be avoided and represents an alternative for these patients.

[Assessment of the modification of the clinical, endocrinal and metabolical profile of patients with PCOS syndrome treated with myo-inositol]

AIM

Aim of the study was to evaluate the effects of 24 weeks administration of myo-inositol plus folic acid (Inofert ®) on clinical, endocrine and metabolic parameters of polycystic ovary syndrome (PCOS) patients.

METHODS

Seventy women, 18 to 35 years, were enrolled; 35 patients were enrolled as study group and treated with Inofert ® (200 µg folic acid plus myo-inositol 2 g per day) for 24 weeks. The other 35 patients, similar at baseline to patients in the study group, were enrolled as control group and received no treatment. In all patients the restoration of ovulation and variations of the endocrine and metabolic profile after treatment were assessed.

RESULTS

After 24 weeks, only five of 35 patients treated with Inofert® and 14 of 35 patients in the control group remained anovulatory and this difference was statistically significant. Body mass index decreased significantly in the study group, while a non-significant increasing was recorded in the control group. Moreover, non-significant reduction in circulating levels of LDL, and a statistically significant increase in the levels of HDL in the study group were observed.

CONCLUSION

Treatment with Inofert® allows to restore rapidly spontaneous ovulation in amenorrheic patients with PCOS and shows a significant advantage in terms of reduction in BMI and a positive trend in terms of changes in serum lipid profile.

Large resection and reconstruction of primary parietal thoracic sarcoma: a multidisciplinary approach on 11 patients at minimum 2-years follow-up

BACKGROUND

Thoracic sarcomas are rare, and resection can leave behind defects that require significant reconstruction by the multidisciplinary surgical team. The aim of this study is to review the experience of our regional referral centre with primary thoracic tumor resection and thoracic reconstruction.

METHODS

We have reviewed the treatment of all chest wall tumors resected at Sir Charles Gairdner Hospital in Western Australia over a 5-year period. There were 11 cases in total that involved removal of deep muscle, ribs and/or sternum.

RESULTS

In the six cases that required bony resection, the surgical team utilized a Gore-Tex (e-PTFE) mesh prosthesis to allow immediate closure of the defect, whilst five other closures were achievable using primary layered closure alone. Four patients had postoperative complications, including one who required prosthesis removal. Mean length of hospital stay was 5 days. No 30-day or 6-month mortality was recorded. All patients were followed-up for a minimum of 24 months, and all patients were alive and free of disease at their most recent follow-up.

CONCLUSIONS

This study concurs with previous literature indicating that thoracic tumor resection and immediate reconstruction often involving use of prosthetic mesh is a safe and effective one stage surgical procedure for a variety of chest wall defects with low postoperative morbidity.

Coeliac disease and autoimmune cholangitis: a case report

Autoimmune cholangitis can be associated with other autoimmune disorders. The case is described of a 58-ear-old female who developed severe microcytic anaemia resistant to oral iron treatment. Evaluation of the patient led to the diagnosis of coeliac disease, a rarely described association. Gluten-free diet and treatment with oral haematinics led to reversal of the anaemia.

[Ovarian cysts in adolescence: epidemiologic, clinical and management assessment]

BACKGROUND

To evaluate the frequency of ovarian cyst formation in the adolescents and to report on the clinical implications of these cysts.

METHODS

A prospective analysis of data on 94 girls (aged 10-19) with diagnosed ovarian cysts was performed at the Gynecology Department of Aversa and Naples hospitals between 1995-2000. Operations were performed because of pains or ultrasound suspected features. The patients who were not operated on were kept under observation and had ultrasound tests monthly, receiving gestogen to facilitate resolution of the cyst and as treatment of menstrual disorders. The site, number, size and type of the cysts were examined.

RESULTS

The ovarian cysts were unilateral, unilocular, and simple, with the size varying between 3 cm and 5 cm in 83 cases, more than 5 cm in 8 cases and less than 3 cm in 3 cases. Among 94 patients 6 (6.4%) were initially qualified for the operation because of the strong pains or ultrasound equivocal aspect. Hormonal treatment was given in 74 cases, whereas in 14 cases only follow up sonography was performed. Cysts resolved spontaneously in 2 months on average, or in 1 month after hormonal treatment. No malignant tumors were found in the observed group.

CONCLUSIONS

Clinical observation periodically repeated ultrasound tests seems to be the most appropriate procedure employed at adolescent girls with asymptomatic ovarian cysts. Hormonal treatment shortened the duration of the cysts somewhat, even if in a not significant manner, and thus was useful mainly in the treatment of concomitant menstrual disorders.

[Borderline ovarian tumors. Retrospective analysis of 20 cases]

BACKGROUND

To evaluate the clinical features, the surgical management and outcome of 20 patients with stage-I borderline ovarian tumors.

METHODS

Twenty cases of FIGO stage-I ovarian tumors, aged from 31 to 58 years (mean 37 years) have been reviewed. All informations of clinical stage, surgical intervention and prognosis were achieved by reviewing hospital records. Minimal requirements for conservative management were adequate staging and complete information about the therapeutic options. Factors important in the choice of the treatment were, age, wish to preserve fertility, histologic type and grade, and the stage of the tumour.

RESULTS

Eleven of the 20 patients (55%) were at stage IA, 6 cases (30%) were at stage IB, 3 cases (15%) were at stage IC. Thirteen (65%) were with mucinous cystadenoma of borderline malignancy, 7 cases (35%) were of serous type. Thirteen patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO). Seven patients were treated with unilateral oophorectomy or unilateral salpingo-oophorectomy (USO). One patient underwent enucleation of ovarian tumor and biopsy of contralateral ovary. Any patient were treated with chemotherapy after operation. With a median follow up of two years, we observed no recurrence of carcinoma in women treated conservatively or in those treated more radically.

CONCLUSIONS

Conservative surgery remains a therapeutic option in selected patients with borderline ovarian tumors. Prolonged intensive follow-up is required for women treated conservatively for borderline malignant ovarian tumours.

Metastasis to the male breast from carcinoma of the urinary bladder

We report a case of male breast metastasis from a urothelial carcinoma. Only two cases of this type of metastasis have been previously reported, and these were in the female breast. Clinical examination showed a progressive swelling of the left mammary region, with periareolar skin infiltration. Both mammography and ultrasound showed a rounded mass. Only histological examination with immunohistochemical staining permitted the correct diagnosis to be made. A particular feature of the present case is the absence of contralateral gynaecomastia, normally seen in cases of metastatic tumour to the breast from prostatic carcinoma.

Benign schwannoma surrounding and obstructing the ureteropelvic junction. First case report

With a varied presentation and a difficult preoperative diagnosis, schwannoma accounts for only a small percentage of retroperitoneal tumors. Moreover, malignant schwannoma of the adrenal gland, kidney and renal pelvis has previously been described. We report the first case of benign schwannoma causing obstruction by external compression of the ureteropelvic junction. A case report of a male patient who complained of a 3-month history of dull lumbar pain on the right side is reported. Using intravenous pyelogram, sonography and computed tomography a benign tumor of the retroperitoneum was suspected. Upon exploration, the suspected diagnosis of the tumor's retroperitoneal origin was confirmed. After the histological and immunohistochemical studies the diagnosis was verified. The diagnosis, treatment and histological features of benign schwannoma are discussed. A brief review of the literature is also included.

So-called "petit mal status": epileptic syndrome or seizure type?

In 1945, Lennox was the first to describe the epileptic states mainly expressed by various degrees of consciousness disturbance, which have their onset in children who present epileptic absences correlated with ictal EEG patterns of spike-wave complex discharges at about 3 Hz. As the clinical picture seemed to be similar to an uninterrupted series of absences, this led to the definition "Petit Mal Status" (PMS). Many authors have subsequently reported that PMS can occur in epileptic subjects who have never presented absences (and even in subjects without a previous history of epilepsy) and that the related EEG pictures were characterised by paroxysmal generalized activity of various morphology, but hardly ever consisted of the continuous rhythmic spike-wave or polyspike-wave complexes at 3 Hz found in petit mal absences. Finally, in reporting the onset and recurrence of this condition typically in adults and the elderly, some authors have proposed the existence of a particular form of PMS (dependent on different types of pathologic factors and characterising a specific syndrome of this age) that is different from that of the "real PMS" typical of childhood and related to petit mal absences. This paper describes fifteen patients in whom the onset of the condition occurred at different ages, and who seem to exemplify the various possible clinical expressions of PMS, with the aim of making a contribution towards the better nosographic definition of this epileptic condition. On the basis of our study, we sustain that the so-called PMS is a seizure type of Idiopathic Generalized Epilepsy which may appear at nearly all ages, and may occur in isolation or in association with other epileptic manifestations, but cannot itself be considered as characterising one or more age-dependent syndromes.

Attention problems in epilepsy: possible significance of the epileptogenic focus

Investigation of the relation between epilepsy and cognition presents serious methodologic problems because several factors may contribute to impair neuropsychological performances in epileptic persons. Benign epilepsy of childhood with rolandic paroxysmal discharges (EPR) may be a very useful model of investigation in relation to opportunity to examine subjects without brain damage, therapy, and negative environmental influences. Thus, neuropsychological dysfunction in patients with EPR may support the hypothesis that epilepsy itself plays a specific role in the genesis of cognitive disturbances. We assessed the impact of the laterality of the epileptogenic focus on cognition of children with EPR. All subjects performed a figure cancellation task, a test used to evaluate mainly attention mechanisms and abilities in processing visuospatial information. Results showed that children with right-sided (or bilateral) focus scored worse, whereas children with left-sided focus performed as well as the control subjects. Our data agree with those of studies suggesting that focal discharges may be related to poor cognitive performance. Evidence of a concordance between neurophysiologic and neuropsychologic findings may have great practical and theoretical implications in management of epileptic patients.

Neuropsychological follow-up of parkinsonian patients with and without cognitive impairment

In order to evaluate possible progression in the severity of their cognitive impairment, 34 parkinsonians with intellectual impairment were followed longitudinally for 7 years. Each patient was matched for age, sex, severity and duration of illness, and pharmacological treatment, with a parkinsonian patient without cognitive impairment. Results suggest that cognitive deficits are not static but rather there is a progression in the severity. Furthermore, patients suffering from severe dementia are more likely to die during the follow-up period. The prognosis of Parkinson's disease seems to be changed substantially by the occurrence of dementia. The natural history of parkinsonian dementia does not seem to differ from the history of other forms of dementia with a progressively disabling course leading to a complete loss of autonomy.

Allopurinol as add-on therapy in refractory epilepsy: a double-blind placebo-controlled randomized study

The antiepileptic effect of allopurinol was assessed in a double-blind, randomized, placebo-controlled, cross-over trial in 84 patients with epileptic seizures refractory to standard antiepileptic drugs (AEDs). During a retrospective baseline period, patients experienced at least four seizures of any type per month. The effects of allopurinol and matching placebo were examined for 4-month periods. Allopurinol dosage was 150 mg daily for children weighing < 20 kg and 300 mg daily for other patients. Efficacy analysis based on the Wilcoxon rank-sum test was conducted for the 80 patients who completed the study. No significant period effect or treatment-period interaction was noted. Allopurinol significantly reduced total seizures (p = 0.005), and secondarily generalized seizures (p = 0.0015). Median seizure reduction for total seizures was 10.5 and 27.9% for secondarily generalized seizures. Subjective preferences by clinicians evaluated blindly significantly favored allopurinol. No significant change occurred in the plasma concentration of concomitant AEDs between treatment periods, but serum urate decreased by 32% during allopurinol treatment. No clinically relevant side effects or changes in routine laboratory clinical chemistry or hematology were ascribed to allopurinol.

Epilepsy with bilateral occipital calcifications: Sturge-Weber variant or a different encephalopathy?

A series of cases of epilepsy with associated bilateral occipital calcifications (EBOC) without signs of phakomatosis and without any disorders known to produce cerebral calcifications have been reported. It is unclear whether EBOC is an incomplete variant of Sturge-Weber disease (SWD) or if it is a different, as yet undefined encephalopathy. We describe four new cases of EBOC that are different clinically by age of onset, type, course, severity of epilepsy, and associated cognitive deficits but that are linked by similar neuroradiologic findings. Similar to cases described in the literature, there is convincing evidence in favor of the hypothesis that these cases belong to an encephalopathy different from SWD and frequently associated with celiac disease.

Cerebral organization for language in Down's syndrome patients

Language lateralization was assessed with a dual task procedure in 10 male right-handed patients with Down's Syndrome and relatively preserved linguistic skills. Their performance was compared with that of two control groups, with and without mental retardation, matched with Down's Syndrome individuals for sex, handedness and I.Q. Results did not support the hypothesis that mental retardation is related to specific pattern of cerebral lateralization.

Electrophysiological and neuropsychological functions in patients treated with interferon-beta

The neurotoxicity of interferon-beta (IFN-beta) was assessed by performing electrophysiological examinations and neuropsychological tests on 22 patients with malignant hematological diseases before, during, and after IFN-beta treatment. IFN-beta (6 x 10(6) IU/m2) was infused i.v. for 6 h daily for 7 days on alternate weeks for a total of three cycles (induction therapy) and was then continued at the same dose, twice a week, for an additional 24 weeks (maintenance therapy). Twenty-one of the 22 patients were evaluable. There were no significant changes in EEGs, visual evoked potentials, sensory conduction central time or motor nerve conduction velocity of two long nerves in the 15-19 patients studied before and after induction therapy, nor in the 6-8 patients investigated at the end of maintenance therapy. Neuropsychological monitoring failed to disclose any IFN-induced deterioration in 21 patients tested before and at the end of induction therapy or in the 10 patients who were also studied at the end of maintenance therapy. Despite certain limitations in the patient follow-up, the results underline the good general tolerance of IFN-beta.

[The verbal fluency test for the diagnosis of dementia]

Two forms of verbal fluency test, phonological (FF) and semantic (FS) sets, have been administered to four groups of demented patients: 11 with Alzheimer-type dementia (DAT), 13 with multi-infarct dementia (MID), 8 with Parkinson-Dementia (P-D) and 11 with adult chronic hydrocephalus (ICA). Patients were matched for age, educational level and neuropsychological impairment pattern. Further, ten neurologically healty subjects were selected as control group. Control subjects result to be different from all other groups in both FF and FS; moreover, FF test results to be more impaired in ICA than in DAT. Furthermore, FF is more impaired than FS in P-D and ICA patients. On the basis of our results, verbal fluency tests might represent an useful instrument to differentiate demented subjects from non-demented ones and within demented groups to characterize the different neuropsychological pattern of the cortical and subcortical type of cognitive deterioration.

Neuropsychological features of benign partial epilepsy in children

Rolandic paroxysmal epilepsy (RPE) is a useful model for investigating the complex links between epilepsy and cognitive dysfunction. 44 children with RPE who met the following (among other) criteria: negative CT scan, freedom from drug treatment, and IQ greater than or equal to 80, were assigned to three subgroups by side of EEG focus: left, right and bilateral. A neuropsychological battery elicited small differences in cognitive performance between the whole group and the controls and among the subgroups, only partially correlated with EEG side. A follow-up assessment showed that the short falls had disappeared along with the seizures and EEG anomalies, thus confirming the benign nature of RPE. Our findings suggest too that the mere presence of paroxysmal cortical activity is enough to trigger cognitive dysfunction.

Frontal lobe dysfunction in Parkinson's disease: prognostic value for dementia?

The purpose of this longitudinal study was to investigate if the presence of frontal motor deficits in parkinsonians without signs of global intellectual impairment may have a predictive value for the development of a progressive dementing process during the course of the illness. An examination of the higher level of motor organization, using skills thought to depend upon the integrity of the frontal regions, was performed by 30 parkinsonian patients who did not present any signs of general intellectual impairment. According to their performance, as compared with controls, they were divided into two subgroups: those with and those without frontal dysfunctions. After a mean period of 4 years, a second neuropsychological examination was carried out to assess any eventual change of mental status. The results suggest that frontal dysfunctions may be observed several years before the appearance of generalized intellectual impairment and may be considered one of the predictive factors for development of dementia in Parkinson's disease. Careful consideration of these defects during examination of motor abilities may be of value in the clinical management of parkinsonian patients.

Individual differences in cerebral organization: influence of sex and familial sinistrality in the language lateralization of strongly right-handed subjects

Sixty right-handed subjects, divided into four groups of 15 according to sex and familial sinistrality (FS), performed a test of language lateralization. A verbal-manual dual-task paradigm was employed. Results suggest that the pattern of cerebral organization may differ among right-handers in relation to both sex and FS. However, it is not merely the separate influence of these two factors, but rather their interaction which determines the pattern. It is stressed that identification of individual predictors of language laterality may provide some information on prognosis and management of aphasic patients.

Endocrine and morphological study of a case of ovarian sex-cord tumor with annular tubules in a woman with Peutz-Jeghers syndrome

A bilateral ovarian sex-cord tumor with annular tubules (SCTAT) was incidentally discovered in an amenorrheic patient with Peutz-Jeghers syndrome during conservative surgery in which a small non-capsulated mass was removed from each ovary. Ovulation was then induced over two consecutive cycles with urinary gonadotropins; the couple did not conceive because of a male infertility factor. Hysterectomy and bilateral oophorectomy were performed to prevent recurrence and avoid the possibility of a cervical malignant adenoma. Immunohistochemistry of the SCTAT showed positivity for estradiol and testosterone similar to that of Sertoli and granulosa cell tumors; progesterone was not detected in any cellular component of the neoplasia. Electron microscopy showed that the neoplasm consisted of numerous solid cords of cells surrounded by fibrillary layers of basal lamina, as well as central hyaline bodies. Two types of cells, clear and dark, were noted; clear cells were predominant and intermixed with scattered dark cells. No crystalloids or Charchot-Bottcher filaments were detectable in the tumors.

Language lateralization in children with benign partial epilepsy

To investigate the relationship between epilepsy and hemispheric asymmetries for language, a dual-task procedure was used to assess language lateralization in children with benign rolandic childhood epilepsy. In the sample selection, care was taken to include factors believed to influence both the mental capabilities of epileptic patients and the individual functional cerebral organization. Results suggest that the interhemispheric prevalence pattern is related to the focus site. Controls as well as epileptic patients with a right hemispheric focus showed the expected left language lateralization; conversely, children with a left unilateral focus showed a different pattern of functional representation, suggesting an involvement of the right hemisphere in language mechanisms. It is emphasized that this atypical cerebral organization is found in subjects with no structural lesion and no therapy. It seems likely that the presence of a focal epileptic activity itself can alter the cerebral mechanisms underlying cognitive functions. A relationship between this modified hemispheric specialization and subtle neuropsychological dysfunctions observed in the children with focal epilepsy is suggested.

[Articulation disorders in aphasia. Considerations in several clinical cases]

Selective deficit of verbal output not associated to other anomalies of language, represents a syndrome in which articulatory as well as linguistic aspects can be independently affected. The critical lesion for pure articulatory deficit appears to involve left prerolandic cortico-subcortical structures. Nevertheless, in relation to individual differences in cerebral organization, damage in these structures can be responsible for a simultaneous deficit of articulatory and linguistic mechanisms.

[Dopaminergic receptors]

The functions of multiple brain dopamine receptors are discussed in relation to the physiological role of dopamine in CNS.