Vocal Fold Paralysis After Spinal and Epidural Anesthesia: A Case Report and Scoping Review

OBJECTIVES

Cranial nerve paralysis is a rare complication of spinal and epidural anesthesia, and some cases of vocal fold paralysis (VFP) have been reported. The aim of this article is to report a case, identify evidence supporting the possibility of VFP being a complication of spinal and epidural anesthesia and to investigate the frequency, the characteristics, and the possible mechanisms of such a complication.

DATA SOURCES

CINAHL Complete, Google Scholar, Cochrane Library, Pubmed, and EMBASE.

METHODS

Case report according to CARE guidelines; scoping review according to PRISMA-ScR criteria. All types of studies that reported on patients of any age and sex, all types of spinal/epidural anesthesia regardless of the location and of drugs used were included. A data extraction sheet was completed for each study selected for inclusion based on the full-text screenings. Extracted data included: study characteristics, participant characteristics, intervention characteristics, outcome measures, clinical investigations. The study did not receive external funding.

RESULTS

Eight studies met inclusion criteria and a total of 13 events (in 12 patients, including ours) were reported to date. Although there are some hypotheses in regard to the mechanism underlying the phenomena, including mechanical and inflammatory ones, the exact cause is still unclear.

CONCLUSIONS

Only few cases of VFP after spinal or epidural anesthesia have been reported to date; however, it seems possible that VFP might be a potential underreported complication of such procedures. We believe that more research on the topic is warranted, especially considering the wide population potentially at risk.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

p16 Expression in Laryngeal Squamous Cell Carcinoma: A Surrogate or Independent Prognostic Marker?

Laryngeal squamous cell carcinoma (LSCC) is a common malignancy that, despite scientific advancements, has not seen an improvement in its prognosis in the last decades. Few promising predictive markers have been found and none are relevant in clinical practice. p16ink4a, an oncosuppressor protein involved in cell cycle arrest, with a prognostic impact on other cancers, has been widely used in the head and neck region as a surrogate marker of HPV infection. Published papers and recent meta-analyses seem to minimize the biological role of HPV in the context of LSCC's cancerogenesis, and to disprove the reliability of p16ink4a as a surrogate prognostic marker in this context, while still highlighting its potential role as an independent predictor of survival. Unfortunately, the available literature, in particular during the last two decades, is often not focused on its potential role as an independent biomarker and few relevant data are found in papers mainly focused on HPV. The available data suggest that future research should focus specifically on p16ink4a, taking into account both its potential inactivation and overexpression, different patterns of staining, and immunohistochemistry cutoffs, and should focus not on its potential role as a surrogate marker but on its independent role as a predictor of survival.

Submandibular gland degloving: A minimally invasive function-preserving surgical approach for benign diseases

In the Video S1, a modified technique for submandibular gland resection in benign disease is shown. The main plane of dissection is below the fascia and immediately superficial to the fibrous capsule of the gland. The video shows the surgical steps and the structures that become evident along the procedure and illustrates some tips and tricks. Facial vessels are dissected, easily spared, and not ligated as it occurs in the classical technique. This technical variant is minimally invasive, respectful of anatomy, and through preservation of the fascial layer investing the gland aims at reducing the risk of injury to the marginalis mandibulae branch of the facial nerve, which lies within the fascia itself.

Functional and aesthetic results after septorhinoplasty and concomitant radiofrequency of the inferior turbinate: is there a role for patient reported outcome measures (PROMs)?

PURPOSE

Functional and aesthetic results after septorhinoplasty (SRP) are often not clearly demonstrated. There is still an open topic in the literature about analysis of aesthetic, functional results and patients' satisfaction after SRP. The aim of our study is to determine patients' satisfaction after SRP and concomitant radiofrequency of the inferior turbinate (RF) regarding nose appearance and improvement of symptoms, using patient reported outcome measures (PROMs).

METHODS

ROE questionnaire and the NOSE scale were used for a retrospective evaluation to assess patient's satisfaction in 369 patients undergoing SRP surgery from 2003 to 2016. Two additional questions were asked to confirm satisfaction following surgery.

RESULTS

258 patients completed the questionnaires (71.7%). The global average ROE score was 18.14 (75.6%). The percentage of satisfaction of aesthetic result was 87.3%, in particular 10.5% were very happy, 57% very much satisfied and 19.8% moderately satisfied. The global post-operative average NOSE score was 13.1 with the resolution of nasal obstruction in 72.1% cases and a marked improvement in 9.3%. The results of the two additional questions showed that 81% of patients would undergo the procedure again if required and 72.1% of patients were globally satisfied.

CONCLUSIONS

Our study demonstrates the utility of PROMs in evaluating aesthetic and functional results after SRP and simultaneous RF. In our series, the patients undergoing SRP and RF are generally satisfied by the functional and aesthetic results. This kind of assessments should be the most common post-operative evaluation methods in this surgery.

Longitudinal Evaluation of Bone Mineral Density and Bone Metabolism Markers in Patients with Indolent Systemic Mastocytosis Without Osteoporosis

Systemic Mastocytosis has been long identified as a potential cause of osteoporosis; nevertheless, data regarding longitudinal variation of bone mineral density (BMD) in patients with indolent systemic mastocytosis (ISM) are missing . We studied BMD variation at lumbar spine and proximal hip after 30-month (±6 months) follow-up in a large cohort of patients (83) with ISM without osteoporosis, supplementated with vitamin D and/or calcium when needed. We also analyzed the correlation between variation of BMD, basal serum tryptase levels and bone turnover markers (BTM). Sixty-four percent of our population was male; mean age was 52.1 (±11.5) years. Vitamin D insufficiency (serum levels of 25-OH-vitamin D, 25OHD, lower than 75 nmol/L) was found in more than 70 % of patients. After a follow-up of 30 ± 6 months with only vitamin D (5000-7500 IU weekly of oral cholecalciferol) or calcium (500 mg/die) supplementation when needed, we observed 2.1 % increase in BMD at lumbar spine, with no significant changes at hip. At the end of follow-up, almost 60 % of patients showed 25OHD serum levels still lower than recommended, despite vitamin D supplementation. Reduction in BMD after follow-up significantly correlated with high C-telopeptide of type I collagen serum levels at the time of diagnosis. In patients with ISM without osteoporosis, a routinary BMD evaluation within a time <2 years is not justified, except in the presence of elevated BTM. In these patients, vitamin D supplementation is frequently needed.

Comparison of interstitial brachytherapy and surgery as primary treatments for nasal vestibule carcinomas

OBJECTIVES/HYPOTHESIS

Squamous cell carcinoma arising from the nasal vestibule is a rare condition accounting for about 1% of head and neck malignancies with several peculiarities concerning both staging and treatment. The aim of this study was to compare the oncological and functional results of two different treatment modalities for the primary site: surgery and brachytherapy.

STUDY DESIGN

A case series with the comparison of two different treatment modalities.

METHODS

We evaluate clinical and survival data of 12 untreated patients, enrolled by a multidisciplinary tumor board, comparing oncological, functional, and esthetic results after surgery or after interstitial brachytherapy as exclusive treatments for the primary site. The functional and esthetic outcome was subjectively rated by the patients using a five-point scale.

RESULTS

Locoregional control and survival are not significantly different between patients primarily treated by surgery and by brachytherapy. The functional and esthetic outcome, as assessed by the degree of satisfaction of the patients, is significantly better after primary brachytherapy than after primary surgery (P = .014).

CONCLUSIONS

In our experience brachytherapy, accomplished in close cooperation between surgeons and radiation oncologists, achieves oncological results that are not different from surgery, but with a higher degree of patient satisfaction, mainly due to the esthetic outcome.

LEVEL OF EVIDENCE

4.

Arcanobacterium haemolyticum: two case reports

Two uncommon presentations of Arcanobacterium Haemolyticum infection (sinusitis and pharyngitis) are described, emphasizing the poor response to commonly used antibiotics and the possibility of serious local and systemic complications. The difficulties still encountered in the clinical diagnosis are underlined, since this organism could easily pass unrecognized in bacteriological cultures.

Multistep laryngeal carcinogenesis helps our understanding of the field cancerisation phenomenon: a review

In this paper, we try to briefly review the most recent knowledge on head and neck cancer, and especially multistep laryngeal carcinogenesis, and to simply explain how this has modified our understanding of field cancerisation phenomenon. Experimental studies, made possible by the recent evolution of microdissection systems, have demonstrated that the "spatial progression"of the histopathological phenotype in the surroundings of malignant or premalignant head and neck lesions correlates with molecular progression. Such a "spatial progression" can be hypothesised to reflect temporal progression. The field cancerisation process has been divided into three phases, each with its own histological and molecular characteristics. Each of these phases may have clinical implications: detection and monitoring of fields may help cancer prevention (molecular epidemiology), early detection of recurrence (or, more exactly, of second field tumours (SFTs)) (molecular diagnostics) and prognostic prediction after treatment. This model appears plausible, especially in explaining the development of multiple primary tumours (MPTs) in adjacent head and neck mucosal regions, with peculiar clinical and prognostic implications: These tumours can be defined as multiple field tumours (SFTs). However, the model, in our opinion, does not convincingly explain the development of second primary tumours (SPTs) at more distant sites, such as the lung, colon and prostate.

Pauci-symptomatic large epidermoid cyst of cerebellopontine angle: case report

It is estimated that 10% of intra-cranial tumours are localized in the cerebellopontine angle and internal auditory canal and early symptoms of the different histological forms are almost identical. Acoustic neuroma account for 90% and meningioma for 5-10% of these tumours, while a small percentage of rare tumours exist, the most frequent being epidermoid cyst, also known as congenital cholesteatoma or keratoma. The case is reported here of a large epidermoid cyst of the right cerebellopontine angle, and the clinical-radiological course is reviewed. The patient, a 35-year-old, male, initially presented an episode of objective rotatory vertigo, and a history of right ear fullness, of a few months' duration, with normal otoscopy. Audiometric test was normal in left ear, while slight pantonal sensori-neural hypoacusia was observed in the right ear. The impedenzometric findings were normal as was the vestibular test. Auditory brainstem evoked response showed an increased latency of fifth wave. Gadolinium-enhanced magnetic resonance imaging of brain revealed the presence of a voluminous epidermoid cyst occupying the extra-axial side of the right cerebellopontine cistern with superior extension into the cistern. Due to the low-grade of symptoms, we had chosen to wait and not perform surgery immediately, with otologic and vestibular test-controls every 6 months, with cerebral magnetic resonance imaging to control extension of the mass, without radiation exposure for the patient. One year after diagnosis, at the last control, otofunctional findings were not modified and repeat magnetic resonance imaging did not demonstrate important variations compared to the first. Thus, the choice not to proceed with surgery was justified since surgery is burdened by the risk of important complications. At magnetic resonance imaging, the epidermoid cyst, unlike the majority of intra-cranial tumours, such as acoustic neuroma and meningioma, does not show gadolinium-enhancement; this again supporting the important role of magnetic resonance imaging in the differential diagnosis of intra-cranial neoformations. It is, therefore, worthwhile stressing the validity of the approach, step by step, in the diagnosis of patients with otologic symptoms, together with the importance of magnetic resonance imaging that, in comparison with computed tomography, allowed us to exactly assess the growth rate of the mass and to "wait and see" without risks and without radiations for the patient.

Canal wall down tympanoplasty surgery with or without ossiculoplasty in cholesteatoma: hearing results

Aim of the study was to evaluate the functional results, in two homogeneous groups, for severity of the disease, submitted to canal-wall-down tympanoplasty (TPL CWD), with and without ossiculoplasty. A total of 60 patients who underwent canal-wall-down tympanoplasty for cholesteatoma were evaluated: 31 underwent ossiculoplasty (group A) and 29 classic Wullstein type III and IV operation (group B). Hearing results were evaluated 2 years after surgery according to the AAO-HHS guidelines. Pre-operative audiometrics revealed an air conduction PTA (AC-PTA) of 45.12 dB in group A, and 56.25 dB in group B. Bone conduction PTA (BC-PTA) was 16.86 dB in group A and 26.06 in group B. Two years after surgery, AC-PTA was 42.98 dB in group A and 58.65 dB in group B; BCPTA was 18.79 dB in group A and 25.13 dB in group B. The mean pre-operative ABG was 28.44 dB in group A and 30.14 dB in group B. Two years after surgery, group A showed a mean ABG of 24.06 and group B of 35.54 dB, the difference between the two groups was significant (p = 0.03). In conclusion, the functional results observed in the present study support the need to reconstruct the ossicular chain in canal-wall-down tympanoplasty, in fact, ossiculoplasty is associated with a better hearing gain than the classic Wullstein operations.

Role of dynamic posturography (Equitest) in the identification of feigned balance disturbances

Clinico-instrumental criteria to reliably detect simulated vertigo remain to be defined. Computed dynamic posturography (Equitest) has been used to identify additional factors to distinguish simulated, from real vertigo. The present study population comprised 23 normal subjects and 16 patients with documented vestibular impairment. Normal subjects were also studied during a state of simulated vertigo. In malingerers, the Equilibrium Score and the Composite Equilibrium Score showed a statistically significant reduction in all test conditions as compared to normal subjects, patients and "non-malingerers". Upon Sensory Analysis, statistically significant differences were found for the somatosensory component between malingerers and "non-malingerers". In 20/23 cases, Strategy Score values recorded in malingerers were 2 Standard Deviations lower than the mean obtained in "non-malingerers" in at least one of the six test conditions. By combining the latter observation with Goebel's 1st criterion it was possible to differentiate malingerers from non-malingerers with 86.9% sensitivity and 89.7% specificity. The Equitest, therefore, in combination with conventional methods, provides the clinician with an important tool, in the identification of a state of simulated vertigo.

New method for imaging innervation of the renal preglomerular vasculature. Alterations in hypertensive rats

OBJECTIVE

To develop a new method for viewing adrenergic innervation along renal preglomerular vessels; to assess nerve densities and vascular lesions along arcuate arteries (ArcA), arcuate arterial branches (ArcB), and interlobular arteries (ILA) in spontaneously hypertensive rats (SHR) and in angiotensin II (AngII) and in N(G)-nitro-L-arginine methyl ester (L-NAME) hypertensive rats.

METHODS

Preglomerular vasculatyres were isolated after HCl maceration and were immunostained against synaptophysin, a membrane protein of synaptic vesicles. Lesions were stained with Sudan black. Longitudinal nerve densities and relative frequencies of ArcA, ArcB, and ILA endowed with sudanophilic lesions were assessed separately.

RESULTS

Synaptophysin immunostaining revealed the vascular neural plexus. Nerves were adrenergic, as the plexus was destroyed by treatment with 6-hydroxy dopamine. Vascular lesions were not seen in SHR, and increased nerve density was observed along ArcA and ILA. In L-NAME- and AngII-hypertensive rats, vascular lesions affected predominantly ArcB and ILA, and nerve density was reduced by 12% and 28% (ArcA), 37% and 31% (ArcB), and by 55% and 34% (ILA), respectively, versus normotensive controls. Endothelin-1 receptor blockade did not affect AngII-induced hypertension but prevented both lesion development and reduction of density of the vascular neural plexus.

CONCLUSIONS

The method we have devised provides a direct en face view of the vascular adrenergic innervation of isolated preglomerular vasculature. Measurements in hypertensive rat models suggest a link between vascular lesions and reduction in nerve density in hypertension. Endothelin-1 likely plays a key role in mediation both vascular injury and altered vascular nerve density in hypertension.

[Antileukotrienes in the prevention of postoperative recurrence of nasal polyposis in ASA syndrome]

There is a high incidence of post-surgical recurrences of nasal polyps (NP) in patients suffering from the ASA Syndrome. The numerous theories as to the pathogenesis of the ASA Syndrome include an increase in lipoxygenase-mediated arachidonic acid metabolism, with the subsequent hyperproduction of leukotrienes (LT), and an inhibition of the cycloxygenase. Therefore, based on the information acquired on the immunobiological action mechanism of montelukast, a cysteinyl-LT receptor antagonist, it appeared worth testing the effectiveness of this substance in preventing post-surgical NP recurrences in a group of ASA Syndrome patients. After taking a case history, filling out a questionnaire scoring nasal symptoms, undergoing rhinoendoscopy and rhinomanometry, 40 patients suffering from ASA-Syndrome and NP (age range 30-72 years) were recruited for the study. They were uniformly classified according to Lund and Mackay using high resolution CT of the nose and paranasal sinuses performed after at least 1 month of nasal medical treatment. All the patients underwent microendoscopic anterior-posterior ethmoidectomy and bilateral maxillary antrostomy. After removing the nasal packing, the only treatment administered was 10 mg of montelukast/die for 6 months, with the drug suspended for 1 months after the first 3 months of treatment. The monthly follow-up included rhinoendoscopy, rhinomanometry and the questionnaire to score symptoms. After the seventh month a new CT was performed and compared with the pre-operative CT. In a control group of subjects, homogeneous with the test group, momethasone furoate nasal spray was administered at a dose of 100 mcg per nostril/die and loratadin tablets 10 mg/die. The results obtained in the patients treated with montelukast were analogous with those obtained in the second group, and during follow-up all patients showed total absence of any local recurrence, good nasal patency and no significant nasal symptom score on the questionnaire. In no case did the comparative CT, performed after the seventh month, show any signs of recurrence. The patients taking the montelukast reported a significant reduction in the use of steroids and bronchodilator inhalants during the course of the study than did the second group; indeed the number of asthmatic episodes dropped and they reported an improvement in the quality of life. Based on these results, the authors suggest that the use of montelukast in the treatment of post-surgical NP recurrences in ASA Syndrome is possible and advisable, even in synergetic association with the treatment administered to the second group. The positive results also support the hypothesis of altered arachidonic acid metabolism and call attention to the role of cysteinyl-LT in the pathogenesis of the ASA Syndrome.

[Epidemiological study of Chlamydia trachomatis infection in a sample of women requesting voluntary termination of pregnancy, treated with rokitamycin]

BACKGROUND

Infection with Chlamydia trachomatis usually involves the cervix uteri, causing no symptoms, and may easily be unrecognised and untreated until troublesome symptoms arise, such as pelvic inflammatory disease, which can affect fertility and reproductive life. Therapies include the macrolide antibiotics, and in this class rokitamycin offers marked lipophilia, excellent intracellular penetration, and bactericidal activity at concentrations close to the MIC. The present study was therefore designed to establish the frequency of intracervical infection with Chlamydia trachomatis in women applying for termination of pregnancy, and to assess the efficacy and safety of this drug in this indication.

METHODS

Women aged 18-40 years were admitted for termination of pregnancy, with a positive cervical swab for Chlamydia trachomatis. The study was conducted in accordance with the Declaration of Helsinki and amendments. Patients were given one oral tablet of 400 mg rokitamycin in the morning, and one in the evening, for two weeks. Treatment started ten days before the termination, within 48 h of taking the swab. Partners were to receive the same treatment.

RESULTS

292 women requiring termination of pregnancy, on average at the 9th week of pregnancy, were assessed. Of these, 24 (8.2%), mean (+/- SD) age 27.1 +/- 6.1 years, range 18-39, with a positive cervical swab for Chlamydia trachomatis, were treated with rokitamycin; 22 of their partners were treated too. Forty days after the start of treatment 22 patients (92%) gave negative results; these were all the cases whose partners had received treatment. No adverse events were reported and the acceptability of the treatment was considered good or excellent in 91% and fair in 9% of the cases.

CONCLUSIONS

The findings confirm that rokitamycin is one of the most useful and effective macrolides for the treatment of infections caused by intracellular microorganisms; it is extremely well tolerated and has marked microbiological efficacy.

Nitric oxide and preglomerular vascular lesions in lyon spontaneously hypertensive rats

Accumulation of Sudan black-stainable (SB+) lipids is a hallmark of the focal inflammato-proliferative lesions that develop along preglomerular vessels in N G-nitro-L-arginine methyl ester (L-NAME) and angiotensin II hypertensive rats. We extended our findings to genetically hypertensive Lyon (LH) rats aged 14 and 30 weeks and to age-matched normotensive (LN) rats. Vessels were isolated by HCl maceration. Despite high systolic blood pressure (SBP), hypercholesterolaemia, albuminuria and increased interlobular and afferent arteriolar media thickness, SB+ lesions were rarely found in LH rats, regardless of age. To probe nitric oxide as a potential source of vascular protection, 14-week-old LN and LH rats received L-NAME for 10 days (20 mg kg-1 day-1, per os), which increased SBP to 174 +/- 5 and to >200 mmHg, respectively. It induced formation of focal SB+ lesions less frequently in LN than LH rats, in which they affected 39 +/- 7, 44 +/- 5 and 15 +/- 5% of arcuate arterial branches, interlobular arteries and afferent arterioles, respectively. Immunoreactive endothelin-1 was found to accumulate at the level of SB+ lesions. Co-administered with L-NAME, hydralazine (15 mg kg-1 day-1, per os) limited SBP rise to approximately 10 mmHg in both LN and LH rats. As a result, SB+ lesions were rare in LN rats, but were frequent in LH rats. In conclusion, preglomerular SB+ lesions are spontaneously lacking in LH rats. Endogenous nitric oxide production provides protection against vascular barotrauma. Endothelin-1 likely plays an autocrine/paracrine role in vascular lesion formation.

Candesartan and progression of preglomerular lesions in N(G)-nitro-L-arginine methyl ester hypertensive rats

Chronic administration of N(G)-nitro-L-arginine methyl ester (L-NAME) to rats induces systemic hypertension and progressive development of preglomerular sudanophilic (SB+) lesions. This study investigates whether progression of SB+ lesion formation froin 4 to 6 wk of L-NAME treatment (20 mg/kg per d, orally) would be affected by 2 wk administration of either the angiotensin II type 1 receptor antagonist candesartan cilexetil (3 and 10 mg/kg per d) or the vasodilator hydralazine (15 mg/kg per d). Frequencies of arcuate arterial branches (ArcB), interlobular arteries (ILA), and afferent arterioles (AA) endowed with SB+ lesions were assessed on preglomerular vasculatures isolated after HCl maceration. Systolic BP (SBP, tail-cuff manometry) increased from a baseline of 125+/-2 to 185+/-4, and to 193+/-4 mmHg after 4 and 6 wk of L-NAME treatment, respectively. During the fourth- to sixth-week period, albumin excretion increased significantly from 3.7+/-1.1 to 52.5+/-22.4 mg/24 h. At that time, SB+ lesions affected 62+/-8, 61+/-8, and 13+/-4% of ArcB, ILA, and AA, respectively. Candesartan cilexetil dose dependently reduced SBP, albumin excretion, and lesion development. At the highest dose, SB+ lesions only affected 12+/-6, 15+/-7, and 1+/-1% of ArcB, ILA, and AA, respectively. Hydralazine similarly reduced SBP and albumin excretion, although frequencies of SB+ lesions appeared less affected along ArcB and ILA. In conclusion, progression of preglomerular SB+ lesion formation during L-NAME hypertension can be prevented by angiotensin II type 1 receptor blockade, partly through pressure-lowering effects.

[Postcoital contraception. Dates based on a 5-year use in a private consultation service]

BACKGROUND

The aim of this 5-year retrospective study is to define the efficacy of oestro-progestinic interception.

METHODS

An oestro-progestinic mixture (0.05 mg ethinyl estradiol and 0.250 mg dlnorgestrel) was prescribed to 6003 women attending the gynaecological outpatients clinic of AIED (Associazione Italiana per l'Educazione Demografica) in Genoa, Italy, without evidence of any previous contra-indications. The prescription was of two pills at once and two pills 12 hours after. Before examination, the doctor asked for personal and medical history (age, date of onset of menses, unprotected intercourse date and anticonceptional failure); patients were also asked to report the data of the following menses to the clinic. The largest age range was between 20 and 24 years, probably because of their inadequate knowledge of contraceptives. The reasons for post-coital contraception were: sexual intercourse without contraceptive, failure of coitus interruptus and of the condom.

RESULTS

Post-coital interception efficacy (monthly oestro-progestinic contraception was 99.5%) according to retrospective statistical analysis, was according to Pearl index 92.9% vs 50% without any contraceptive.

CONCLUSIONS

Finally, the efficacy of this method, together with its easy management and low frequency of severe contra-indications, allows us to indicate the "morning after pill" as one of the most useful outpatient strategies to avoid unwanted pregnancies.

Anatomic pairing of afferent arterioles and renin cell distribution in rat kidneys

Close afferent arteriolar (AA) connectivity is a prerequisite for hemodynamic interaction between superficial rat nephrons. Studies were conducted in rat, mouse, rabbit, and human renal vasculatures obtained by an HCl maceration-microdissection technique to document the extent of AA connectivity. In rat kidneys, we assessed the possibility for a slow component of internephron coupling, as reflected by arteriolar renin cell distribution after specific immunostaining for renin. In the four species examined, 51% (human) to 60% (mouse) of total AA populations were organized as vascular units consisting of mostly two AA sharing a common origin and a connecting arterial segment. In rat AA pairs, branch lengths were significantly correlated, suggesting coordinated arteriolar growth. The sum of AA branch lengths averaged 278 +/- 6 microns. Rat arteriolar renin status, ranging from no renin cells to renin-recruited midafferent arterioles, distributed in a significantly nonrandom fashion within AA pairs, and 52% of the pairs had equal renin status. Hence, AA pairing is a consistent anatomic characteristic of mammalian kidneys and may constitute an optimal vascular design for hemodynamic as well as endocrine interactions.

[The conservative treatment of placenta accreta. A clinical case report]

The following description is a clinical case of placenta accreta and its conservative treatment. According to some authors, abnormal adhesion of the placenta depends on the alteration of the equilibrium between the trophoblastic tissue invasion and the reaction of the decidua. Consequently we have various degrees of penetration of the myometrium by chorionic villi into areas of deficit, sparse or absent decidua. Whatever the pathogenetic mechanism, the final clinical picture is slight to deep penetration of the trophoblastic tissue into the uterine wall. That causes absence of the normal plane of cleavage between placenta and maternal decidua, no spontaneous placental detachment during the third stage of labour and no possible manual removal. The patient, primigravida, was admitted at the 36th Week of gestation with PROM and physiologically delivered a neonate weighing 1820 g, after she spontaneously began labour. The newborn was admitted in the neonatal-pathology ward because it was premature although the Apgar score at 1-5 minutes after birth was 5-9. Placental ejection was awaited for 1 hour, then manual exploration of the uterine cavity was undertaken. The normal plane of cleavage between placental tissue and decidua was absent and therefore manual extraction of the placenta was impossible. Surgery was stopped and, after informed consensus was obtained from the patient, a conservative treatment was tried. After cutting the umbilical cord as short as possible and checking for vaginal bleeding, the patient was moved to obstetrics ward.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute pancreatitis in pregnancy]

This paper describes a case of acute pancreatitis occurring in a patient immediately after delivery and in primigravida. The patient had a family case history of dyslipidemia (Type IV). The pregnancy had been complicated by preeclampsia treated at home with nifedipine tablets (one tablet three times a day) with good results on pressure values; lipidic values were high despite dietary measures taken. The baby at birth weighed 3830 g after physiologic labour and a natural delivery. Acute pancreatitis was diagnosed after observation of epigastralgia with irradiation on the left shoulder, vomiting, symptoms of acute abdomen such as sweating, increased pulse rate, hypotension, abdominal pain on palpation, and absence of peristalsis. An analysis of the blood showed high levels of amylase and hyperglycemia, an increase in XDP, and leucocytosis. Instrumental tests such as pancreatic echography revealed an increase in pancreatic volume, uneven structure of the parenchyma and higher levels of liquid in the peritoneum. The patient was moved to intensive-care, a nasal gastric probe inserted, hydroelectrolytic treatment was begun, vital functions monitored, pain kept under control by medical therapy, and antibiotics administered. Subsequent tests showed an improvement in the parameters of pancreatic functions (amylase, lipase, calcium hematic) and their gradual return to normal values. The computerized tomography of abdomen additionally revealed the presence of pancreatic pseudo-cysts and effusion of peritoneal liquid near the right kidney. The patient was discharged after two weeks in the surgical ward. There are many caused of acute abdomen during and immediately after pregnancy, and one of these is acute pancreatitis, though rare (occurring between 1:3800 and 11.467 according to Rabkin).(ABSTRACT TRUNCATED AT 250 WORDS)

International incidence of central nervous system tumors in children

A study of the descriptive epidemiology of central nervous system tumors in children aged 0-14 was undertaken using international incidence data referred to the period 1970-1984. The median incidence rates were found to be 23 per million for males and 19 per million for females. The median cumulative incidence rates were found to be 341 per million for males and 296 per million for females. Males had incidence rates that were about 20 per cent higher than those for females. Variation in incidence rates by age, sex, race, and geographic area are discussed. Data on possible genetic and environmental risk factors for these tumors are reviewed.

[Hysteroscopic diagnosis in patients with abnormal uterine hemorrhage and previous endometrial curettage]

Thirty-four patients, with a history of persistent abnormal uterine bleeding and dilatation and curettage or suction curettage performed within the previous year, were evaluated by office hysteroscopy and biopsy. For 16 patients (47%) the hysteroscopic diagnosis was in agreement with the curettage. Hysteroscopy revealed more information in 18 patients (53%): 8 had polyps, 6 had submucous or pedunculated myoma, 2 had endometrial neoplasia, 1 had myoma and polyp, 2 had endometrial neoplasia and 1 had synechia. Moreover in 3 patients with diagnosis of suspected myoma by curettage, hysteroscopy revealed a normal cavity. The high incidence of missed diagnosis of pathologic conditions by "blind" curettage supports the opinion that diagnostic hysteroscopy is the method of choice in the evaluation of abnormal uterine bleeding.

[Delivery after previous cesarean section. Experience with 173 patients]

We have taken into consideration the obstetric outcome in 173 women, with prior cesarean section, who were delivered in our hospital between june 1988 and january 1991. This group of patients represented 5.3% of our obstetric population. Overall 64 patients (37%) achieved vaginal delivery and 109 (63%) underwent an iterative cesarean section. Considering the 76 patients (44%) admitted to trial of labour, 64 (84.2%) achieved vaginal delivery and 12 (15.8%) were delivered with iterative cesarean section. No maternal or neonatal complications occurred, even though the silent dehiscence of the uterine scar, found during cesarean section, seems to occur four times (12%) more frequently than that reported in recent literature. It follows that vaginal delivery after prior cesarean section is, in our experience, lacking in risks, and we think that such management may be widely adopted. In 1986 iterative cesarean section represented 35% of cesarean section indications, in 1990 this rate was reduced to 23.7% by the introduction of a policy to allow women to undergo trial of labour.

[Colposcopic-histologic results in 97 patients with mild dysplasia shown by Pap test]

Colposcopy and biopsy were performed in 97 patients whose referral smears showed mild dysplasia (CIN 1). Of 97 women, 40 (41.2%) had a biopsy or a colposcopic examination alone considered normal, 36 (37.1%) had CIN 1 or HPV changes, 12 (12.4%) had CIN 2 and 9 (9.3%) had CIN 3. No invasive cancer was detected. This data suggest that, if colposcopy resources are available, repeat smear alone is inadequate to follow women who have a mild dysplasia smear.

[Ambulatory hysteroscopic diagnosis. Analysis of 425 cases]

The use of outpatient diagnostic hysteroscopy is discussed with reference to a series of 425 women. The test was performed in an outpatient setting with no form of analgesia, anesthesia or premedication in 385 patients (90.6%); the degree of acceptability was very low (intolerable) in 5.5%, supportable in 15.8% and excellent in 78.7% of patients. Fourty-two per cent of patients were aged between 45 and 54 years old, and the mean age was 47.5 years with a range between 18 and 83 years. The indication for the test was pre- or postmenopausal anomalous uterine bleeding in 74% of patients. Hysteroscopic diagnosis was normal in 56% of cases; endometrial polyps were diagnosed in 11.4% of patients; myomas in 11%; low-risk hyperplasia in 9.9% and malignant tumours in 3.6%. The correlation between hysteroscopic diagnosis and histological tests was above 95% in cases of malignant tumours, atrophy and functional endometrium, whereas it was 67% in cases of low-risk hyperplasia. No accidents or complications related to hysteroscopy were reported.

[Topical intranasal cortisone therapy]

Owing to improvements made during the last 15 years in the pathophysiological and pharmacological research, many new corticosteroids have been successfully experimented. They have high activity on the target organ and they are suitable for long term therapies since they have not any systemic and/or local side effects. Nowadays the topical intranasal corticosteroid therapy is indispensable for allergic rhinitis treatment and it is very useful for many nasal and bronchopulmonary diseases (some chronic rhinitis, nasal polyposis, bronchial asthma, chronic obstructive bronchopulmonary diseases). The authors use their personal experience and carefully review the literature to describe the general aspects (pharmacology, pharmacokinetics, toxicology, side effects and contraindications) and to analyze the single drugs currently used in Italy and abroad. Finally, they compare the efficacy of each topical intranasal glucocorticoid among themselves and with other drugs.

Thyroid carcinoma mimicking a toxic adenoma

A young woman with a thyroid papillary carcinoma behaving as an autonomously hyperfunctioning nodule is described. Only 17 similar patients have been seen in the past 25 years. It is emphasized that hyperthyroidism does not exclude malignant disease in hot nodules. This possibility suggests that all thyroid nodules, either cold or hot, require careful management. Therefore, in "at risk" cases, surgery could be the most useful treatment.

Clinical and therapeutic aspects of sinusitis in children with bronchial asthma

Eighty children between 4 and 14 years of age suffering from bronchial asthma were investigated. Fifty-five of them showed clinical and radiological findings of sinusitis. Of these, 13 patients with purulent postnasal drip were treated with ampicillin, phenylephrine and triprolidine (therapy A) and for the other 42 ampicillin was replaced by beclomethasone (therapy B). Thirty-four of 55 children showed improvement in sinus X-rays; 20 children had a considerable decrease in the severity of asthma and many symptoms cleared up after the therapy for sinusitis (P less than 0.001). In conclusion, owing to the high prevalence of sinusitis in children with bronchial asthma, all asthmatic children should be investigated to check for a sinus disease.