Spontaneous healing of an avulsed ischial tuberosity in a young football player. A case report

There is a paucity of orthopaedic literature describing avulsion of the ischial tuberosity, but its spontaneous healing does not seem to have been reported to-date. This article describes the case of a young football player who suffered an avulsion fracture of the ischial tuberosity while kicking vigorously next to the ball during a football match. The diagnosis was not made at the time of trauma, and the fracture was found five years later to have healed spontaneously. A review of the literature is provided.     

Pneumoperitoneum: is exploratory laparotomy always indicated?

Pneumoperitoneum usually indicates a surgical emergency because of visceral perforation in 85 to 95% of cases. Spontaneous pneumoperitoneum without peritonitis is a rare phenomenon which poses a dilemma for the surgeon who is faced with this problem. Some cases of pneumoperitoneum can and should be managed conservatively. We report three cases of pneumoperitoneum and describe their outcomes. Two cases were treated conservatively, and one underwent laparotomy but no perforated viscus was found. We review the aetiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas. Furthermore, a compilation of other aetiologies of pneumoperitoneum without peritonitis as reported in the literature is presented. Pneumoperitoneum, preceded by a reasonable clinical history in a patient with an adequate abdominal examination, may warrant continued observation, thus avoiding an unnecessary laparotomy.     

Investigating indicators and determinants of asthma in young adults

Background: In epidemiological studies on asthma determinants an extreme variability in results exists, probably due to different criteria utilised for defining of an asthma ‘case’ and for measuring determinants. We aimed to assess multiple indicators and multiple determinants of asthma in young adults by applying latent variable mixture models (LVMMs), a novel statistical modelling with hidden (or latent) variables. Methods: We consider the pooled data of 1103 subjects (aged 20–44 years) from the three Italian centres of the European Community Respiratory Health Survey (ECRHS 1), a standardised database. Underlying multiple asthma indicators (clinicians’ diagnosis, self-report symptoms, respiratory trials) both a latent two-class of asthma syndrome, and three continuous latent variables (severity of diagnosed asthma, severity of asthma symptoms, and severity of respiratory function) were investigated. Results: Family history was the more relevant predictor of the two-class of asthma syndrome with a risk increase of about 60% per 1 relative with early life events (OR = 1.60, 95% CI: 1.30–1.97). Smoking, active and passive, are predictive for the indicators of severity of asthma symptoms. On average the risk increase of about 10% (OR = 1.10, 95%CI: 1.01–1.20) either per 1 source point of environmental tobacco smoke (ETS) or per 1 packet a day per 10 years. While, the risk of the indicators of both severity of asthma symptoms (OR = 1.59, 95%CI: 1.23–2.06) and severity of respiratory function (OR = 1.37, 95%CI: 1.03–1.82) increase in women compared to men, the risk of the indicators of severity of diagnosed asthma (OR = 0.57, 95%CI: 0.35–0.91) decreases. Conclusions: Considering latent modelling perspective for formulating plausible hypotheses in asthma research, this study highlighted that the host (genetic) component measured as number of relatives with life-events of asthma and/or allergies seems to be the primary determinants of overall observed asthma indicators summarised by hidden two-class of asthma syndrome. Furthermore, a secondary (or trigger) role of smoking on the continuous latent variable of severity of asthma symptoms, and a gender reversal effect were suggested.Mario Grassi developed the idea of the study, was responsible for statistical modelling, and paper writing.Massimiliano Bugiani was responsible of the recruitment of data from Torino centre, and collaborate in paper writing.Roberto de Marco is the national coordinator of Italian ECRHS group, was responsible of recruitment of data from Verona centre, and collaborate in paper writing.     

Subcutaneous panniculitis lymphoma: erythema nodosum-like

We report the case of a patient who presented with painful nodular subcutaneous lesions on the lower limbs and episodes of high temperature (> 39.5 degrees C). Histologic examination and immunohistochemical study of a biopsy specimen from a nodular lesion were consistent with the diagnosis of subcutaneous panniculitis-like T-cell lymphoma, a rare form of non-Hodgkin lymphoma. Diagnosis is made particularly difficult, especially in the early stages, by nonspecific clinical features shared by many types of panniculitis. Therefore, it seems advisable to consider the possibility of this type of lymphoma in all cases of panniculitis and to perform careful and continuous follow-up of all cases in which a clear diagnosis is not formulated at the outset, with regular repetition of skin biopsies at appropriate intervals.     

Propionyl-L-carnitine therapy: effects on endothelin-1 and homocysteine levels in patients with peripheral arterial disease and end-stage renal disease

BACKGROUND/AIMS: Recent data have addressed the issue of higher levels of homocysteine (Hcy) and endothelin-1 (ET-1) in end-stage renal disease (ESRD) that may be considered an independent predictor for cardiovascular disease. The prevalence of peripheral arterial disease (PAD) in patients with ESRD has been reported to be relevant, highlighting its clinical importance. We aimed to explore the therapeutic role of propionyl-L-carnitine (PLC) in hemodialysis patients with PAD by measuring ankle/brachial index (ABI), ET-1 and Hcy. DESIGN: Randomized, double-blind, placebo-controlled trial. METHODS: Sixty-four patients on hemodialysis with chronic renal insufficiency and PAD were assigned to receive either intravenous PLC (600 mg) or placebo 3 times weekly for 12 months. The ABI and plasma levels of ET-1 and Hcy were measured at baseline, 6 and 12 months. RESULTS: In the PLC-treated group, progressive increases in ABI were observed, while in the placebo group the reverse trend was seen. Highly significant and progressive reductions in plasma levels of ET-1 and Hcy, compared to baseline, were also seen in the PLC-treated group. CONCLUSIONS: Hemodynamic flow, endothelial profile and Hcy levels were ameliorated by the administration of PLC in hemodialysis patients with ESRD and PAD.     

Breast cancer and pregnancy

The diagnosis of breast cancer during pregnancy is a rare event, but the young age of the patient together with the emotional impact for both the family and the doctors make therapeutic choices usually very difficult. Until recently, the occurrence of pregnancy associated breast cancer was thought to hold a grave prognosis and therapeutic abortion was very often advised in common practice. The hormonal environment with the increase in estrogens and progesterone was the main factor for the fear of tumor stimulation. The course of breast cancer, however, does not appear to be adversely affected by continuation of pregnancy. In the last years it was realized that potentially curative therapies can be administered even when pregnancy is continued. Of course in the medical literature there is no randomized clinical trial helping in taking decision in this setting; however, a significant experience already exists in some institutions and can guide management in these difficult cases. The aim of our review is to give an answer to questions usually coming from various specialists who collaborate with the oncologists in treating these patients and furthermore to try and find some basic guidelines which can be used in the information of the patients regarding previous experience in this field. The problem of a pregnancy after treatment for breast cancer is also analyzed, as this aspect is an emerging issue in clinical oncology. The decision should be evaluated for each single patient, taking into account the prognosis of the patient and her desire of pregnancy.     

Topotecan plus ifosfamide in patients with platinum refractory advanced/metastatic non-small cell lung cancer: a phase II trial

A number of second line treatments have been proposed in patients with advanced pretreated non-small cell lung cancer (NSCLC). However, either single agents or two or three drug combinations achieved very poor results with no superiority of any combination over monotherapy. We have treated 42 patients (30 males) affected by advanced/metastatic NSCLC progressing during front line cisplatin-based chemotherapy with a combination of topotecan (1.2 mg/m2) plus ifosfamide (1200 mg/m2) for 3 consecutive days every 3 weeks. The median age was 63 years (range 43-76); cell types were: squamous carcinoma (n=17), adenocarcinoma (n=16), large cell carcinoma (n=3), broncho-alveolar carcinoma (n=2) and undifferentiated carcinoma (n=4). All patients were treated with a platinum containing chemotherapy: 39 patients with cisplatin, 2 patients with carboplatin and 1 patient with oxaliplatin, respectively. The ECOG PS was 0 in 8 patients (19%), 1 in 11 patients (26%), and 2 in 23 patients (55%). The median number of courses administered was 3 (range 1-8). Grade 3-4 neutropenia was the dose limiting toxicity, observed in 36% of patients. Moreover, grade 3-4 anemia and thrombocytopenia were observed in 17% and in 12% of patients, respectively. One PS 2 patient died of grade 4 hematological toxicity after the first cycle. No complete response was observed. Six (14.2%) subjects obtained a partial response (PR). In addition, 1 (2.4%) minimal response (MR) plus 14 (34%) stable diseases (SD) and 21 (51%) progressive diseases (PD) were observed. Median time to disease progression and median survival were 9 weeks (range 1-13) and 26 weeks (range 1-91+), respectively. The 1-year survival rate was 14%. Combination of topotecan and ifosfamide demonstrated antitumor activity in patients with relapsing or refractory NCSLC with a modest side effect profile and an overall disease control (PR + MR + SD) of 50.7%. Nevertheless, the still low response rate and the shortness of median survival indicates the need for more effective second line treatments in this disease.     

Type III female genital mutilation: clinical implications and treatment by carbon dioxide laser surgery

OBJECTIVE: The purpose of this study was to examine clinical implications of type III female genital mutilation and to evaluate the use of carbon dioxide laser surgery to restore vulvar opening and to treat associated epithelial inclusion cysts. STUDY DESIGN: Twenty-five infibulated patients underwent carbon dioxide laser treatment. Seven of the women (28%) were pregnant, between 10 and 37 weeks of gestation. Vulvar examination revealed five cases of epidermal inclusion cysts. One pregnant patient, with a cyst that was 7 cm in diameter, was at 24 weeks of gestation. Deinfibulation was performed in an outpatient setting with local anesthesia. A colposcopy-guided laser beam was used to create an incision along the fusion midline of the labia majora. In case of vulvar epidermal inclusion cyst, the capsule was opened and emptied of sebaceous contents; the inner surface of the cyst was vaporized completely. RESULTS: The carbon dioxide laser procedure restored a complete vulvar opening in all 25 patients. The complete vaporization of cyst capsule was possible in all five cases. No case of intraoperative or postoperative complication occurred. The average duration of follow-up was 11 months. Four patients who underwent deinfibulation antenatally had labor with spontaneous vaginal delivery and no evidence of perineal trauma. CONCLUSION: On the basis of the advantages that were observed, deinfibulation treatment must be offered to all infibulated patients. The procedure is particularly appropriate during pregnancy to prevent childbirth complications. Laser carbon dioxide has been proved to be a suitable technique for the treatment of female genital mutilation when inclusion cysts are associated with it.     

Transvaginal hydrolaparoscopy vs. conventional laparoscopy for evaluating unexplained primary infertility in women

OBJECTIVE: To verify the usefulness and reliability of transvaginal hydrolaparoscopy (THL) as a screening tool for evaluating infertility in women in comparison with conventional diagnostic laparoscopy. STUDY DESIGN: Sixty consecutive women with unexplained primary infertility were prospectively enrolled into the study. After examination of the whole pelvic cavity, tubal patency was evaluated and the uterine cavity studied by hysteroscopy. Immediately after THL, conventional laparoscopy was performed. Main outcome measures were the success rate of accessing the pouch of Douglas, rate of complete examinations, rate of complications and accuracy of THL in comparison with laparoscopy. RESULTS: Success rate of accessing the pouch of Douglas and performing THL was 93.3%. The rate of complete evaluation of all the pelvic structures was 76.8%. In studying tubal pathology, 77.8% agreement was found between the two techniques. Diagnosis of endometriosis was correct in 55.5% of patients. Overall, THL results correlated closely with conventional laparoscopic results in 92.86%, but the diagnostic accuracy of THL was 100% in cases of complete pelvic evaluation. CONCLUSION: THL is a feasible, reliable and safe procedure and can be considered an alternative procedure for evaluating infertility in women. In cases of incomplete pelvic evaluation or abnormal findings, conventional laparoscopy is indicated as the second step in the evaluation.