Attilio Allione

Spontaneous dissection of the celiac artery: a pitfall in the diagnosis of acute abdominal pain. Presentation of two cases

Spontaneous visceral artery dissection is an uncommon event with an unpredictable natural history and is rarely considered in the diagnosis of acute abdominal pain. It is frequently asymptomatic and usually diagnosed at autopsy after fatal hemorrhage or ischemia but may be revealed by abdominal angina or acute hemorrhage. Spontaneous resolution, definitive occlusion of the artery, and formation of an aneurysm with severe complications are other possible outcomes. Isolated dissection of the celiac artery (CA) is exceptional and there are only 13 cases in the literature (1). This paper describes two cases recently treated at the Department of Internal Medicine, Molinette Hospital, Turin. The first case was successfully managed by surgical resection of the CA; the second, by close medical surveillance.

Pericyte adhesion is impaired on extracellular matrix produced by endothelial cells in high hexose concentrations.

Abstract.Aims/hypothesis: Thickening of the basement membrane and selective loss of pericytes are early events in diabetic retinopathy. We aimed at checking whether pericyte interaction with extracellular matrix produced by endothelial cells is influenced by the hexose concentrations in which endothelial cells are cultured. Methods: Conditioned extracellular matrixes were obtained by growing human umbilical vein endothelial cells in media containing 28 mmol/l hexoses (d-glucose, d-galactose, l-glucose), which undergo different intracellular processing, before and after adding the inhibitors of protein glycation thiamine or aminoguanidine. Having removed the endothelium, bovine retinal pericytes were grown on such matrixes and, in separate experiments, on laminin, fibronectin or type IV collagen. Pericyte adhesion was determined by cell counts 18 h after seeding. Results: Reduced adhesion was observed on matrixes produced in high d-glucose, high d-galactose and high l-glucose. Both thiamine and aminoguanidine restored impaired pericyte adhesion when added to high d-glucose and high d-galactose, but not l-glucose. Laminin, fibronectin and type IV collagen did not consistently modify pericyte adhesion. Conclusions/interpretations: Pericyte adhesion is impaired on extracellular matrix produced by endothelium in high hexose concentrations. This could result from excess protein glycation, corrected by aminoguanidine and thiamine, rather than altered glycoprotein composition. [Diabetologia (2002) 45: 416–419]

Benfotiamine is similar to thiamine in correcting endothelial cell defects induced by high glucose

Abstract We investigated the hypothesis that benfotiamine, a lipophilic derivative of thiamine, affects replication delay and generation of advanced glycosylation endproducts (AGE) in human umbilical vein endothelial cells cultured in the presence of high glucose. Cells were grown in physiological (5.6 mM) and high (28.0 mM) concentrations of D-glucose, with and without 150 μM thiamine or benfotiamine. Cell proliferation was measured by mitochondrial dehydrogenase activity. AGE generation after 20 days was assessed fluorimetrically. Cell replication was impaired by high glucose (72.3% ±5.1% of that in physiological glucose, p=0.001). This was corrected by the addition of either thiamine (80.6%±2.4%, p=0.005) or benfotiamine (87.5%±89%, p=0.006), although it was not completely normalized (p=0.001 and p=0.008, respectively) to that in physiological glucose. Increased AGE production in high glucose (159.7%±38.9% of fluorescence in physiological glucose, p0.003) was reduced by thiamine (113.2%±16.3%, p=0.008 vs. high glucose alone) or benfotiamine (135.6%±49.8%, p=0.03 vs. high glucose alone) to levels similar to those observed in physiological glucose. Benfotiamine, a derivative of thiamine with better bioavailability, corrects defective replication and increased AGE generation in endothelial cells cultured in high glucose, to a similar extent as thiamine. These effects may result from normalization of accelerated glycolysis and the consequent decrease in metabolites that are extremely active in generating nonenzymatic protein glycation. The potential role of thiamine administration in the prevention or treatment of vascular complications of diabetes deserves further investigation.

Worsening of hypertension in a pregnant woman with renal arteriovenous malformation: a successful superselective embolization after delivery.

A 30-year-old female presented with uncontrolled hypertension due to arteriovenous malformation in the upper third of the right kidney, which worsened during pregnancy. The arteriovenous malformation was detected by color-coded Doppler sonography, confirmed by angiography, and the fistula was sealed by superselective arterial embolization with metallic coils. Superselective embolization is the most effective and safe treatment for this rare and complex pathology.

Diagnostic accuracy of magnetic resonance imaging in patients with suspected pulmonary embolism: A bivariate meta-analysis

BACKGROUND Computed tomographic pulmonary angiography (CTPA) has simplified the diagnostic approach to patients with clinically suspected pulmonary embolism (PE), but alternative imaging tests are still advocated. We aimed to systematically assess the diagnostic accuracy of magnetic resonance imaging (MRI) for PE diagnosis. METHODS Studies evaluating the diagnostic accuracy of MRI for the diagnosis of PE were systematically searched in the PubMed and EMBASE databases (up to May 2016). QUADAS - 2 tool was used for the quality assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity. RESULTS Thirteen studies, for a total of 1170 patients, were included. Weighted mean prevalence of PE was 37% at random-effect model. Weighted mean inconclusive MRI results were 19% at random-effect model. After exclusion of technical inadequate results, MRI bivariate weighted mean sensitivity was 80.9% (95% confidence interval [CI] 68.2, 89.4%), with a bivariate weighted mean specificity of 96.4% (95% CI 92.4, 98.3%), CONCLUSIONS: MRI has high specificity but limited sensitivity for the diagnosis of PE. Inconclusive results are a major limitation to the practical application of MRI. Management studies are needed to more precisely define the role of MRI in the diagnostic workup of patients with suspected PE.

Erythema multiforme caused by tattoo: a further case

Since the increasing popularity of tattoos among young people, numerous and variegated complications are described. For several years, para-phenylenediamine (PPD) has been used to darken the henna dye commonly used for tattoos. PPD is a potent additive sensitizer and contact dermatitis is the most common reaction pattern. Erythema multiforme (EM)-like reaction secondary to PPD henna tattoo contact is a well described but unusual manifestation, and only six previous cases are reported [1–3].

Multiple abscesses in brucellosis with Wright's test negativity.

We report a case of metastatic abscesses caused by a chronic form of brucellosis in a shepherd. When she was admitted the patient was cachectic with haematological signs of phlogosis. An abdominal computed tomography scan revealed the presence of multiple hepatic and renal abscesses with a fluid mass in the abdominal wall. The blood cultures, tuberculin skin test, and Wright reaction all gave negative results, but the brucellosis Coombs test for Brucella species was highly positive. Diagnosis was confirmed by a high titre of anti-Brucella IgM antibodies. The patient started antibiotic treatment with a progressive clinical improvement, but after discharge she was lost to follow-up and died 7 months later.

Thiamine, beta-cell function and peripheral glucose utilization in thiamine-responsive megaloblastic anemia (TRMA) syndrome

that thiamine may also improve glucose utilization in noninsulin-sensitive tissues, such as human and bovine endothelial cells cultured in the presence of high (28 mmol/l) glucose [5]. However, normalization of lactate production was observed for levels of thiamine much higher than those measured in the blood, although accumulation of vitamin B1 at specific tissue sites cannot be ruled out. However, the favorable effects of thiamine on glucose metabolism in patients with TRMA, and lack thereof in IDDM, suggest that residual beta-cell function may be required for vitamin B1 to influence glucose metabolism in vivo and that stimulation of endogenous insulin production may play a more important role than increased peripheral glucose utilization.

Trying to prolong life no matter what, or to dignify it till the end: the dilemma of modern medicine—comment

The unplanned hospital admission of advanced cancer or end-stage chronic organ failure patients is a crucial topic in modern medicine. Thus, we read the paper of Mercadante et al. [1] and the commentary of Cotogni et al. [2] with interest. As Cotogni et al. report, the availability of in-hospital acute palliative care units (APCU) and the possibility of early palliative care consultation in the Emergency Department (ED) is very limited [2]. Nonetheless, all over the world, EDs are visited with surprising frequency by severely ill patients whose death paths are approaching, but these wards are not designed to provide end-of-life care and are poorly suited to do so because the often overcrowded and seemingly chaotic nature of the emergency department may add more suffering to the stress that patients and their families feel. The Emergency Department is the hospital “entrance door”, and everyday more advanced cancer and end-stage chronic organ failure patients are entering these doors, due to the complexity of their symptoms, their growing number due to demographic reasons (baby boomers are crossing the “geriatric” threshold, their millennial kids are fewer and less available to take care of them full time), the not yet availability of home palliative care. Thus, palliative care is now becoming an important tool for emergency physician taking care of these patients in the ED. Gomes et al. [5] report that in England and Wales, home deaths have been decreasing while home death proportions fell from 31 to 18% overall, and if recent trends continue, fewer than one in ten patients will die at home in 2030. An impressive paper reports that most cancer patients spend about 1/3 of the last months of their life in hospital, with half of them receiving chemotherapy or aggressive treatments in the last month of life [3, 4]. It is easy to think that we could find the same figures for end-stage chronic organ failure patients, but unfortunately, fewer data can be found in the medical literature about useless/harmful treatments in the last months, weeks or days of life in these patients. High-tech modern medicine, such as emergency medicine, intensive care medicine, hemodialysis, intensive care cardiology and oncology are widely available in the Western world and close to all potential beneficiaries receive it. Although very successful, high-technology medicine can sometimes elicit ethical questions revolving around just distribution of resources, it is hard for the physician to know when the above mentioned technology can be considered “useless” or even “harmful” for the patient, with the apparent dichotomy between “prolonging life” and “dignifying death”. The human mind is prompt to choose the easy way to solve problems: we cannot face them, so we repress them. Thus, usually for an in-hospital clinician, the availability of a high-technology therapeutic option is easy to choose, and seems better than withdrawal of life support or not starting the treatment that involves in depth discussions between the health-care professional, patient and the family to identify the patient’s values, priorities and preferences for future care. Each specialist has an ace up the sleeve: emergency physicians use non-invasive-mechanical ventilation (NIMV) and norepinephrine, intensive care physicians use orotracheal intubation and norepinephrine, nephrologists use hemodialysis, oncologists use the last (often experimental) chemotherapy protocol, cardiologists use PTCA and amine, but unfortunately patients die, too, paying a huge physical and emotional price trying to squeeze out a few more months or days of life, most of the time not even having asked for it. * Bartolomeo Lorenzati lorebato@gmail.com

We have to “think” before prescribing an opioid in Italian Emergency Department?

We read with interest the article of Smulowitz et al. examining the rise of opioids use/abuse and variation in opioids prescriptions between ED in the past decade in US [1]. Surprisingly, we read that US, Australia, Canada and also Germany are facing a deep crisis of opioid prescriptions, and that the focus on improved pain management, which has received increased emphasis in the past two decades, contributes to this current crisis [2]. The authors have studied the variation in opioid prescription of their own institution’s emergency medicine (EM) providers observing a great disparity, but they did not explain the reason for the reported variation. It could be interesting knowing if the prescribers’ gender, age, religion, years of training, years of clinical experience could influence the prescribing patterns. In Italy, Bortolussi et al. [3], in 2004, reported a very low opioid consumption rate that was the lowest in economically developed countries. They indicate as possible reasons for this trend, a lack of systematic education of health care professionals regarding pain control, a sort of ‘‘opiophobia’’ induced by measures designed to control the improper use of drugs, and the chaotic environment of the Emergency Department (ED). Thus, for about a decade in Italy, a promotional campaign sought to increase the use of opioids by providers for chronic and acute pain management in the ED. Two years ago, we analyzed the opioid prescription behavior of emergency physicians of our institution observing the same level of variation reported from Smulowitz et al. As a result of these data, we conducted a before-and-after observational study to ameliorate the quality of pain treatment, and the appropriateness of prescribing pain medications in the ED. First, we organized a 6-h training program, and then, we analyzed changes in pain management 3 months (T0) prior to the training program and 3–6 (T1–T2) months following it. We enrolled all consecutive adults (16 years old or older) admitted with acute pain or complaining of pain after admission. A total of 10,169 patients were sampled in the first control period (T0), and, respectively, 10,577 in the second period (T1, 3 months after the training), and 9696 in the third period (T2, 6 months after the training). Each period was comparable as race, gender and age. We considered the use of opioid, NSAIDs and paracetamol in endovenous or oral formulation and we expressed it in vials for 1000 patients. The use of opioid increased from 22.9 vials/1000 patients in the control phase to 44.2 vials/1000 patients in the second phase and 38.9 vials/1000 patients in the third phase; both differences between the control phase and the second phase (T0–T1) and between the control phase and the third phase (T0–T2) are statistically significant (p\ 0.001). Probably, we can identify the answer of the title in this dataset. Smulowitz et al. show a mean rate of total opioid prescriptions per 1000 visits of 127 (122–132, 95% CI) that is very far from the 22.9, 44.2 or 38.9 vials per 1000 patients/visits observed in our study in different phases. The opioid’s reported prescription rate in US is three times as much as we observed in Italy. On the one hand, we can assume that Italian physicians are ‘‘opiophobic’’, and the promotional campaign seeking & Bartolomeo Lorenzati lorebato@gmail.com