Roberto Salmaso

Necrotizing fasciitis: classification, diagnosis, and management.

Necrotizing fasciitis (NF), a life-threatening rare infection of the soft tissues, is a medical and surgical emergency. It is characterized by subtle, rapid onset of spreading inflammation and necrosis starting from the fascia, muscles, and subcutaneous fat, with subsequent necrosis of the overlying skin. Once suspected, immediate and extensive radical debridement of necrotic tissues is mandatory. Appropriate antibiotics and intensive general support avoid massive systemic diffusion of the infective process and are the key for successful treatment. However, early diagnosis is missed or delayed in 85% to 100% of cases in large published series: because of the lack of specific clinical features in the initial stage of the disease, it is often underestimated or confused with cellulitis or abscess. Mortality rates are still high and have shown no tendency to decrease in the last 100 years. Unfortunately, the prevalence of the disease is such that physicians rarely become sufficiently confident with NF to be able to proceed with rapid diagnosis and management. This review covers the literature published in MEDLINE in the period 1970 to December 31, 2010. Particular attention is given to the clinical and laboratory elements to be considered for diagnosis. A wide variety of diagnostic tools have been described to facilitate and hasten the diagnosis of NF, but the most important tool for early diagnosis still remains a high index of clinical suspicion.

POLYTETRAFLUOROETHYLENE GIANT GRANULOMA AND ADENOPATHY: LONG-TERM COMPLICATIONS FOLLOWING SUBURETERAL POLYTETRAFLUOROETHYLENE INJECTION FOR THE TREATMENT OF VESICOURETERAL REFLUX IN CHILDREN

PURPOSE The use of polytetrafluoroethylene as bulking agent for the endoscopic treatment of vesicoureteral reflux in children has raised many concerns about the implant histocompatibility and the risk of migration of polytetrafluoroethylene particles. We report on 3 cases of long-term complications following subureteral polytetrafluoroethylene injection (STING) and an extensive review of the literature is presented. MATERIALS AND METHODS Between January 1993 and December 1995, 3 children (2 males, 1 female; 4, 7 and 6 years old), previously submitted to STING, underwent open surgery for recurrent vesicoureteral reflux. RESULTS In 1 case a hard nodular mass, strictly adherent to the ureteral wall, was a foreign body giant granuloma. All patients demonstrated a heavy multinucleated foreign body reaction around polytetrafluoroethylene particles in the pelvic nodes. CONCLUSIONS Many experimental studies and some clinical observations have demonstrated that polytetrafluoroethylene particles elicit a foreign body granulomatous reaction and have the tendency to migrate. Until the long-term effects of their presence are well known, STING should be carefully evaluated in children and young patients.

Human amniotic fluid stem cells protect rat lungs exposed to moderate hyperoxia.

Treatment of bronchopulmonary dysplasia (BPD) remains as yet an unmet clinical need and recently stem cells have been proposed as a therapeutic tool in animal models. We investigated the role of amniotic fluid stem cells (AFS) in an adult rat model of hyperoxia lung injury.

Histological evolution of chronic wounds under negative pressure therapy

BACKGROUND Negative pressure wound therapy (NPT) has achieved widespread success in the treatment of difficult wounds. However, its effects are but partially explored, and investigations mostly concentrated at the wound-dressing interface; a detailed histological description of the evolution of wounds under NPT is still lacking. MATERIALS AND METHODS Subsequent punch biopsies of NPT-treated chronic wounds of human patients were analysed. Phenomena occurring in wounds were quantified by analysis of proliferating cells nuclear antigen (PCNA) (proliferating nuclei), CD31 (blood vessels), CD68p (macrophages) and CD45 (lymphocytes) stained slides. RESULTS Three layers were identified in day-0 wounds. Over time, under NPT, the layers behaved differently: the most superficial (1.5 mm) developed granulation tissue, constant in thickness, with high proliferation index, increased in blood vessels density and developed acute inflammation. Instead, the two deeper layers decreased in proliferation rate, maintained vessels density unchanged, were cleared of chronic inflammation and oedema and underwent progression towards stable tissue. DISCUSSION Indeed, while most research has focused on induction of superficial granulation tissue by NPT, deeper layers appear to be also affected, with relieving of chronic inflammation and tissue stabilisation. This may be an important and under-appreciated effect, playing a role in the known positive outcomes of NPT, such as better graft-taking rates.

Fetal aorta wall inflammation in ultrasound-detected aortic intima/media thickness and growth retardation

Several studies have reported that fetuses with intrauterine growth restriction (IUGR) and infants with low birth weight present increased intima/media thickness (aIMT) of the abdominal aorta wall compared with fetuses and infants appropriate for gestational age (AGA). Evidence suggested that aIMT might be related to inflammation, probably indicating a very early stage of future adulthood disease, such as atherosclerosis. We aimed to investigate histological findings in the abdominal aorta wall of one IUGR stillbirth in which ultrasound had detected aIMT. Microscopy observations of the abdominal aorta wall confirmed the intima thickening and detected condensation of the elastic fibers forming an evident internal elastic membrane and presence of inflammatory elements, such as macrophages, activated endothelial cells, and fibroblastoid cells. The present study highlights that IUGR associated with aIMT is related to inflammation, which might represent a very early sign of future adult lesions.

Early detection by magnetic resonance imaging of fetal cerebral damage in a fetus with hydrops and cytomegalovirus infection

We discuss the use of magnetic resonance imaging (MRI) to reveal early fetal neurological involvement of cytomegalovirus (CMV) infection. A woman presented at 21 weeks of pregnancy with active CMV infection. Cerebral ultrasound examination had been normal. An MRI scan revealed a thickened germinal matrix, which was histologically confirmed, associated with underdevelopment of the gyri. Brain MRI proved particularly useful in identifying the findings not disclosed by routine ultrasound during pregnancy and subsequently confirmed at histology.

IL-1β and IL-23 in amniotic fluids of ultrasound-detected aortic intima/media thickness and growth retardation

Intrauterine growth restriction (IUGR) and/or neonatal low birth weight are often associated with increased intima/media thickness of the abdominal aortic wall (aIMT). Several studies in children suggested that aIMT might be related to inflammation, probably indicating an early stage of adulthood diseases, such as atherosclerosis. Our previous study performed on the abdominal aortic wall of a stillbirth presenting with IUGR and aIMT suggested an association among IUGR, aIMT, and inflammation, also highlighting the presence of fibroblastoid cells, which are thought to represent peculiar elements of the pre-atherosclerotic lesions. These observations led us to analyze two cytokines involved in the inflammation cascade, IL-1β and IL-23, in amniotic fluid samples of IUGR fetuses and small-for-gestational-age newborns presenting with aIMT and in normal controls. Our results indicate that IL-23, but not IL-1β, concentrations differed in the groups analyzed. Therefore, IL-23, a regulatory element that bridges the innate and adaptive arms of the immune system, might be involved in the inflammatory process observed in fetal aIMT.

Apert syndrome with fused thalami.

Apert syndrome (Acrocephalosyndactyly type I; AS) is a rare but well-known autosomal dominant disorder characterized by craniosynostosis, midface hypoplasia, bony/cutaneous syndactyly of fingers and toes as well as a variety of associated congenital anomalies involving the brain, heart, limbs and other organ systems. We report the case of a fetus with molecularly confirmed Apert syndrome and additional fusion of the thalamic nuclei. Various central nervous system anomalies, have been reported in patients with AS. However, as far as we know cases of fused thalami in Apert syndrome have never been reported so far.

Achromic Superficial Spreading Melanoma Accidentally Treated with Imiquimod

© 2012 The Authors. doi: 10.2340/00015555-1166 Journal Compilation

Sudden death due to aortic rupture in acromegaly

Acromegaly, when left untreated, is associated with premature mortality which is chiefly related to cardiovascular complications. We report on a 50-year-old acromegalic woman, resistant to therapy, who died suddenly because of thoracic aortic rupture and massive bleeding into the left pleural space. The postmortem examination disclosed, nearby the point of rupture, a pulmonary abscess as well as extensive intrinsic alteration of arteries originating from the aortic arch and aorta itself, which featured microscopic cystic medial necrosis. We discussed how these aspects could be related to long-term exposition to growth hormone excess. In particular, this case gives further evidence of vascular system frailty in acromegaly.