Volvulus of the gallbladder. Presentation of a case and review of the literature

A case of acute torsion of the gallbladder in a 83-year old woman is presented. According to the literature, the pathogenetic mechanism, the anatomical bases and the clinical presentation of this disease are discussed. The age intervals more often affected are the pediatric and teen-ager and, mostly, the elderly over the 70's. The basic anatomical defect is the gallbladder flotation, congenital or acquired. The clinical feature is that of right acute abdomen, and emergency cholecystectomy is the treatment of choice.     

Possible relationships between headache–allodynia and nocturnal sleep breathing

Sleep and headache are linked in a bidirectional way. Breathing quality during sleep may be a possible link between them. The objective of this study were to evaluate the prevalence of headache—and of allodynia—in a population of subjects who underwent cardiopulmonary monitoring during sleep for presumed respiratory problems; to evaluate the possible relationships between the presence of headaches—and of allodynia—and respiratory parameters. We studied 181 subjects, 112 without headache (mean age 59.4 ± 13.1 years, 97 men and 15 women); 69 with history of headache (42 men and 27 women; 41 migraineurs and 28 with tension type headache). Headache diagnosis was made according to ICHD-II criteria. A semi-structured ad hoc questionnaire was used to evaluate the presence of allodynia. Full cardiopulmonary monitoring was performed by SOMNO check^® effort (WEINMANN) with SaO₂, T90 and AHI determination. Headache and headache-associated allodynia were particularly frequent in this population, suggesting a positive correlation between breathing problems during sleep and head pain, and allodynia. The observation that better respiratory parameters were found among headache sufferers with respect to those without headache, even in allodynic subjects, seems to reverse this point of view: headache and allodynia may possibly have an allostatic function preventing deep sleep and, in turn, avoiding prolonged apneas.

     

Blood pressure homeostasis and microvascular complications in diabetic patients

The retinopathy and nephropathy are among the most prevalent and disabling complications associated to microvascular damage in diabetes mellitus. The severity of hyperglycaemia and the presence of arterial systemic hypertension are among the main risk factors for these complications. The ambulatory blood pressure provided a better understanding of patterns of blood pressure in diabetic patients. There is a growing number of evidence relating diabetic patients with abnormal 24 h blood pressure patterns. Even subtle modifications of these patterns, frequently shown by patients diagnosed as normotensives in office blood pressure measurings, may be implicated in an increased risk of microvascular complications. Hyperglycaemia and these abnormal pressure patterns appear to have a synergistic effect on promoting and aggravating diabetic retinopathy. Impairment of the normal retinal autoregulation is one of the implicated physiopathological mechanisms. Probably, ABP may be useful in predicting an increased risk of microvascular complications on diabetic normotensive patients. The objective of this paper is to provide an updated and clinically oriented review in blood pressure homeostasis and diabetes mellitus.     

ACE and PC-1 gene polymorphisms in normoalbuminuric Type 1 diabetic patients: a 10-year prospective study

The aim of this study was to analyze the role of ACE gene insertion/deletion (I/D) and PC-1 gene K121Q polymorphisms in the changes of glomerular filtration rate (GFR), urinary albumin excretion rate (UAER), and blood pressure (BP) levels in a cohort of normoalbuminuric Type 1 diabetic patients. This is a 10.2+/-2.0-year prospective study of 30 normotensive normoalbuminuric Type 1 diabetic patients. UAER (immunoturbidimetry), GFR ((51)Cr-EDTA single injection technique), GHb (ion exchange chromatography), and BP levels were measured at baseline and at 1.7+/-0.6-year intervals. The presence of ACE gene I/D and PC-1 gene K121Q polymorphisms was determined by polymerase chain reaction (PCR) and restriction enzyme techniques. Three patients developed diabetic nephropathy (DN), all carriers of allele D. The presence of allele D was the only predictor (R(2)=.15, F=4.92, P=.035) of the observed GFR decline (-0.29+/-0.34 ml/min/month, P<.05). UAER increased during the study (log UAER=0.0275+/-0.042 microg/min/month, P=.002) and was associated with baseline UAER levels only (R(2)=.17, F=5.72, P=.024). A significant increase (P<.05) in cases of hypertension and retinopathy were observed in ID/DD (n=19) and not in II patients (n=11). Patients with the KQ/QQ genotype (n=8) presented a significant increase (P=.045) in new cases of retinopathy. In conclusion, the presence of the ACE gene D allele in this sample of normoalbuminuric normotensive Type 1 diabetic patients was associated with a higher proportion of microvascular complications and hypertension.     

Latero-lateral choledochoduodenostomy in benign pathology of the common bile duct. A prospective study

Biliodigestive derivations for benign diseases of the biliary tract are currently accepted in case of extended to recurrent choledochal stenosis, excessive dilation of the choledochus, impacted ampullary stones. This paper concerns 19 subjects that underwent laterolateral choledochoduodenostomy (CDS) according to the Roesner technique over the period January 1986 through December 1987 in order to evaluate long-term functional results of this operation. Hepatic serum enzymes and bilirubin were determined at intervals of two weeks during the first three months and of four weeks until the sixth month postoperatively. At this time a battery of controls was performed, namely standard plain X-ray of the abdomen, hepatobiliary sequential scintigraphy with HIDA, endoscopic examination of the anastomosis. The level of serum enzymes was then determined at 18 months postoperatively and scintigraphy was repeated as well. Based on the results of this study and the review of the recent literature, our opinion is that CDS has shown as a safe procedure with good long-term results in the treatment of benign disease of the biliary tract, mostly if high-risk aged subjects are concerned.     

Surgical treatment of lithiasis of the common bile duct: our experience

On the basis of their personal experience of biliary pathology, the authors present their opinion of surgical treatment of benign diseases of the common bile duct. From 1980 to 1988 a total of 930 patients were assessed, 140 of whom were affected by choledocholithiasis. Data confirmed that, with the exception of choledochotomy as a direct approach for removing stones, good results were achieved using papillosphincterotomy, since this technique best restores the physiology of the biliary tract. In cases where common duct dilation exceeded 20 mm or where the patient was in poor clinical condition, bile was drained into the gut forming a side-to-side choledochoduodenostomy.     

Current indications for percutaneous transhepatic cholangiography (PTC)

Percutaneous transhepatic cholangiography (PTC) showed its widest diffusion during the late '70s while since the early '80s it was gradually replaced by endoscopic retrograde cholangiopancreatography (ERCP). Anyway, a well definite role for PTC still exists. PTC was performed in 60 of 131 cases of obstructive disease of the biliary tree: the indications are illustrated in detail. The statistical indicators utilized to choose this examination were: echographic determination of the diameter of the biliary tree, bilirubinemia, alkaline phosphatase (ALP) and serum gamma-GT. Data collected during this study showed that biliary dilation has a significant correlation to serum levels of ALP, while bilirubin has not. Biliary dilation is currently well established by echography: in some instances, however, biliary obstruction is earlier suggested by elevated serum enzymes of biliary stasis, while it is clearly demonstrated that biliary dilation is a precursor of jaundice, better defined as an expression of biliary hypertension. Based on these observations and on the review of the literature, the Authors believe that PTC still remains a second choice examination as compared to ERCP: when the latter be not effective for diagnosis or decompression of the biliary tree, then PTC can be resolutive.     

Environmental tobacco smoke may induce early lung damage in healthy male adolescents

STUDY OBJECTIVE: Childhood exposure to environmental tobacco smoke (ETS) adversely affects dynamic spirometric indexes as a result of combined early life (including in utero) and current exposure to parental smoking. The aim of our study was to investigate the effect of ETS on lung function and to identify the most sensitive functional parameter for evaluating lung damage. DESIGN: Cross-sectional survey. SETTING: Health survey on secondary school children. SUBJECTS: Eighty adolescents boys (mean age +/- SD, 16 +/- 1 years) classified in three groups: 21 smokers, 30 nonsmokers, and 29 passive smokers. MEASUREMENTS: Standardized questionnaire on the smoking habits of the subjects and their parents; assay of urinary cotinine level and measurement of the cotinine/creatine ratio (CCR); and lung function tests, including measurements of lung volumes, spirometric dynamic parameters, and the single-breath diffusing capacity of the lung for carbon monoxide (DLCO). RESULTS: Passive smokers presented a higher residual volume than nonsmokers, and a lower maximal expiratory flow at 25% of FVC (MEF(25)) and DLCO. Passive smokers whose mothers had smoked during pregnancy had significantly lower MEF(25) percentage, DLCO, carbon monoxide transfer coefficient, and diffusion capacity of the alveolar-capillary membrane (DM) values than did passive smokers whose mothers had given up smoking during pregnancy. Nevertheless, the MEF(25) and DM values of subjects with mothers who had given up smoking during pregnancy were lower than those observed in nonsmokers (p < 0.05), suggesting a negative effect of passive smoking independent of the mother's smoking habit during pregnancy. A statistically significant, negative correlation was found between CCR and DLCO in smokers (r = - 0.63, p < 0.01) and in passive smokers (r = - 0.91, p < 0.001), but not in nonsmokers (r = 0.26, p = not significant), suggesting a dose-effect relationship. CONCLUSIONS: Current exposure to ETS in healthy male adolescents is associated with lung function impairment independently of the effects of maternal smoking during pregnancy. More information may be obtained from determining static lung volumes and DLCO.     

Autonomic dysfunction and urinary albumin excretion rate are associated with an abnormal blood pressure pattern in normotensive normoalbuminuric type 1 diabetic patients

OBJECTIVE: To analyze the role of autonomic function and other possible factors associated with a blunted fall in nocturnal blood pressure. RESEARCH DESIGN AND METHODS: A total of 39 normotensive normnoalbuminuric type 1 diabetic patients were studied. Glomerular filtration rate (51Cr-EDTA technique), extracellular volume (51Cr-EDTA distribution volume), and urinary albumin excretion rate (UAER) (by radioimmunoassay) were measured. The subjects' 24-h ambulatory blood pressure and a 24-h electrocardiogram were recorded simultaneously Heart rate variability was calculated in the time domain for 24 h, in the frequency domain at night, at rest in the supine position, and during tilt. Patients were classified according to diastolic blood pressure (dBP) night/day ratio as dipper patients (< or =0.9) and nondipper patients (>0.9). RESULTS: Nondipper patients presented a higher low-frequency (LF) component (a sympathetic index) and higher LF/high-frequency (HF) ratio during sleep than dipper patients (0.29 +/- 0.12 vs. 0.19 +/- 0.10 normalized units [n.u.], P = 0.008; and 0.98 +/- 0.53 vs. 0.55 +/- 0.45 n.u., P = 0.007, respectively). At rest, the LF component in nondipper patients (0.38 +/- 0.13 n.u.) was higher than in dipper patients (0.27 +/- 0.12 n.u., P = 0.04). After the tilt, nondipper patients did not show an increase in the LF component (P = 0.32), but in dipper patients, the increase was significant (P = 0.001). In both groups, tilting promoted a decrease in the HF component (a parasympathetic index). In a stepwise multiple linear regression analysis, the LF component during sleep and the UAER accounted for 24% of the variability in the dBP night/day ratio. CONCLUSIONS: The predominance of sympathetic activity and increased levels of UAER, although within the normal range, are associated with a blunted fall in nocturnal dBP in normoalbuminuric normotensive type 1 diabetic patients.     

Hypersomnolence in fibromyalgia syndrome

OBJECTIVE: To evaluate hypersomnolence in patients affected by fibromyalgia syndrome. METHODS: Thirty consecutive patients affected by fibromyalgia syndrome (FMS) (28 F) completed a sleep questionnaire and underwent the following evaluations: lung function tests; polysomnography; the Epworth sleepiness scale (ESS), which measures sleep complaints and daytime hypersomnolence; and the visual analogical scale (VAS) to detect subjective pain, fatigue, anxiety and depression. RESULTS: The FMS patients were divided into two groups based on their ESS score. Patients complaining of daytime hypersomnolence had a higher number of tender points (15 +/- 2 vs. 12 +/- 1, p < 0.01), a higher subjective pain score (72 +/- 15 vs. 52 +/- 13, p < 0.05), and more fatigue (p < 0.05). The diffusing capacity of the lung (Tlco) was more impaired and the occurrence of periodic breathing was higher. FMS patients complaining of daytime somnolence had significantly less efficient sleep than the FMS patients with no daytime somnolence (p < 0.05), i.e. a lower proportion of stage 3 sleep (5 +/- 2% vs. 12 +/- 3%; p < 0.001), stage 4 sleep (1 +/- 0.5% vs. 4 +/- 1%; p < 0.001), and twice as many arousals per hour of sleep (p < 0.01). The respiratory pattern of FMS patients with hypersomnolence showed a higher occurrence of periodic breathing (p < 0.05). The short length of apneas and hypopnoeas did not affect the apnea/hypopnea index (5.1 +/- 3 vs. 7 +/- 4; ns), but FMS patients with daytime hypersomnolence had a greater number of desaturations per hour of sleep (11 +/- 6 vs. 6 +/- 5; p < 0.05). Pulmonary volumes did not differ between the two groups. The EES score was significantly correlated in FMS patients, and even more markedly in the FMS patients with hypersomnolence, TLco, A/I, and disease duration. The ESS score was correlated significantly with the number of tender points only in FMS patients with daytime hypersomnolence. CONCLUSION: The occurrence of daytime hypersomnolence in FMS patients is linked to a greater severity of fibromyalgia symptoms and to more severe polysomnographic alterations.