Missed Diagnosis of Cancer in Critically Ill Patients: A Single-Center Experience

Abstract Purpose and methods: In order to evaluate the rate of missed diagnoses (MD) of tumors in critically ill patients died in our Intensive Care Unit (ICU) and correlate them with the outcome, all the autopsy records from January 1st, 1996 and December 31st, 2014 have been reviewed. When the tumor was not diagnosed during the admission but discovered only at the post-mortem examination, the effect of the MD on the outcome was classified according to the Goldman\u2019s criteria. Results: A total of, 1045 autopsies were examined; a solid or hematological cancer was discovered in 74 cases (7%, 50 M, 24 F, age 75.5, IQR 29-90 years). Major discrepancies occurred in 42 patients, but only in one of them (2.4%) a class 1 error was identified; in the other cases the MD did not influence the outcome (class 2 errors) due to the underlying conditions determining the ICU admission and/or the very short length of stay in the ICU; for another 32 patients the MD were considered without clinical relevance. Conclusions: In our experience, autopsy remains an extremely valuable tool to detect MD and to improve the clinical and diagnostic procedures

An Unsuspected Case of Aortic Dissection

Aortic dissection is a rare life-threatening condition that typically presents with acute onset of severe chest, abdominal, or back pain. Some patients might present with atypical symptoms and findings, such as neurological syndromes, making it difficult to make the diagnosis. Here, we report a case of a painless acute aortic rupture over an already existing Stanford type A chronic aortic dissection in a 59-year-old patient, with prevalence of neurological symptoms. The aortic dissection presented as recurrent episodes of dizziness/syncope and transient amnesia. We believe it is important to report this case because of the rare clinical presentation of aortic dissection, raising the awareness and diagnosing level of atypical aortic dissections

DEFINITIONS, EPIDEMIOLOGY AND PREDISPOSING FACTORS

Endocarditis is defined as the inflammation of the endocardium, the inner layer of the heart, mainly affecting heart valve leaflets, The term endocarditis was introduced for the first time in the scientific community by Sir William Osler who studied a series of 209 cardiac infections of different origins and delivered a Lecture at the Royal College of Physicians in London on "Malignant Endocarditis" in March 1885

An unusual unilateral breast enlargement in a prepubertal girl

A girl aged 4 years and 3 months presented to our department for a right breast mass, slowly enlarging since the age of 6 months. The mass was tender at the outer and harder at the medial quadrants to palpation, with apparently regular margins. The nipple over the mass was not altered

Neoplastic Embolization from Cardiac Papillary Fibroelastoma with Unusual Presentation: A Case Report

Papillary fibroelastoma is the second most frequent primary tumor of the heart. We report the case of a cardiac papillary fibroelastoma, arising from the interatrial septum, symptomatic from distal embolization to lower limb arteries. Such a clinical presentation is extremely infrequent for cardiac papillary fibroelastomas. Moreover, the site of origin not from cardiac valves and the pathogenetic mechanism underlying the clinical manifestation both represent peculiar additional findings of our case

Keratin-14 expression in pneumocytes as a marker of lung regeneration/repair during diffuse alveolar damage

Diffuse alveolar damage (DAD) is the chief pathological basis of life- threatening acute pulmonary conditions like the acute respiratory distress syndrome (ARDS). It may be considered as a model of lung regeneration and wound-repair, because the natural history of ARDS may include the resolution of diffuse alveolar damage (DAD) and a complete function recovery. Recent murine models of ARDS due to H1N1 infection suggested p63+/Krt5+ basal cells as tissue precursors for both airways and alveoli, but no human confirmation have been provided to date. Objectives: To investigate in human biopsy/autopsy samples of ARDS if p63+/Krt5+ cells have a pivotal role in lung regeneration following DAD. Secondarily, we challenged other possible markers of human lung regenerative process activation. Methods: We immunohistochemically analyzed a series of stem-cell related markers in 15 lung specimens of patients with ARDS/diffuse alveolar damage (DAD), comparing them with normal lung samples. Measurements and Main Results: Bronchiolar proliferation was not observed in regenerating parenchyma, where hyperplastic type-II pneumocytes did not express basal-cell markers Krt5 and 06N-p63 (only scattered pneumocytes exhibited TA-p63 immunoreactivity revealed by a pan-p63 antibody). A striking finding in our study was a diffuse high percentage of Krt14+ pneumocytes in all DAD cases, at variance with normal controls where Krt14 expression was entirely negative. Variable Krt14 expression was evidenced in bronchiolar epithelium. A high proliferating index was observed in Krt14-expressing pneumocytes on double-stain Ki67/Krt14 preparations. No correlation was found between Krt14+ cells and clinical outcome (p>1.00). Conclusions: Our study suggests that basal cells are not involved in alveolar epithelial regeneration/repair and that Krt14 might be considered as a marker of alveolar regeneration/repair

Tailored resections in oral and oropharyngeal cancer using narrow band imaging

In a previous pilot study we observed that intra-operative narrow-band imaging (NBI) helps achieve clear superficial resection margins. The aim of this study was to verify if the use of intra-operative NBI can help to obtain tailored resections and if it is influenced by the lesion site, aspects not investigated in our previous study. MATERIALS AND METHODS: The resection margins of 39 oral and 22 oropharyngeal squamous cell carcinomas were first set at 1.5cm from the macroscopic lesion boundary (white light, WL, tattoo). Then, the superficial tumor extension was more precisely defined with NBI, giving rise to three possible situations: NBI tattoo larger than the WL tattoo, NBI tattoo coinciding with the WL tattoo, or NBI tattoo smaller than the WL tattoo. For each of these situations the space comprised between the NBI and WL tattoos was defined "NBI positive", "NBI null", and "NBI negative", respectively. Resections were performed following the outer tattoo. The number of clear superficial resection margins, and the pathological response on the "NBI-positive" and the "NBI-negative" areas were recorded. RESULTS: We obtained 80.3% negative superficial resection margins. NBI provided a more precise definition of superficial tumor extension in 43 patients. Sensitivity, specificity, positive and negative predictive values were 94.4%, 64%, 79.1% and 88.9%, respectively; a test of proportions demonstrated they were not influenced by tumor site. CONCLUSIONS: NBI could allow for real-time definition of superficial tumor extension with possible tailored resections and fewer positive superficial resection margins; it is not influenced by tumor site

Effects of Simvastatin on Fetal Cardiac Impairment in the Diaphragmatic Experimental Hernia Model

BACKGROUND: Statins and sildenafil have been shown to exert beneficial effects in cardiac injury. We hypothesized that antenatal maternal administration of simvastatin and/or sildenafil might also promote benefits in cardiac remodeling of congenital diaphragmatic hernia (CDH). Therefore, we performed micro-CT image analysis and histology of the heart after antennal treatment in experimental nitrofen-induced CDH. METHODS: At 9.5 days post conception (dpc), pregnant rats were exposed to nitrofen. At 16 and 20 dpc fetuses were treated with simvastatin and/or sildenafil. At 21 dpc postmortem micro-CT and autopsy were performed. RESULTS: All nitrofen-treated fetuses had a lower birth weight compared to controls; in the simvastatin-treated group, a significant improvement in CDH was noted. Impairment of the lung and liver was also noted in CDH. Compared to controls, CDH rats showed lower ventricular mass, with greater left ventricular thickness; simvastatin decreased the ventricular mass and improved wall thickness. CDH rats exhibited myocardial hypotrophy, severe vascular depression in the left ventricle, and intense interstitial edema compared to controls and nitrofen-exposed animals without CDH. In CDH, the cardiac morphology appeared deformed with left ventricular wall verticalization. Simvastatin improved cardiac myocyte appearance and heart morphology. CONCLUSION: The potential to treat CDH with antenatal simvastatin may improve the management of this malformatio

In haematopoietic SCT for acute leukemia TBI impacts on relapse but not survival: results of a multicentre observational study

The aim of this study was to determine whether parameters related to TBI impacted upon OS and relapse in patients with acute leukemia in CR who underwent haematopoietic SCT (HSCT) in 11 Italian Radiation Oncology Centres. Data were analysed from 507 patients (313 males; 194 females; median age 15 years; 318 with ALL; 188 with AML; 1 case not recorded). Besides 128 autologous transplants, donors included 192 matched siblings, 74 mismatched family members and 113 unrelated individuals. Autologous and allogeneic transplants were analysed separately. Median follow-up was 40.1 months. TBI schedules and HSCT type were closely related. Uni- and multi-variate analyses showed no parameter was significant for OS or relapse in autologous transplantation. Multivariate analysis showed type of transplant and disease impacted significantly on OS in allogeneic transplantation. Disease, GVHD and TBI dose were risk factors for relapse. This analysis illustrates that Italian Transplant Centre use of TBI is in line with international practice. Most Centres adopted a hyperfractionated schedule that is used worldwide (12 Gy in six fractions over 3 days), which appears to have become standard. TBI doses impacted significantly upon relapse rates