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A psychodynamic profile at the origin of anorexia was described. In order to provide reliability to the considerations presented, the work made use of a sample of anorexic and depressed patients compared with controls, to whom a series of statistically processed personality tests were administered. This methodology brought to light that anorexic profile originated in childhood (adverse attitudes enacted by the personality of parental figures), interpreted by the child as a refusal of her own (fat) corporeity and the tendency to process information, express emotions and affections, react and act accordingly. These traits characterize the nascent personality and become apparent in adolescence (disesteem, insecurity, immaturity, social isolation, and sexual issues). Therefore, clinical work on the personality and anorexic behavior should aim at understanding the meanings attributed to the food and the body to initiate a correction and change. Such an intervention would tend to facilitate a gradual change in the original feeling and thinking of these dimensions in anorexia.
Koch’s Bacillus bovis (Mycobacterium bovis) was made avirulent by special culture conditions, i.e., 230 passages on medium containing potatoes treated with bile salts. It has been used mainly to prevent tuberculosis. The vaccine was named after the bacteriologist Albert Calmette and the veterinarian Camille Guérin, i.e., Bacillus Calmette-Guérin (BCG). These researchers worked at the Pasteur Institute in Lille and launched the vaccine in 1921.Recently, BCG was used also for its non-specific immunostimulant action. Intravesical administration of BCG is an adjunctive therapy for the treatment of bladder cancer, which does not invade the muscle wall.We will discuss the clinical case of a patient who had fever of unknown origin for about 2 months and was resistant to treatment with multiple lines of antibiotics.
Peritonitis is the most frequent complication of peritoneal dialysis (PD) and 3–6% of episodes have fungal origin. Candida guilliermondii is an uncommon species of Candida with invasive behavior in patients affected by severe underlying disorders or using indwelling vascular devices.Here we report the case of an 84-year-old woman undergoing outpatient PD for 4 years who had fever, chills, and diffuse increasing abdominal pain. After empiric antimicrobial therapy, based on teicoplanin in the dialytic circuit plus oral ciprofloxacin plus fluconazole, the patient was hospitalized. Afterwards, the culture from the peritoneal fluid showed the presence of C. guilliermondii.PD-related fungal peritonitis is an infrequent event, but the morbidity and mortality rates are significant. In this scenario, appropriate prevention strategies including antifungal prophylaxis during antibiotic treated bacterial peritonitis should be evaluated.
Common variable immunodeficiency (CVID) is a rare disorder characterized by primary antibody deficiency leading to hypogammaglobulinemia and increased risk of infections. Pulmonary hypertension (PH) is an unusual complication of CVID and may be associated with chronic hypoxemic respiratory failure.We described the case of a 47-year-old female patient hospitalized with worsening dyspnea, which had emerged about 10 days before and was associated with productive cough. 26 years before, she was diagnosed with common variable hypogammaglobulinemia, that was treated with intravenous immunoglobulin infusions for at least 20 years. She had suffered from recurrent secondary infections of the respiratory tract with inveterate bronchiectasis, pulmonary hypertension, and chronic respiratory failure.This case suggests that Internal Medicine wards, due to their global vision of the patient, are well suited to manage subjects with serious, complex, and genetically determined pathologies.
Cecal volvulus is a surgical emergency which is associated with the risk for bowel ischemia and perforation. Occasionally, volvulus can be caused by an internal hernia.We report the case of a 73-year-old woman with no prior surgical history who had abrupt onset abdominal pain, distension, bilious emesis, and obstipation. Computed tomographic imaging showed a twisted, dilated cecum within the lesser sac with the base of the volvulus at the foramen of Winslow and mass effect against a decompressed stomach. In the operating room, the patient underwent exploratory laparotomy, reduction of the cecal volvulus through the lesser sac, and right hemicolectomy with primary ileocolic anastomosis.Given the substantial morbidity and mortality risk if a closed loop obstruction is left untreated, it is of paramount importance to consider internal hernias as a potential cause to allow an early diagnosis and an urgent surgical treatment.
The psychopathological diagnosis, which is crucial in the psychological-psychiatric work, is performed through tests and interviews aimed at evaluating the cognitive processes and the patients’ behavior. Feeling-thinking-communicating-acting process is particularly important, as it characterizes patients’ evolutionary phases and allows to move closer to the diagnosis.In this study, three patients with different psychological-psychiatric pathologies are described. For each case, verbal and non-verbal communication and psycho-emotional and cognitive sequence are analyzed. After this description, psychodiagnostic test results are discussed in order to highlight signs and symptoms of considered subjects.The described method allows to “explore” psychodynamic spaces hidden by psychic defenses that prevent a clear understanding of the psychic functioning and the operative plot at the intra- and inter-personal level of the subject.
The psychopathological diagnosis, which is crucial in the psychological-psychiatric work, is performed through tests and interviews aimed at evaluating the cognitive processes and the patients' behavior. Feeling-thinking-communicating-acting process is particularly important, as it characterizes patients' evolutionary phases and allows to move closer to the diagnosis. In this study, three patients with different psychological-psychiatric pathologies are described. For each case, verbal and non-verbal communication and psycho-emotional and cognitive sequence are analyzed. After this description, psychodiagnostic test results are discussed in order to highlight signs and symptoms of considered subjects. The described method allows to "explore" psychodynamic spaces hidden by psychic defenses that prevent a clear understanding of the psychic functioning and the operative plot at the intra- and inter-personal level of the subject.
Baclofen is commonly used to treat muscular spasticity and other conditions such as pain, alcohol withdrawal, and myoclonus. It is contraindicated in chronic kidney disease. As it is eliminated predominantly by the kidneys, acute kidney injury can lead to acute baclofen overdose with central nervous system affection due to drug accumulation. Currently, there is no consensus about the treatment of baclofen intoxication. A 67-year-old woman was admitted with altered mental status and vomiting. Initially, she was unresponsive/lethargic and kept the intermittent ability of nonverbal communication gradually sliding into a comatose state with apneas. Initial neurologic and radiologic examinations ruled out a structural lesion of the central nervous system. Laboratory data showed acute kidney injury and suspected urinary tract infection with extremely high inflammation parameters. The patient had a history of multiple sclerosis and received daily oral baclofen. Baclofen-induced coma secondary to baclofen overdose caused by renal insufficiency was suspected and renal dialysis started within 24 hours. Cystoscopy and implantation of a ureteric stent were necessary because of obstructive nephropathy. During hemodialysis, the patient’s mental status steadily improved. The patient woke up and was oriented and cooperative. Both clinical and laboratory data were widely normalized within days. Diagnosis of baclofen overdose can be challenging, but adequate supportive therapy, including hemodialysis, should be considered to reduce the length of comatose state and the risk of aspiration pneumonia.
Historically, general anesthesia, is preferred to reduce the mother’s anxious state, allow the anesthetist to focus on the hemorrhage and the cardiovascular stability, and avoid the risk for hemodynamic instability due to an urgent shift from locoregional to general anesthesia. Our protocol, although indicating general anesthesia in emergency regimens, provides the use of epidural anesthesia both during birth and hysterectomy, considering the shift to general anesthesia in case of emergency. In our opinion, epidural analgesia offers several advantages: y reduced risk of Mendelson syndrome; y better post-surgery pain control; y no risk of awareness; y the fetus is not exposed to the effect of general anesthetics; y participation of the mother to the birth; y continuous monitoring of the consciousness status, which indicates the level of brain perfusion and, thus, of the hemodynamic status; y abolition of the side effects of general anesthetics (e.g., reduction of the uterine tone and platelet functionality). INTRODUCTION
The incidence of placenta accreta spectrum (PAS) disorders, characterized by abnormal invasion of trophoblastic tissue through the myometrium and uterine serosa, has been growing considerably, thus exposing mothers to the risk of massive bleeding and death. The most recent guidelines suggest producing in-hospital protocols and establishing a step-by-step plan, from ultrasound-based detection of placenta previa to post-surgery management.
We describe the case of a 53-year-old man, recently diagnosed with decompensated type II diabetes mellitus, admitted to our Department for fever, asthenia, and detection of multiple lung abscesses and pulmonary embolism at chest tomography.His clinical history revealed just a recent orthopedic surgery of osteosynthesis on the left wrist with normal clinical and instrumental post-surgical evolution. Empirical antibiotic therapy with piperacillin/tazobactam and clindamycin was initiated. During hospital stay, swelling and functional impotence in the right knee occurred. They were investigated by arthrocentesis and magnetic resonance, and diagnosed as septic arthritis.Blood culture performed at admission tested positive for Citrobacter koseri on several samples where meropenem was added according to antibiogram. On the other hand, the cultures of bronchoaspirate, pulmonary fine needle aspiration, and arthrocentesis were negative.Antibiotic therapy was administered up to two weeks after discharge and radiological and physical features progressively improved.
41 Using a widely available technology (a computer with a webcam and dedicated platforms that can ensure patients’ data safety), a virtual consultation can be established between patient and clinicians in total safety. Besides the evident convenience for patients (who can overcome the travel and parking issues and are not required to find an accompanying person), telemedicine offers some peculiar advantages, such as: y getting a more informal assessment of mental status thanks to the opportunity to observe patients in their home environment; y gather other social information, e.g.: y living environment; y interactions with family and caregivers; y patients’ lives at home [11]. The most significant question is whether telemedicine is comparable (“as good as”) to in person consultation in terms of outcomes and quality. In some non-inferiority studies, tele-psychiatric outcomes were deemed as not inferior to in person care in terms of diagnosis and treatment, decreasing length of hospital stays, improving medication adherence, and reducing symptoms in conditions such as posttraumatic stress disorder on an evidenced based level [2]. Unfortunately, this comparison has not been made in other specialties. Despite its attractivity, this tool has some obvious limitations: Telemedicine and telehealth are often considered synonyms, but while telemedicine refers particularly to clinical patient care, telehealth includes all the educational, administrative, and other non-clinical healthcare activities. Although the roots of telemedicine date quite far back, the modern era of telemedicine started in 1968: in that date, the Massachusetts General Hospital (MGH) became the first hospital-based multispecialty telemedicine practice offering remote clinical examinations to travelers and airport workers at Logan International Airport [1]. Historically, telemedicine has been applied in several medical specialties such as psychiatry, cardiology, pediatrics, gynecology, geriatrics, with general patient satisfaction [2-9]. With the evolving technology, more specific applications of telemedicine have been developed, e.g., tele-dermatoscopes (pecific general patient cameras mounted on webcams or smartphones and controlled by app) have been used to monitor skin lesions [10]. During the COVID-19 pandemic, telemedicine has been increasingly used to bypass the severe restrictions for outpatients’ visits and access to hospitals. As often happens, an urgent need (in this case the necessity to guarantee follow up for patients suffering from chronic conditions who cannot postpone their visits) became the driving force to rapidly develop and implement telemedicine and telehealth systems. Editorial
Literature on antiepileptic induced iatrogenic hypoglycemia is scanty. Due to its broad spectrum of activity and mechanisms of action, valproic acid (VPA), a fatty acid, is the most widely prescribed epilepsy treatment worldwide.Herein, we describe an adult epileptic patient, where persistent, otherwise unexplained hypoglycemia, was most likely induced by VPA, as suggested by the VPA time course and glucose blood levels. Indeed, no further hypoglycemic episodes occurred after VPA discontinuation and the diagnostic work-up ruled out other possible causes of hypoglycemia.This case supports the hypothesis that VPA may induce hypoglycemia, due to still not well-defined metabolic mechanisms of action. Moreover, it emphasizes the fact that an iatrogenic pathogenesis should be considered if an apparently unexplained hypoglycemia occurs in a patient on chronic therapy with antiepileptics, even at a therapeutical dosage.
This case report describes a male patient born in 1953 presenting an occasional increase in serum amylase and lipase forty years ago. The monitoring of enzymes was accompanied by radiological investigations, which did not reveal pancreatic pathology. In his family, including 10 siblings, half were carriers of this isolated anomaly; multiple cysts in pancreas, kidneys, and liver were present in some family members, in addition to a pancreatic neoplasia in a sister who did not carry the enzymatic abnormality. Our patient developed colon adenocarcinoma at the age of 67.Here we examine the characteristics of non-pathological chronic pancreatic hyperenzymemia defined as such by the main Italian pioneer Professor Gullo.
Colorectal cancer (CRC) is slightly increased in inflammatory bowel disease (IBD) patients, with roughly a 2.5-fold increase compared to the general population. Clinical features associated to CRC risks are extent and severity of colonic involvement, disease duration, concomitant primary sclerosing cholangitis (PSC) and/or familial history of CRC in first-degree relatives. Colonic Crohn’s disease (CD) and ulcerative colitis (UC) share similar risks when similar colonic extent is affected. Risk stratification affects outcomes and surveillance programs.Newer endoscopic techniques substantially ameliorated diagnostic performance of endoscopy, and nowadays the standard for CRC surveillance in IBD patients is high-definition endoscopy, with dye-spray or virtual colonoscopy, oriented at targeted (+ random) colonic biopsies.Visible dysplastic lesions should be considered for endoscopic resection, while invisible dysplasia is still a mandatory proctocolectomy indication.Newer endoscopic interventional techniques (endoscopic mucosa resection, EMR, and endoscopic submucosal dissection, ESD) are appropriate therapeutic techniques to be delivered, but long-term risks of cancer should be balanced towards proctocolectomy.
Lithium is the most effective therapy for bipolar and schizoaffective disorders. Despite its efficacy, lithium has a narrow therapeutic index and adverse effects are frequent. Lithium intoxication (LI) generally affects brain, but less frequently can affect kidneys, thyroid, and parathyroid. Here, we report the case of a patient with lithium neurotoxic effects complicated by parathyroid and renal adverse effects. The patient was a 52-year-old woman treated with lithium, who was recently diagnosed with hypercalcemia and hyperparathyroidism. She was admitted for severe agitation, confusion, and diffuse tremor. Despite serum lithium and calcium normalization, laboratory tests revealed a life-threatening hypernatremia caused by nephrogenic diabetes insipidus (NDI). Hemodialysis was started, but after the first treatment the patient died for cardiac arrest. Neurological symptoms of LI may occur even if the dosage is close to the normal therapeutic range. Hypercalcemia and NDI are rare, but should be promptly diagnosed and treated. In case of poor clinical outcome, hemodialysis should be performed independently of lithium serum level.
