Pericarditis and spontaneous pneumomediastinum are among the pathologies that are in differential diagnoses when a patient describes dorsal irradiated chest pain: if the patient is young, male, and long-limbed, it is necessary to exclude an acute aortic syndrome firstly. We present the case of a young man who arrived at the Emergency Department for chest pain: an echocardiogram performed an immediate diagnosis of pericarditis. However, if the patient had performed a chest X-ray, this would have enabled the observation of pneumomediastinum, allowing a correct diagnosis of pneumomediastinum and treatment. The purpose of this report is to highlight the importance of the diagnostic process.

AIM OF THE STUDY The aim of this work was to evaluate the epidemiology of suicidal attempts by ingestion of drugs in our area. MATERIALS AND METHODS This is a retrospective study considering all patients admitted to the hospital between January 2004 and December 2006 for suicidal attempts using drugs. RESULTS A total of 111 patients were seen in our Department in the evaluated period. The large majority of patients were women (75%). Suicidal attempt was more common in individuals aged 31 to 40 years. The more common drugs used were: BDZ (28%), anti-depressive (21%), anti-psychotics (10%) and anti-epileptics (8%). A gastric washout was performed in 65.8% of all patients admitted to the hospital. The most used antidote was flumazenil. Alterations of laboratory exams were seen only in a small percentage of the cases. In the majority of cases, suicide was at the first attempt. 71% of patients were followed by psychiatrist and were taking daily psychiatric pharmacologic therapy; 5% had a history of previous admission to the hospital in a psychiatric ward; only 24% had no a history of a prior mental illness. 43% of patients were admitted to a psychiatric ward after intensive treatment in our department. Self-discharging was not usual (10%), and only few patients were restrained against their will (3%). CONCLUSIONS Our study has identified some risk factors for a suicidal attempt. Family doctors should have a stronger control of their patients with mental illness especially during the first period of treatment. In future it should be very helpful to create an informatic network connecting all departments involved in the care of these patients. Moreover, it is crucial to increase the role of family doctors in the care of psychiatric patients after their hospitalization.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially fatal complication of pulmonary embolism (PE). Organized thrombus in the pulmonary artery causes a chronic obstruction, leading to a vascular system remodeling, an increase of pulmonary vascular resistance and a chronic pulmonary hypertension. Epidemiology is mostly unknown due to the difficult diagnostic process that often leads to a late diagnosis: findings of persistent pulmonary hypertension (PH), despite correct treatment of PE, lead to the diagnostic suspect. The first choice treatment is pulmonary endarterectomy (PEA) associated with lifelong anticoagulant therapy with vitamin K antagonist. We present the case of a 53-year-old male affected by dyspnea for months, admitted to a sub-intensive care unit for intermediate low-risk PE; echocardiography showed signs of PH persisting after anticoagulant therapy; after 2 months of specific treatment the diagnosis of CTEPH was confirmed and the patient was successfully treated with PEA.

Renal infarction is a rare cause of abdominal pain whose diagnosis is often misunderstood or severely delayed. The difficulty in identifying this time-dependent condition greatly limits the possibilities of therapeutic intervention and determines the loss of renal parenchyma that could have been saved with prompt diagnosis. It is, therefore, essential to include renal infarction in the differential diagnosis in case of abdominal pain and to identify this pathology beforehand. We present a case of a 65-yearold male with atrial fibrillation in therapy with Edoxaban who was admitted to the hospital for acute onset of widespread abdominal pain with nausea, vomit, and a worsening of renal function according to the laboratory tests. An abdominal computed tomography with contrast confirmed the presence of a bilateral renal infarction. The patient developed chronic kidney disease and was discharged on anticoagulant therapy. The aim of this paper is, therefore, to increase physician awareness towards this condition, the best opportunity to diagnose early renal infarction and to establish acute and long-term therapy.

Splenic artery pseudoaneurysm is a rarely described condition and it is even more rarely considered as a complication of peptic disease. The most common etiologies are pancreatitis, both chronic and acute, and trauma. Diagnosis can be challenging, including ultrasonography, computed tomography scan and angiography, the latter being useful also for therapy (embolization). Given her history of bulimia nervosa and the stress related to hospitalization, our patient was particularly predisposed to peptic ulcer.

Esophageal-pleural fistula is a rare and challenging condition to diagnose and requires strong clinical suspicion in order to be recognized promptly. Chest computed tomography (CT) with contrast medium for oral contrast medium (OS) is the gold standard for diagnosis. The definitive therapy is purely surgical, except for a few selected cases that benefit from endoscopic therapy. Our case involves a 45-year-old woman who came to the Emergency Department with dyspnea and thoracalgia. Chest X-ray and high-resolution CT showed empyema and pleural effusion to the left hemithorax. The lack of improvement despite the therapy and a subsequent clinical finding gave rise to the suspicion of esophageal-pleural fistula, confirmed with CT with contrast medium for OS. In this case, we opted for endoscopy correction of the esophageal defects. The diagnostic delay and the pre-existing comorbidities (previous kidney transplant for chronic kidney disease from lupus nephritis, high blood pressure, familiarity with Ischemic cardiomyopathy) could justify the inauspicious course of our case.