Gait patterns of a patient with myoclonus of a lower limb, when OFF and ON treatment with antiepileptic drugs

We describe kinematics, kinetics and electromyographic patterns of a patient with spinal myoclonus of the left lower limb, during walking. Gait analysis was performed when the patient was OFF and ON his treatment with antiepileptic drugs. When OFF, we mainly observed clonic bursts and out-of-phase activations of m. tibialis anterior and m. rectus femoris, with increased hip flexion, reduction of knee flexion during swing and excessive ankle dorsal flexion. Furthermore, large oscillations of knee moment of force and power during stance phase were also observed. These abnormal patterns markedly recovered when ON drugs.

Nail aplasia, microcephaly, severe mental retardation and MRI abnormalities: report of two unrelated cases

We present the clinical and laboratory features of two unrelated mentally retarded females with sporadic bilateral periventricular nodular heterotopia (BPNH), hypoplastic/absent nails and other malformative features. Clinical examination, MRI scanning, EEG recording, karyotyping and neuropsychological testing were performed. From a molecular genetic point of view, direct sequencing analysis, X-inactivation assay and telomere analysis were carried out in one patient. The two patients showed convincing similarities from clinical and neuroradiological points of view with BPNH, mental retardation, microcephaly and hypoplastic/absent nails of fingers and toes. Our two unrelated mentally retarded females may be affected by complex malformative syndromes sharing some common features such as BPNH, mental retardation and hypoplastic/absent nails. Further genetic studies are needed to better understand the pathogenetic bases of this neurological disease. These two cases widen the spectrum of BPNH-associated syndromes.

[Adverse outcomes in the surgical treatment of acute appendicitis]

OBJECTIVES

To describe adverse outcomes after appendectomy for acute appendicitis and to analyze the association between these outcomes and specific characteristics of the patient and hospital admission.

MATERIAL AND METHODS

We studied a cohort of 792 patients who underwent appendectomy for acute appendicitis. Postoperative complications, reoperations and deaths were prospectively studied and all readmissions were retrospectively identified. Logistic regression was used to evaluate the relationship between complications and patient characteristics, as well as hospital admission.

RESULTS

Postsurgical complications developed in 9.8% of the patients. These complications mainly consisted of surgical wound infection (4.2%) and intra-abdominal complications (2.1%). A total of 0.7% of patients underwent reoperation during admission, 0.5% were admitted to the intensive care unit and five patients (0.6%) died in hospital. The rate of operation-related readmissions in the following year was 3.2%. Length of hospital stay was longer in patients with complications than in those without complications (9.6 and 3.5 days, respectively). Postoperative complications were associated with older age (45-65 years, OR 3.62, p < 0.001; more than 65 years OR 8.68, p < 0.001) and acute appendicitis complicated with peritonitis or perforation (OR 3.69, p < 0.005). Readmissions related to previous surgery were associated only with complications during the first admission (OR 18.79, p < 0.001).

CONCLUSIONS

In appendectomy, the most frequent adverse outcomes are surgical wound infection and intra-abdominal complications, which are associated with older patients and perforations. This subgroup of patients at high risk requires closer surveillance.

[Significance of the synergy between the ASL and the Association of Formerly Exposed to Asbestos]

In Frosinone's district there is a lot of attention for ex-exposed to asbestos problems. The aim of this study is to demonstrate the importance of synergy between AEA (ex-exposed to asbestos workers association) and the Health Service Unit (ASL) of Frosinone for timely diagnosis of professional diseases.

EEG synchronisation during sleep-related epileptic seizures as a new tool to discriminate confusional arousals from paroxysmal arousals: preliminary findings

Confusional arousals, paroxysmal arousals (as part of the nocturnal frontal lobe epilepsy) and normal arousals and awakenings from NREM sleep are frequently a challenge for differential diagnosis. In this article we describe the course of synchronisation between different EEG channels during nocturnal seizures in 3 patients with sleep-related epileptic seizures and in 1 patient with sleep terrors. The functional interactions between the different EEG channels during the nocturnal seizures were analysed by means of the so-called synchronisation likelihood (SL). SL is a measure of the dynamical (linear and nonlinear) interdependencies between a time series (EEG channel) and one or more other time series. The main results of our study are the confirmation of a significant increase in EEG synchronisation during sleep-related seizures and the indication that clinically similar ictal motor patterns might be generated by different neurophysiological mechanisms, characterised by different patterns of synchronisation involving multiple or single frequency bands. This new approach might be useful to differentiate motor seizures, emerging from NREM sleep, from parasomnias (arousal disorders) when both ictal and interictal EEGs are uninformative.

Association of IL-1 RN*2 allele and methionine synthase 2756 AA genotype with dementia severity of sporadic Alzheimer's disease

BACKGROUND

Genetic polymorphisms of APO-E, homocysteine, and the IL-1 gene cluster (IL-1A, IL-1B, receptor antagonist IL-1RN) are associated with sporadic Alzheimer's disease and may involve interdependent pathways of neuronal toxicity.

OBJECTIVE

To determine whether these polymorphisms and the genetic determinants of homocysteine (methylenetetrahydrofolate reductase, MTHFR; methionine synthase, MTR; transcobalamin, TC) are associated with an increased risk of severe dementia in Alzheimer's disease.

METHODS

152 patients with Alzheimer's disease and 136 controls were studied. The association of occurrence and dementia severity (Reisberg score <6 and >or=6) of Alzheimer's disease with APO-E, IL-1A, IL-1B, IL-1RN, MTHFR677 C-->T and 1298A-->C, MTR 2756 A-->G, and TC 776 C-->G polymorphisms was evaluated by multivariate logistic regression analysis after adjustment for age, sex, and age of onset of Alzheimer's disease.

RESULTS

IL-1A TT and IL-1B CT/TT associated genotypes were at risk of Alzheimer's disease (odds ratio 4.80 (95% confidence interval, 1.32 to 17.40), p = 0.017); the MTR 2756 AA genotype was at risk of severe dementia (OR 2.97 (1.23 to 7.21), p = 0.016); IL-1 RN*2 was protective (OR 0.28, (0.11 to 0.69), p = 0.006). Allele epsilon4 of the APO-E and IL-1B CC genotypes increased the risk of severe Alzheimer's disease associated with the MTR 2756 AA genotype by 3.3-fold and 1.5-fold, respectively.

CONCLUSIONS

Distinct determinants of the IL-1 gene cluster are related to the generation and progression of Alzheimer's disease. MTR only influences progression of the disease, which may be enhanced by carriage of allele epsilon4 of APO-E.

Isolated monolateral neurosensory hearing loss as a rare sign of neuroborreliosis

Lyme disease, or borreliosis, is a zoonosis transmitted by Borrelia burgdorferi which also involves the central nervous system (CNS), in 15% of affected individuals, with the occurrence of aseptic meningitis, fluctuating meningoencephalitis, or neuropathy of cranial and peripheral nerves. Encephalopathy with white matter lesions revealed by magnetic resonance imaging (MRI) scans in late, persistent stages of Lyme disease has been described. In this report, we describe a patient with few clinical manifestations involving exclusively the eighth cranial nerve, monolaterally and diffuse bilateral alterations of the white matter, particularly in the subcortical periventricular regions at cerebral MRI. This single patient study shows that the search for antibodies against Borrelia burgdoferi should always be performed when we face a leukoencephalopathy of unknown origin. An isolated lesion of the eighth cranial nerve can be the only neurologic sign in patients with leukoencephalopathy complicating Lyme disease.

ISCHEMIC STROKE AND FIBRINOGEN IN THE ELDERLY

Senescence is accompanied by an important increase in prevalence and incidence of ischemic stroke. The plasma level of fibrinogen tends to increase with age in the elderly similarly to the prevalence of stroke. The aim of our study was to evaluate the age-related increase in fibrinogen plasma level in the elderly and to assess the presence of eventual differences between normal subjects and patients with previous ischemic stroke associated with precerebral atherosclerosis. Eighty inpatients (41 males and 39 females), consecutively admitted to our Geriatric Unit, were included to this study. The patient group was formed 32 subjects (20 males and 12 females) aged 50-79 years, suffering from cerebrovascular disease with one or several previous ischemic stroke episodes, having occurred at least 1 year earlier. The control group consisted of 48 normal subjects (21 males and 27 females) aged 50-79 years. Both control and patient groups were subdivided into three subgroups, according to their age: Group 1 (50-59 years), Group 2 (60-69 years)and Group 3 (70-79 years). The statistical comparison was carried out by means of the Mann-Whithney nonparametric test. In normal controls, a mild age effect is evident because only Group 3 shows fibrinogen levels significantly higher than those of Group 1. On the contrary, in patients with ischemic stroke, an age effect is already evident between Group 2 and Group 1; of course, also the comparison between patient Group 3 and Group I shows a statistically significant difference. Moreover, the levels of fibrinogen were significantly increased in patient Group 2 and 3 when compared to those of their respective age-matched controls. Our data are in agreement with those already available in the literature and demonstrate that fibrinogen in normal aging changes with age and shows a 19 %increase between age Group 1 and Group 3. Patients with ischemic stroke show an earlier and more evident age-related increase in fibrinogen than normal controls. Even if it is not possible to know, if the increase in fibrinogen is a consequence or not of the ischemic stroke, we can affirm that certainly the increased levels of fibrinogen should be considered as an important risk factor in the elderly for cerebrovascular disease and deserve treatment.

Reversion of transformed phenotype in ovarian cancer cells by intracellular expression of anti folate receptor antibodies

The alpha-folate receptor (FR) is selectively overexpressed in 90% of nonmucinous ovarian carcinomas, whereas no expression is detectable in normal ovarian surface epithelium (OSE). Indirect evidence suggests that FR expression is associated with tumor progression and affects cell proliferation. To evaluate better the role of FR, we developed an approach based on intracellular expression of single-chain (sc) antibodies (intrabody) to downmodulate membrane expression of FR in ovary cancer cells. IGROV-1 and SKOV3 ovarian carcinoma cell lines were transfected with an anti-FR intrabody. Transfectants and parental cells were tested for FR, integrins and anti-FR intrabody expression by fluorescence-activated cell sorting (FACS), reverse transcription and polymerase chain reaction (RT-PCR) and/or immunoblotting. Cell growth characteristics and adhesion properties were evaluated in liquid, semisolid and organotypic cultures. The anti-FR scFv inhibited FR expression from 60 to 99%. At physiological concentrations of folate, proliferation varied directly as a function of FR expression. FR downmodulation was accompanied by reduced colony-forming ability in soft agar, morphological change of the cells, significant enhanced adhesion to laminin or Matrigel, a two- to three-fold increase in alpha6beta4 integrin expression, and a marked reduction in laminin production. In three-dimensional organotypic cultures, anti-FR intrabody-transfected IGROV1 cells grew as a single-ordered layer, reminiscent of normal OSE growth in vivo. In conclusion, the anti-FR intrabody reverses the transformed phenotype in ovary cancer cells and may provide an efficient means to inhibit selectively the growth of these cells.

Transcranial magnetic stimulation after pure motor stroke

OBJECTIVES

The objective of this study was to assess the sensitivity of motor-evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS) in demonstrating the possible subclinical impairment of the corticospinal pathway after recovery, in patients with a clinical history of pure motor stroke (PMS) due to a single lacunar infarct detectable by magnetic resonance imaging (MRI).

METHODS

MEPs were recorded from the first dorsal interosseous muscle of 20 healthy subjects and 40 patients, 6 months or more after PMS onset. Patients were evaluated clinically by means of the NIH stroke scale, the Medical Research Council (MRC) scale and the Barthel Index. The patients with full hand strength recovery and the normal controls were also tested by means of the 9-hole peg test.

RESULTS

Motor threshold (MT), MEP amplitude and central motor conduction time (CMCT) of the affected side were significantly different from those of the normal side and of the control subjects. MT, MEP amplitude and CMCT obtained after stimulation of the affected hemisphere were significantly correlated with the MRC scale values of the affected hand. Eighty-six percent of patients with persistent hand strength deficit showed MEP abnormalities. In 21 patients with complete clinical recovery, a significant increase in MT and decrease in MEP amplitude on the affected side were observed.

CONCLUSIONS

After PMS, neurophysiological changes may persist despite complete clinical recovery. TMS represents a sensitive tool that enables to demonstrate objectively the clinical and subclinical impairment of the corticospinal pathway.

Non-linear EEG analysis in children with epilepsy and electrical status epilepticus during slow-wave sleep (ESES)

OBJECTIVE

The objective of this work was to study the non-linear aspects of electroencephalography (EEG) in children with epilepsy and electrical status epilepticus during slow-wave sleep (ESES).

METHODS

In this study, we recorded the sleep EEG in 5 subjects with ESES (4 males and one female, aged 6.5-10 years) who were also mentally retarded and affected by cerebral palsy (3 subjects) and hydrocephalus (two subjects). The signals were sampled at 128Hz and stored on hard disk. All the subsequent computational steps were performed on EEG epochs (4096 data points) selected from wakefulness and non-rapid eye movement (non-REM) (with ESES) or REM sleep. The dynamic properties of the EEG were assessed by means of the non-linear cross prediction (NLCP) test which uses 3 different 'model' time series in order to predict non-linearly the original data set (Pred, Ama and Tir). Pred is a measure of the predictability of the time series and Ama and Tir are measures of asymmetry, indicating non-linear structure. Moreover, the correlation dimension (D2) was estimated by means of the algorithm by for the epochs showing non-linear nature.

RESULTS

The NLCP test provided evidence of significant non-linear dynamics in all epochs of non-REM sleep, when ESES was evident. Only during this stage, the possible presence of low-dimensional chaos could also be suspected (average D2=4.02; range 3.16-6.21). EEG without ESES could not be distinguished from linearly filtered noise.

CONCLUSIONS

The results of the present study seem to indicate that subjects with ESES show a profound modification of their EEG dynamics with the occurrence, during sleep, of long periods characterized by non-linear dynamics and, probably, low-dimensional chaotic structure able to modify in a substantial way their brain functioning during sleep.

Transcranial magnetic stimulation in Alzheimer disease: motor cortex excitability and cognitive severity

To study the possible changes of cortical excitability in the Alzheimer disease (AD) by transcranial magnetic stimulation (TMS) and to evaluate their eventual correlation with its stage twenty-one AD patients and 18 normal controls underwent TMS. Motor threshold, amplitudes of motor evoked potentials (MEPs), central motor conduction time (CMCT) and silent period (SP) were considered. The motor threshold in AD patients was lower than in normal subjects with a significant correlation between the stage of cognitive severity. The amplitude of MEPs was increased and the SP duration was reduced in AD patients. No significant differences were obtained for CMCT. These findings could suggest a correlation between increased motor cortical excitability and cognitive severity. Moreover, the increased cortical excitability could represent a key to understand the mechanism of AD and may have implication for novel treatment strategies.

Friction melanosis, friction amyloidosis, macular amyloidosis, towel melanosis: many names for the same clinical entity

Macular or friction amyloidosis is a cutaneous entity characterized by a brownish pigmentation distributed on the skin over bony regions of the trunk and limbs after the use, for many years, of a nylon towel or scrub brush to clean the skin. Electron microscopy is necessary for the diagnosis of this dermatosis and reveals deposits of amyloid in the papillary dermis. This condition is relatively unknown in Western countries. In this report, we describe 24 Italian patients affected by friction amyloidosis which was caused by the use of cotton towels, horse-hair gloves or artificial and rough sponges to clean their skin.

Relationship between Delta, Sigma, Beta, and Gamma EEG bands at REM sleep onset and REM sleep end

OBJECTIVE

The aim of the present study was to analyze in detail the relationship of two newly introduced measures, related to the Beta and Gamma EEG bands during REM sleep, with Delta and Sigma activity at REM sleep onset and REM sleep end, in order to understand their eventual role in the sleep modulation mechanism.

METHODS

For this purpose, power spectra of 1 EEG channel (C4, referred to A1) were obtained by means of the fast Fourier transform and the power of the bands ranging 0.75-4.50 Hz (Delta), 4.75-7.75 (Theta), 8.00-12.25 (Alpha), 12.50-15.00 (Sigma), 15.25-24.75 (Beta), 25.00-34.75 (Gamma 1), and 35.00-44.75 (Gamma 2) was calculated for the whole period of analysis (7 h), in 10 healthy subjects. Additionally, two other time series were calculated: the ratio between Beta and Gamma2, and between Gamma1 and Gamma2 (Beta and Gamma ratios). For each subject, we extracted 3 epochs of 30 min corresponding to the 15 min preceding and the 15 min following the onset of the first 3 REM episodes. Data were then averaged in order to obtain group mean values and standard deviation. The same process was applied to the 30-min epochs around REM sleep end.

RESULTS

The course of the Delta band around REM sleep onset was found to be characterized by a first phase of slow decline lasting from the beginning of our window up to a few seconds before REM onset; this phase was followed by a sudden, short decrease centered around REM onset, lasting for approximately 1.5-2 min. At the end of this phase, the Delta band reached its lowest values and remained stable up to the end of the time window. The Sigma band showed a similar course with stable values before and after REM sleep onset. The Beta and Gamma ratios also showed a 3-phase course; the first phase, in this case, was characterized by stable low values, from the beginning of our window up to approximately 5 min before REM onset. The following second phase was characterized by an increase which reached its maximum shortly after REM sleep onset (approximately 1 min). In the last phase, both Beta and Gamma ratios showed stable high values, up to the end of our time window. At REM sleep end, the Delta band only showed a very small gradual increase, the Sigma band presented a more evident gradual increase; on the contrary, both Beta and Gamma ratios showed a small gradual decrease.

CONCLUSIONS

The results of the present study show a different time synchronization of the changes in the Delta band and in Beta and Gamma ratios, at around REM sleep onset, and seem to suggest that the oscillations of these parameters might be modulated by mechanisms more complex than a simple reciprocity. All these considerations point to the fact that REM sleep can be considered as a complex phenomenon and the analysis of high-frequency EEG bands and of our Beta and Gamma ratios represent an additional important element to include in the study of this sleep stage.

Regional cerebral hyperperfusion and nitric oxide pathway dysregulation in Fabry disease: reversal by enzyme replacement therapy

BACKGROUND

Fabry disease is an X-linked lysosomal deficiency of alpha-galactosidase A that results in cellular accumulation of galacto-conjugates such as globotriosylceramide, particularly in blood vessels. It is associated with early-onset stroke and kidney and heart failure.

METHODS AND RESULTS

Using [(15)O] H(2)O and PET, we found increased resting regional cerebral blood flow in Fabry disease without evidence of occlusive vasculopathy or cerebral hypoperfusion. Because nitric oxide is known to play an important role in vascular tone and reactivity, we studied plasma nitrate, nitrite, and low-molecular-weight S-nitrosothiol levels by chemiluminescence. Skin biopsy specimens and archived brain tissue were also examined immunohistochemically for nitrotyrosine. Plasma nitrate, nitrite, and low-molecular-weight S-nitrosothiol were in the normal range; however, enhanced nitrotyrosine staining was observed in dermal and cerebral blood vessels. After a double-blind, placebo-controlled trial of alpha-galactosidase A therapy, the resting regional cerebral blood flow in the treated group was significantly reduced, with a notable decrease of nitrotyrosine staining in dermal blood vessels.

CONCLUSIONS

These findings suggest a chronic alteration of the nitric oxide pathway in Fabry disease, with critical protein nitration that is reversible with enzyme replacement therapy.