[Venous gas embolism from pleurovenous fistula]

We report the case of an iatrogenic gas embolism related to a subclavian vein catheterization complicated by a preexisting partial pneumothorax. Catheterization was indicated because of a septic shock due to nosocomial pneumonia. Five days after the catheterization, the haemodynamics and gas exchanges of the patient worsened. A transthoracic echography showed gas embolism in the right heart related to a right partial pneumothorax. A leak between the pleura and the left subclavian vein was diagnosed. The insertion of a chest tube stopped the airflow, by suppressing the pneumothorax.

Familial effects on the clinical course of multiple sclerosis

BACKGROUND

Familial factors influence susceptibility to multiple sclerosis (MS) but it is unknown whether there are additional effects on the natural history of the disease.

METHOD

We evaluated 1,083 families with > or =2 first-degree relatives with MS for concordance of age at onset, clinical course, and disease severity and investigated transmission patterns of these clinical features in affected parent-child pairs.

RESULTS

There is concordance for age at onset for all families (correlation coefficient 0.14; p < 0.001), as well as for affected siblings (correlation coefficient 0.15; p < 0.001), and affected parent-child pairs (correlation coefficient 0.12; p = 0.03) when each is evaluated separately. Concordance for year of onset is present among affected siblings (correlation coefficient 0.18; p < 0.001) but not the parent-child group (correlation coefficient 0.08; p = 0.15). The clinical course is similar between siblings (kappa 0.12; p < 0.001) but not affected parents and their children (kappa -0.04; p = 0.09). This influence on the natural history is present in all clinical subgroups of relapsing-remitting, and primary and secondary progressive MS, reflecting a familial effect on episodic and progressive phases of the disease. There is no concordance for disease severity within any of the considered family groups (correlation coefficients: all families analyzed together, 0.02, p = 0.53; affected sibling group, 0.02, p = 0.61; affected parent-child group, 0.02, p = 0.69). Furthermore, there are no apparent transmission patterns of any of the investigated clinical features in affected parent-child pairs and no evidence for anticipation or effects of genetic loading.

CONCLUSION

Familial factors do not significantly affect eventual disease severity. However, they increase the probability of a progressive clinical course, either from onset or after a phase of relapsing remitting disease. The familial effect is more likely to reflect genetic than environmental conditions. The results are relevant for counseling patients and have implications for the design of studies seeking to identify factors that influence the natural history of the disease.

Chronic high frequency stimulation of the posteromedial hypothalamus in facial pain syndromes and behaviour disorders

Chronic high frequency stimulation (HFS) of the posteromedial hypothalamus (PMH) has been the first direct therapeutic application of functional neuroimaging data in a restorative reversible procedure for the treatment of an otherwise refractory neurological condition; in fact, the target coordinates for the stereotactic implantation of the electrodes have been provided by positron emission tomography (PET) studies, which were performed during cluster headache attacks. HFS of PMH produced a significant and marked reduction of pain attacks in patients with chronic cluster headache (CCH) and in one patient with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). The episodes of violent behaviour and psychomotor agitation during the attacks of CCH supported the idea that the posteromedial hypothalamus could be also involved in the control of aggressiveness; this has been previously suggested, in the seventies, by the results obtained in Sano's hypothalamotomies for the treatment of abnormal aggression and disruptive behaviour. On the basis of these considerations, we have performed HFS of the PMH and controlled successfully violent and disruptive behaviour in patients refractory to the conventional sedative drugs. Finally, we also tested the same procedure in three patients with refractory atypical facial pain, but unfortunately, they did not respond to this treatment.

Acute hypothalamic stimulation and ongoing cluster headache attacks

Long-term hypothalamic stimulation is effective in improving drug-resistant chronic cluster headache (CH). We assessed acute hypothalamic stimulation to resolve ongoing CH attacks in 16 patients implanted to prevent chronic CH, investigating 136 attacks. A pain intensity reduction of > or =50% occurred in 25 of 108 evaluable attacks (23.1%). Acute hypothalamic stimulation is not effective in resolving ongoing CH attacks, suggesting that hypothalamic stimulation acts by complex mechanisms in CH prevention.

EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias

Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this study was to give evidence-based recommendations for the treatment of these headache disorders based on a literature search and consensus amongst a panel of experts. All available medical reference systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT syndrome. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies resulting in level A, B or C recommendations and good practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as alternative treatments. Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute therapy when patients are extremely distressed and disabled by frequent attacks.

SOD1 gene mutations in Italian patients with Sporadic Amyotrophic Lateral Sclerosis (ALS)

Mutations in the SOD1 gene exons and exon/intron boundaries were searched in 66 sporadic and 4 familial Italian ALS cases consecutively referred to our centre from different Italian regions. A mutation was found in three sporadic cases (4.5%): a new nonsense mutation in exon 5 (K136X) in a patient with a rapid and severe disease course and two previously described missense nucleotide substitutions (N65S and A95T) in two patients with a mild disease course. Comparison of the clinical characteristics with previously reported patients carrying the same or similar mutations showed a remarkable genotype-phenotype correlation. No association was found with intronic sequence variations by comparing their frequency in the patients and in 181 matched controls.

Criticality on networks with topology-dependent interactions

Weighted scale-free networks with topology-dependent interactions are studied. It is shown that the possible universality classes of critical behavior, which are known to depend on topology, can also be explored by tuning the form of the interactions at fixed topology. For a model of opinion formation, simple mean field and scaling arguments show that a mapping gamma'=(gamma-mu)(1-mu) describes how a shift of the standard exponent gamma of the degree distribution can absorb the effect of degree-dependent pair interactions J(ij) proportional to (k(i)k(j))(-mu), where k(i) stands for the degree of vertex i. This prediction is verified by extensive numerical investigations using the cavity method and Monte Carlo simulations. The critical temperature of the model is obtained through the Bethe-Peierls approximation and with the replica technique. The mapping can be extended to nonequilibrium models such as those describing the spreading of a disease on a network.

Comment moduler la pression artérielle en cas de lésion cérébrale ?

One of the goals of the medical management of head injured patients is to get a cerebral perfusion pressure between 60 and 70 mmHg. To reach such a goal, catecholamines are used after fluid challenge. Systemic effects of catecholamines depend on their affinity for the receptors alpha and beta. The topical application of norepinephrine (alpha predominant) induced a vasoconstriction on large cerebral arteries only. Cerebral blood flow increased in the pericontusionnal area, suggesting a loss of autoregulation. The topical application of dopamine at low concentration relaxed large cerebral arteries. Dopamine increased cerebral blood flow in the pericontusional area but data suggest a possible raise in the volume of contusion. Four human comparative studies have been published. The first study, which was not randomized, showed an intracranial pressure increase associated with dopamine. Two randomized clinical trials, published by the same group, demonstrated a better predictability with norepinephrine. The fourth study did not find any difference regarding cerebral haemodynamics. In conclusion, the quality of data on the effects of catecholamines on cerebral haemodynamics of head injured patients do not make it possible to conclude about their use.

Quelle sédation pour la prévention et le traitement de l'agression cérébrale secondaire ?

The aim of sedation and analgesia is to prevent secondary brain insult. The goals of sedation are the prevention and treatment of intracranial hypertension and systemic disorders. In such situation, the use of sedative and analgesic therapy should respect the rate of cerebral blood flow/cerebral oxygen consumption coupling while preserving cerebral perfusion pressure and decreasing the intracranial pressure. This treatment should have an analgesic and myorelaxing action with short and predictable time of action. The optimal agent with all these characteristics does not exist, but the combination of several pharmacological compounds may reach this goal. Benzodiazepines are the most frequently agents used. In most of cases they are associated with analgesics like opioids or ketamine. Opioids are the basis of analgesia because they do not produce brain haemodynamic alterations if arterial pressure is maintained. Ketamine, which use in this indication is matter of debate, has the advantage to maintain haemodynamics. Ketamine has no side effects on brain haemodynamics when used in combination with propofol or midazolam. Because of their side effects on haemodynamics and immune response, barbituric are no longer used as long term sedative agents. However, they are still recommended in cases of refractory intracranial hypertension. Propofol remains the optimal sedative agent because of its short duration action although its use is restricted because it is an expensive drug. Its use is recommended for short time sedation with or without opioids. The use of neuromuscular blockers should be focused on the patients with an intracranial hypertension refractory to standard treatment. The presence of brain damage in patients makes difficult to assess the level of sedation. One should avoid over sedation, which increases morbidity by prolongation of the duration of mechanical ventilation.

Neuroimaging and pain: a window on the autonomic nervous system

Pain is one of the most common experiences of humans. Neuroimaging techniques can visualize the main brain areas involved in pain modulation, the pain matrix. It is noteworthy that many of the brain areas forming the pain matrix are also involved in modulating autonomic nervous system (ANS) activity that in turn plays a major role in determining the best adaptive response to the pain experience. The tight connection between the pain system and ANS is also evident from neuroanatomical studies indicating that the lamina 1 neurons receive both painful and visceral stimuli from all visceral organs giving rise to the spinothalamocortical pathway concerned with conveying interoceptive information to central structures. The resulting interoceptive stream projects to the viscerosensory cortex in the mid-insula and onto the right anterior insula and orbitofrontal cortices. Right anterior insula activation is involved in the sympathetic arousal associated with mental tasks. This brain region receives numerous other inputs including pain and painful stimuli are conveyed somatotopically to both insulae. A similar somatotopic organization of painful stimuli has also been shown in the basal ganglia involved in cognitive, affective, motor and autonomic states. This highly specialized organization of nociceptive information in these brain areas may subserve a number of functions, particularly of coupling pain with the most appropriate autonomic states and affective/emotional states. The anterior cingulated cortex, another brain area playing a crucial role in nociception, is also directly involved in the control of autonomic functions such as arousal during volitional behaviour, including effortful cognitive processing. It is evident that the nociceptive system and ANS closely interact in many processes involved in maintaining internal homeostatis and in order to give the most appropriate biological substrate for cognitive, affective and emotional states.

A genome-wide scan and HCRTR2 candidate gene analysis in a European cluster headache cohort

OBJECTIVE

To investigate the molecular genetic basis of cluster headache (CH), using a genome-wide scan and candidate gene strategy.

METHODS

Northern European CH families and a case-control cohort of Danish, Swedish, and British origin (total n = 259 sporadic CH patients), including 267 control subjects matched for ancestry, participated in the study. A genome-wide genetic screen using approximately 400 microsatellite markers was performed for five informative Danish CH families. Additional markers were typed for those loci generating statistical evidence suggestive of linkage, together with genotypes for 111 individuals from further Danish and Italian kindreds. Sporadic CH patients and controls were investigated by association analysis for variation in the candidate gene, HCRTR2. Finally, complete HCRTR2 sequencing was undertaken for eight independent probands.

RESULTS

Potential linkage was identified at four possible disease loci in Danish kindreds, yet no single chromosome location generated a lod or NPL score of recognized significance. No deleterious sequence variants of the HCRTR2 gene were detected by comparison to wild-type sequence. Association of the HCRTR2 gene was not replicated in this large dataset, even when the data were stratified into distinct populations.

CONCLUSIONS

Cluster headache is a complex genetic disorder, with possible phenotypic and genetic heterogeneity compounding attempts at gene identification.

[Management of ventilator acquired pneumonia]

Ventilator-associated pneumonia occurs in the evolution of 8 to 70% of patients in the Intensive Care Unit. It is the main site of nosocomial infection for mechanically ventilated patients. Nosocomial pneumonia represents an important cause of morbidity and mortality, despite progresses in antibiotic prescription, use of intensive care and prevention. This review is based on the ATS guidelines, and reviews epidemiology, diagnosis and treatment of ventilator-acquired pneumonia, in non-immunocompromised adults.

Core percolation and onset of complexity in boolean networks

The determination and classification of fixed points of large Boolean networks is addressed in terms of a constraint-satisfaction problem. We develop a general simplification scheme that, removing all those variables and functions belonging to trivial logical cascades, returns the computational core of the network. The transition line from an easy to a complex regulatory phase is described as a function of the parameters of the model, identifying thereby both theoretically and algorithmically the relevant regulatory variables.

Leucocytospermia: Which Relationship with Male Infertility?

Leucocytospermia is usually associated with genito-urinary tract infections and its role on male infertility is currently under debate. The aim of this study was to investigate the relationship between leucocytospermia and seminal fluid alterations in men with fertility problems. We evaluated 40 consecutive spemiograms of leucocystospermic men, and another 40 from individuals without leucocytospermia, with regard to age, number, motility and sperm morphology, and presence of genito-urinary tract infections. There was a significant difference in terms of motility (23.27% in non-leucocytospermic pts vs. 15.57% in leucocytospermic pts., p=0.0034). Furthermore, asthenozoospermia was more frequent in leucocytospermic pts (45% vs. 72.,%, p=0.0231), as also teratozoospermia (32.5% vs. 62.5%, p=0.0138). The probability to have at least one of the major seminal alterations was greater in leucocytospermic pts (75.3% vs. 52.5%, p=0.0048). The incidence of infections in leucocytospermic group was 13%. Our study underlines the relationship between leucocytospermia, motility, and normal morphology reduction in human semen. These data might suggest the presence of a damage due to the ROS produced by seminal leucocytes on spermatozoa. Our analysis wants to emphasize the need to treat this condition, with special regard to the frequent use of PMA procedures.

Predictive perioperative factors for developing severe sepsis after major surgery

BACKGROUND

Early identification of high-risk patients undergoing major surgery can result in an aggressive management affecting the outcome.

METHODS

We designed a prospective cohort study of 93 adult patients undergoing major oncological surgery to identify the predictive risk factors for developing postoperative severe sepsis.

RESULTS

Nineteen of 93 patients developed a severe sepsis after surgery; seven of the septic patients died in intensive care unit. Multivariate analysis discriminated preoperative and postoperative (first and second day after surgery) predictive risk factors. The postoperative severe sepsis was independently associated with preoperative factors like male gender (OR 4.7, 95% CI between 1.5 and 15.5, P<0.01) and Charlson co-morbidity index (OR 1.3, 95% CI between 1.07 and 1.6, P<0.01). After the surgery, the presence of systemic inflammatory response syndrome (OR 4.0, 95% CI between 1.02 and 15.7, P<0.05) and a logistic organ dysfunction score on day 2 (OR 3.3, 95% CI between 1.9 and 5.7, P<0.001) were found as independent predictive factors.

CONCLUSION

We have shown that some of the markers that can be easily collected in the preoperative or postoperative visits can be used to screen the patients at high risk for developing severe sepsis after major surgery.

Hématomes intra-crâniens extra-duraux : à propos de 100 cas récents

We present a retrospective study on the management of 100 patients who presented epidural hematoma over a four-year period. Our goal was to provide an update on management of this injury. Computed tomography was performed because of the clinical presentation. Results provided information on the type of injury and appropriate treatment. A three-phase clinical progression was observed in only 6% of the patients. Despite state-of-the-art management, mortality remained high in these brain-injured patients (21%). No progress appears to have been achieved in the last ten years. This paradoxical fact probably results from the enhanced severity observed in our patients, who often suffered from associated intracranial injuries as well as multiple trauma (thoracic, abdominal trauma). Analysis study of the results confirms an improvement in mortality among patients with isolated epidural hematoma (6.6%), but great concern remains about the high mortality among patients with associated intracranial lesions (33.3%) or multiple trauma (32%).

Un cas de botulisme de type A

The neurotoxin produced by Clostridium botulinum, is responsible for botulism. The clinical signs are digestive disorders, pupillar alterations, and peripheral muscular weakness. The failure of thoracic muscles is responsible for the severity of botulism. We describe a case of a 74 year old woman who presented a severe form of botulism, requiring a prolonged intensive care unit stay.

[Therapeutic management of peritonitis]

Antibiotherapy is a fundamental for the treatment of peritonitis. It may be used before surgery or as a complementary treatment after. Experimental models have demonstrated that infections are both aerobic and anaerobic. During the first stage, septicemic with a high death rate, the infection is due to enterobacteria, mostly Escherichia coli. Between D5 and D7 in surviving animals, there is a second stage with abscesses due to anaerobic bacteria, mostly Bacteroides fragilis. The antibiotic treatment must include these two types of bacteria in its spectrum. The role of Enterococcus faecalis is not clearly defined, but this bacterium must be taken into account in case of organ failure or associated septic shock. Treatment options for secondary peritonitis may be, according to severity, cefoxitin, an Augmentin + gentamycin combination, Tazocillin, or ertapenem. The reference treatment for nosocomial or tertiary peritonitis is the imipenem + amikacin combination. An antifungal treatment (fluconazole) is usually necessary, at least until the results of peritoneal fluid culture are available. The duration of treatment is quite variable, ranging from 48 h in less severe forms to 14 days.

Stroke and transient ischaemic attack in 18 neurology departments from two Italian Regions: the SINPAC database

This observational prospective multicentre study aims to describe a hospital-based database collecting information about clinical features, management and follow-up of stroke patients. In 18 neurological departments (mostly first-referral) in Piedmont and the Aosta Valley, Italy, between May and July 1999, 604 consecutive patients (97 TIA, 443 ischaemic, and 64 haemorrhagic stroke) were studied. Ischaemic stroke aetiologies were as follows: large-artery atherosclerosis (148), small-artery occlusion (133), cardioembolism (76), other causes (13) and undetermined (73). According to Bamford's classification, 164 were PACI, 126 LACI, 87 TACI and 66 POCI. The diagnostic workup and management of patients is described; only 4% of patients did not receive a CT scan. Four hundred and three patients were discharged to their home, 78 to a rehabilitation unit, 44 to long-term institutional care, 20 to other wards and 59 died while in hospital. After six months, 10 patients were lost to follow-up, 499 were alive and 95 had died. The SINPAC database allows for evaluation of current practice of care in a first-referral stroke population.

The Frontal Assessment Battery (FAB): normative values in an Italian population sample

The Frontal Assessment Battery (FAB) is a short cognitive and behavioural six-subtest battery for the bedside screening of a global executive dysfunction; although recently devised, it is already extensively used thanks to its ease of administration and claimed sensitivity. The aim of the present study was to derive Italian normative values from a sample of 364 control subjects (215 women and 149 men) of different ages (mean: 57.4+/-17.9 years; range: 20-94 years) and educational level (mean: 10.4+/-4.3 years; range: 1-17 years); the Mini Mental State Examination (MMSE) was concurrently administered. Multiple linear regression analysis revealed significant effects for age and education whereas gender was not significant; thus, from the derived linear equation, a correction grid for FAB raw scores was built. Based on nonparametric techniques, inferential cut-off scores were subsequently determined and equivalent scores (ES) computed. Test-restest and interrater reliabilities were both satisfactory. Interestingly, MMSE was significantly correlated with FAB raw scores, whereas adjusted scores were not. The present data may improve the accuracy in the use of the FAB both for clinical and research purposes.

The role of the ear, nose and throat specialist in diagnosing headaches

The revised International Headache Society classification (2004) represents a very good reference also for ear, nose and throat (ENT) specialists and can be largely shared. The authors follow the classification outline and comment on the chapters of ENT interest. The classification leaves unsolved problems and most of them are of ENT competence, such as mucosal contact point headache. It will be a task for ENT specialists to clarify the real role of very hypothetical primary forms frequently assigned to diagnosis without a correct rationale.

Trading interactions for topology in scale-free networks

Scale-free networks with topology-dependent interactions are studied. It is shown that the universality classes of critical behavior, which conventionally depend only on topology, can also be explored by tuning the interactions. A mapping, gamma'=(gamma-mu)/(1-mu), describes how a shift of the standard exponent gamma of the degree distribution P(q) can absorb the effect of degree-dependent pair interactions J(ij)proportional to(q(i)q(j))(-mu). The replica technique, cavity method, and Monte Carlo simulation support the physical picture suggested by Landau theory for the critical exponents and by the Bethe-Peierls approximation for the critical temperature. The equivalence of topology and interaction holds for equilibrium and nonequilibrium systems, and is illustrated with interdisciplinary applications.

Deep brain stimulation and cluster headache

In recent years, neuroimaging data have greatly improved the knowledge on trigeminal autonomic cephalalgias' (TACs) central mechanisms. Positron emission tomography studies have shown that the posterior inferior hypothalamic grey matter is activated during cluster headache attacks as well as in short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Voxel-based morphometric MRI has also documented alteration in the same area in cluster headache patients. These data suggest that the cluster headache generator is located in this region and leads us to hypothesise that stimulation of this brain area could relieve intractable cluster headache just as deep brain stimulation improves intractable movements disorders. This view received support by the observation that high frequency stimulation of the ipsilateral hypothalamus prevented attacks in an otherwise intractable chronic cluster headache patient previously treated unsuccessfully by surgical procedures to the trigeminal nerve. So far, 16 patients with intractable cronic cluster headache (CCH) and one intractable SUNCT patient have been successfully treated by hypothalamic stimulation. The procedures were well tolerated with no significant adverse events. Hypothalamic DBS is an efficacious and safe procedure to relieve otherwise intractable CCH and SUNCT.