Disclosing the Risk Associated with Isolated REM Behavior Disorder: The Sleep Experts' Perspective

BACKGROUND

Isolated rapid-eye-movement sleep behavior disorder (iRBD) is associated with a high risk for phenoconversion to a neurodegenerative disorder, but the optimal approach for disclosure of this risk to patients is still debated.

OBJECTIVES

The aim of this study was to explore views and experiences of iRBD experts regarding risk disclosure.

METHODS

In this qualitative study, semi-structured interviews with sleep experts caring for patients with iRBD were analyzed through a conventional content analysis approach.

RESULTS

We interviewed 22 iRBD experts (eight female, average age of 51.8 years) from 18 Italian sleep centers; 21/22 regularly disclosed the risks associated with iRBD, usually after the video-polysomnography, and 8/22 regularly mentioned phenoconversion rates. Content analysis allowed us to identify three main themes. First, sleep experts reported several points in favor of risk disclosure, especially related to the principle of beneficence, but some highlighted the need for specific learning on the topic. Second, experts favored a patient-tailored disclosure that should not upset the patient unnecessarily, since phenoconversion is uncertain. Third, risk disclosure was seen by participants as a relational task that should be carried out in person in the context of a trusting patient-physician relationship, while they had contrasting views regarding patients' previous knowledge.

CONCLUSIONS

Sleep experts generally preferred a tailored and reassuring approach to risk disclosure within a framework of relational autonomy. The results of this study indicate the need for specific education, training, and recommendations concerning risk disclosure that should also include patients' and families' preferences.

[Neurology: what's new in 2023]

The year 2023 is marked by the arrival on the market of lecanemab for the treatment of Alzheimer's disease. New biomarkers have demonstrated their usefulness in monitoring peripheral neuropathies and diagnosing synucleinopathies. A genetic study has highlighted the role of nervous system cells in the risk of progression of multiple sclerosis (MS). The adverse effects of anticonvulsant treatments after prenatal exposure and on lipid metabolism have been clarified. New anti-CGRP treatments have demonstrated their efficacy in migraine attacks and chronic migraines. The criteria for thrombectomy have been further broadened. And finally, rehabilitation is refining the management of cerebrovascular patients and those with secondary progressive MS.

Resilience and its correlates in patients with narcolepsy type 1

STUDY OBJECTIVES

This study aimed to explore resilience and its possible association with sociodemographic and clinical features in patients with narcolepsy type 1 (NT1).

METHODS

This was a cross-sectional study involving patients with NT1 and age-/sex-matched controls (comparison group). Sociodemographic and clinical data were collected through semistructured interviews and validated questionnaires, including the Epworth Sleepiness Scale (ESS), State-Trait Anxiety Inventory (STAI)-State Anxiety, Beck Depression Inventory (BDI), 36-item Short Form Survey (SF-36), and the Resilience Scale (RS). Different statistical approaches were used to investigate the relationship between resilience and NT1 and associations with sociodemographic and clinical features.

RESULTS

The participants comprised 137 patients (mean age, 38.0 years; 52.6% female) and 149 controls (39.6 years; 55.7% female). Compared with controls, patients had a significantly lower (122.6 vs 135.5) mean RS score and a 2-fold risk of having low/mild-range resilience (adjusted odds ratio = 1.99, 95% confidence interval 1.13-3.52). Patients with high resilience had sociodemographic and narcolepsy characteristics similar to patients with low resilience, but they reported anxiety and depressive symptomatology less frequently (4.2% vs 55.8% and 58.3%, respectively), and their SF-36 scores were comparable to those of the comparison group. In patients, RS score was strongly associated with STAI-State Anxiety and BDI (rho = -0.57 and -0.56, respectively) and weakly with ESS (rho = -20) scores.

CONCLUSIONS

The results of this study suggest that resilience may play a key role in patients' adaptation to NT1. Furthermore, this study supports interventions aimed at increasing patients' resilience and provides a base for further studies, preferably longitudinal and including objective measures, directed toward understanding the relationship between resilience, depression, and quality of life in patients with narcolepsy.

CITATION

D'Alterio A, Menchetti M, Zenesini C, et al. Resilience and its correlates in patients with narcolepsy type 1. J Clin Sleep Med. 2023;19(4):719-726.

[Neurology: what's new in 2022]

The year 2022 was marked by the development of numerous new treatments for refractory myasthenia gravis. The link between epilepsy and cerebrovascular disorder was studied and lamotrigine discovered to be the optimal treatment choice for epilepsy secondary to stroke to prevent mortality on patient of 45 years and older. New randomized study finally demonstrated the utility of thrombectomy in selected patients with basilar artery occlusion. The causal relationship between Epstein-Barr infection and multiple sclerosis has been proved thanks to a large cohort study. A new possibility of subcutaneous continuous levodopa administration gave promising result. Finally, numerous studies confirmed the efficacy and excellent tolerability of anti-CGRP antibodies.

An emerging role for DPP6: reciprocal regulation of INa-Ito and implications for arrhythmogenesis

Background

Since the association of a chromosomal risk haplotype harboring dipeptidyl peptidase-like protein-6 (DPP6) to familial idiopathic ventricular fibrillation (iVF), a growing number of DPP6 missense variants has been reported in patients with ventricular tachyarrhythmias. The mechanisms underlying DPP6 mediated-arrhythmogenesis are not yet fully elucidated. DPP6 is a subunit of the transient outward potassium (Ito) channel complex in Purkinje cells (PC) and ventricular myocytes (VM).

Purpose

Since other Ito-channel subunits (Navβ1, KChIP2, KCNE4 and DPP10) are also known to antagonize INa, we examined whether DPP6 could play a broader role in the inter-regulation of Kv4.3 and Nav1.5 channels. We identified two novel DPP6 variants (p.Arg274His and p.His213Tyr), each segregating in families with QT/QU prolongation. DPP6 p.Arg274His carriers suffered from iVF, ectopic beats from the conduction system, and mitral valve prolapse. Other DPP6 variants (p.Ala751Val identified in this study; p.Gln526His and DPP6-T p.His332Arg published) are associated with Brugada syndrome (BrS). We hypothesized that DPP6 has opposing effects on INa and Ito displaying a reciprocal regulation of these currents.

Methods and results

First, we determined the effect of the DPP6 variants on INa and Ito in transfected CHO cells. Ito density was significantly reduced only when PC subunits were co-expressed with the DPP6 p.Arg274His or p.His213Tyr variants. Indeed, DPP6 modulates Nav1.5 channels in CHO cells by reducing INa Peak and INa Late, whereas DPP6 mutants p.Arg274His or p.His213Tyr resulted in an increase of both components compared to WT. Co-immunoprecipitation experiments in human endocardium confirmed an interaction between DPP6 and Nav1.5 channels. Computing of mutant DPP6-driven Ito-INa changes in a published human PC model led to significant prolongation of the action potential duration, mainly caused by increased INa Late.

On the other hand, the DPP6 p.Gln526His and p.Ala751Val variants, linked to BrS, led to a decreased INa Peak compared to the WT, while there was a tendency towards increased Ito density in both PC and VM molecular setups.

DPP6 (p.Arg274His and p.Ala751Val) transfection experiments in hiPSC cardiomyocytes, expressing endogenous INa and Ito, confirmed the reciprocal results obtained in CHO cells.

Conclusions

DPP6 regulates INa and Ito in a reciprocal manner. The cardiac phenotype of DPP6 variants could encompass a spectrum between two opposite poles: 1) QT/QU prolongation by DPP6 variants causing loss of Ito and gain of INa, like p.Arg274His and p.His213Tyr versus 2) BrS by DPP6 variants leading to gain of Ito and loss of INa, like p.Gln526His and p.Ala751Val.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): ESC Personal research grant, obtained in 2019

Multidisciplinary care of patients with narcolepsy during coronavirus disease 2019 pandemic in Italy via televisit: the TElemedicine for NARcolepsy feasibility study

STUDY OBJECTIVES

Narcolepsy is a rare chronic central disorder of hypersomnolence with frequent endocrine-metabolic comorbidities. To address the complex care needs of patients during the COVID-19 emergency, we carried out a feasibility study of the TElemedicine for NARcolepsy (TENAR) protocol with the aim of assessing the feasibility of a multidisciplinary care approach via televisit for patients with narcolepsy.

METHODS

A feasibility single open-arm study on the multidisciplinary care of children (>7 y.o.) and adults with narcolepsy who required a follow-up visit was realized during the COVID-19 pandemic emergency period in Italy. The study included a sleep, metabolic, and psychosocial assessment via televisit at baseline, at 6, and at 12 months from the study inclusion period (15th May-26th June 2020).

RESULTS

In total 39 out of 44 eligible patients (89%) entered the study (30 adults, nine children); 37 patients (95%) ended the 12-month follow-up. At baseline, the median Epworth sleepiness scale score (ESS) was 10 (IQR 8-14), and the median body mass index (BMI) was 25.6 (IQR 22.1-30.9). During the follow-up period, the ESS score decreased from the 6th month onward (p = 0.003), and BMI decreased at the 1-year follow-up (p = 0.047), while there were no differences in depressive and anxiety symptoms, quality of life, compliance with treatment, adverse drug reactions, or accidents.

CONCLUSIONS

High response and retention rates, stability of ESS, and lack of side effects indicate that telemedicine is a feasible and safe approach for adults and children with narcolepsy.

Refractory Status Epilepticus: Risk Factors and Analysis of Intubation in the Multicenter SENSE Registry

BACKGROUND AND OBJECTIVES

Refractory status epilepticus (RSE) bear significant morbidity and mortality. Therapy escalation and in some cases intubation are recommended. Most existing studies are retrospective and focus on ICUs. We aimed to describe routine-care management, and analyze determinants of RSE development and outcomes in a large multicenter cohort.

METHODS

We performed post hoc analysis of an observational, cohort study, who prospectively registered all consecutive adults with SE at 9 centers from 3 German-speaking countries. Only incident episodes were included. Ongoing SE despite 2 anti-seizure medications was defined as RSE. Patients intubated during first- or second-line treatments were excluded. Variables investigated included demographics, severity (Status Epilepticus Severity Score), etiology, and guideline-compliant treatment (defined as fixed minimum doses). Outcome parameters included survival and mRS at baseline and discharge (good: 0-2 or absence of worsening compared with pre-hospitalization).

RESULTS

Among 1179 SE episodes from 1049 adults, 996 patients were eligible (median age: 70 years, 52% female), of which 545 (54.7%) developed RSE. RSE was associated with higher baseline mRS (p<0.001) and treatment deviation from guidelines (p<0.001, OR 0.09; 95%CI 0.06-0.1). Good outcomes were observed in 52.7% of refractory patients, correlating with lower status epilepticus severity (p<0.001), absence of acute etiology (p<0.001, OR 0.5 95%CI 0.3-0.7), adequate first-line benzodiazepine dose (p<0.001, OR 2.5 95%CI 1.6-4.0), shorter durations of SE and hospitalization (both p<0.001), and lack of intubation (p<0.001, OR 0.4 95%CI 0.3-0.6). Most (71.7%) refractory patients were not intubated. Intubation was associated with younger age (p=0.006), more severe consciousness disturbances (p<0.001, OR 3.2 95%CI 2.1-4.8), more severe SE types (p<0.001), higher severity score (p=0.009), acute etiologies (p=0.01, OR 1.6 95%CI 1.1-2.4), more anti-seizure medications (p<0.001), initial treatment after shorter latency (p=0.01), worse outcomes (p<0.001, OR 0.4 95%CI 0.4-0.6), and longer hospitalizations (p<0.001).

DISCUSSION

Variables associated with RSE were identified, some potentially preventable. More than 70% of RSE were treated without intubation, suggesting that focal RSE without deep impairment of consciousness, in older patients, may be successfully treated outside ICUs.

TRIAL REGISTRATION

Original cohort study registered at the German Clinical Trials Register (DRKS00000725).

[Neurology : what's new in 2021]

In 2021, we assisted to the publication of new diagnostic criteria, classifications, and guidelines (CIDP, brain tumors, auto-immune encephalitis). Several studies helped to define the pharmacological management of focal and generalized epileptic seizures and epilepsy in pregnant women. The availability of biomarkers and the approval of immunotherapies are modifying the landscape of dementia management. Endovascular interventions without previous thrombolysis seems to be effective in anterior circulation acute ischemic stroke (AIS) and severe posterior circulation AIS. Neurologic complications of Sars-CoV-2 infection were further studied, as well as the efficacy of vaccines in immunosuppressed patients. New molecules and techniques show promising results for the treatment of migraine and cluster headache.

Terahertz scattering microscopy for dermatology diagnostics

We explore the possibility of detecting anomalous structures buried under the skin surface by studying the deviations from the ideal Airy pattern of the point-spread function (PSF) of a terahertz microscope that includes the skin as one of the reflecting surfaces of the optical system. Using a custom terahertz microscope with a monochromatic point source emitting at 0.611 THz, we record the PSF images with a microbolometer camera. Skin simulants based on collagen gel, with and without artificial buried structures, have been analyzed. The geometrical features characterizing the PSF deformations have been extracted automatically from the PSF images. A machine learning algorithm applied to these geometrical features produces a reliable classification of targets with or without buried structures with error below 5%. It can even classify targets with anisotropic buried structures according to their different orientation.

A comparison of machine learning classifiers for smartphone-based gait analysis

This paper proposes a reliable monitoring scheme that can assist medical specialists in watching over the patient's condition. Although several technologies are traditionally used to acquire motion data of patients, the high costs as well as the large spaces they require make them difficult to be applied in a home context for rehabilitation. A reliable patient monitoring technique, which can automatically record and classify patient movements, is mandatory for a telemedicine protocol. In this paper, a comparison of several state-of-the-art machine learning classifiers is proposed, where stride data are collected by using a smartphone. The main goal is to identify a robust methodology able to assure a suited classification of gait movements, in order to allow the monitoring of patients in time as well as to discriminate among a pathological and physiological gait. Additionally, the advantages of smartphones of being compact, cost-effective and relatively easy to operate make these devices particularly suited for home-based rehabilitation programs. Graphical Abstract. This paper proposes a reliable monitoring scheme that can assist medical specialists in watching over the patient's condition. Although several technologies are traditionally used to acquire motion data of patients, the high costs as well as the large spaces they require make them difficult to be applied in a home context for rehabilitation. A reliable patient monitoring technique, which can automatically record and classify patient movements, is mandatory for a telemedicine protocol. In this paper, a comparison of several state-of-the-art machine learning classifiers is proposed, where stride data are collected and processed by using a smartphone(see figure). The main goal is to identify a robust methodology able to assure a suited classification of gait movements, in order to allow the monitoring of patients in time as well as to discriminate among a pathological and physiological gait. Additionally, the advantages of smartphones of being compact, cost-effective and relatively easy to operate make these devices particularly suited for home-based rehabilitation programs.

Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (à l’exclusion du nouveau‑né et du nourrisson)

La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer denouvelles recommandations sur la prise en charge de l’état de mal épileptique (EME) avec l’ambition de répondre leplus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitementnon spécifique et spécifique. Vingt‑cinq experts ont analysé la littérature scientifique et formulé des recommandationsselon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avecle niveau de preuve le plus fort ne concernent que l’EME tonicoclonique généralisé (EMETCG) : l’usage des benzodia‑zépines en première ligne (clonazépam en intraveineux [IV] direct ou midazolam en intramusculaire) est recommandé,répété cinq minutes après la première injection (à l’exception du midazolam) en cas de persistance clinique. En casde persistance cinq minutes après cette seconde injection, il est proposé d’administrer la deuxième ligne thérapeu‑tique : valproate de sodium, (fos‑)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions30 minutes après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alorsproposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam oupropofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.

Recommandations Formalisées d’Experts SRLF/SFMU : Prise en charge des états de mal épileptiques en préhospitalier, en structure d’urgence et en réanimation dans les 48 premières heures (A l’exclusion du nouveau-né et du nourrisson)

La Société de réanimation de langue française et la Société française de médecine d’urgence ont décidé d’élaborer de nouvelles recommandations sur la prise en charge de l’état mal épileptique (EME) avec l’ambition de répondre le plus possible aux nombreuses questions pratiques que soulèvent les EME : diagnostic, enquête étiologique, traitement non spécifique et spécifique. Vingt-cinq experts ont analysé la littérature scientifique et formulé des recommandations selon la méthodologie GRADE. Les experts se sont accordés sur 96 recommandations. Les recommandations avec le niveau de preuve le plus fort ne concernent que l’EME tonico-clonique généralisé (EMTCG) : l’usage des benzodiazépines en première ligne (clonazépam en intraveineux direct ou midazolam en intramusculaire) est recommandé, répété 5 min après la première injection (à l’exception du midazolam) en cas de persistance clinique. En cas de persistance 5 min après cette seconde injection, il est proposé d’administrer la seconde ligne thérapeutique : valproate de sodium, (fos-)phénytoïne, phénobarbital ou lévétiracétam. La persistance avérée de convulsions 30 min après le début de l’administration du traitement de deuxième ligne signe l’EMETCG réfractaire. Il est alors proposé de recourir à un coma thérapeutique au moyen d’un agent anesthésique intraveineux de type midazolam ou propofol. Des recommandations spécifiques à l’enfant et aux autres EME sont aussi énoncées.

P933Novel missense variant in DPP6 in familial ventricular fibrillation

Funding Acknowledgements

This work was supported by an ESC Research Grant to A.R., and by The Netherlands CardioVascular Research Initiative (CVON PREDICT2), Den Haag, The N

Background

The DPP6 gene, encoding dipeptidyl aminopeptidase-like protein-6, has been associated with familial ventricular fibrillation (VF) and early repolarization. The DPP6 protein is part of the macromolecular Ito-channel complex and functionally expressed in ventricular myocytes (VM) and Purkinje cells (PC). Here we report a novel missense variant in DPP6 identified in a family with sudden cardiac death/arrest due to VF.

Purpose

To examine the consequences of the novel DPP6 variant c.821G &gt; A, p.(R274H) for cardiac Ito and their potential contribution to a VF substrate.

Methods: Clinical

Co-segregation of DPP6-R274H with major adverse cardiac events in the family members was investigated. Ambulatory ECGs, echocardiograms, exercise tests and ICD recordings were systematically analyzed.

Cellular

Chinese hamster ovary cells were transiently transfected with Ito α and β subunits in order to mimic the VM (Kv4.3 + KChIP2) or the PC phenotype (Kv4.3 + NCS1). Additionally, DPP6 wild type (WT) or variant was transfected. Ito was assessed by patch clamping.

Results: Clinical

DPP6-R274H, affecting a conserved region in the extracellular protein domain segregated with an autosomal dominant pattern of inheritance. The female index patient experienced first VF at 17 years, and subsequent ICD therapy, after her brother had died suddenly at 13 years. Both carriers were also known with mitral-valve prolapse (MVP), but otherwise without structural heart disease. A third sibling without arrhythmia, but with mild MVP, did not carry the DPP6 variant. No other pathogenic mutations were found by next generation sequencing in the index patient. ECGs of the index patient revealed dynamic early repolarization, U waves with varying amplitudes and pause-dependent prominence, and &gt;8000/24 h superimposed premature ventricular complexes (PVCs) and (non)sustained VT. PVCs (QRS duration 120 ms) displayed both a left posterior (80%) and anterior (20%) fascicular origin. PVC burden was higher during daytime and exercise, with pause-dependent occurrence.

Cellular

In the PC model DPP6-R274H markedly decreased Ito density (at +30 mV: 291 pA/pF vs 995 pA/pF in WT; p &lt; 0.001), whereas it did not in the VM model. In VM, but not in PC, Ito inactivation was slowed by the variant (Tau at 0 mV: 91 ms vs 49 ms in WT; p &lt; 0.001).

Conclusions

The novel DPP6 variant R274H has differential effects on Ito in cellular models of VM versus PC. Our main finding of a loss-of-function in the PC model combined with a slowed Ito inactivation in the VM phenotype may exaggerate electrical heterogeneity, especially at the PC-VM junction. Ito loss in PC would prolong action-potential duration and promote early afterdepolarizations, consistent with the dynamic patterns of T-U-dispersion and (fascicular) ectopy in the index case. Mechano-electric influences by the MVP further promote arrhythmogenesis.

Diagnosis and First-Line Treatment of Patients with Lung Cancer in Italian General Hospitals

The quality of diagnostic and therapeutic care was examined in a series of 380 consecutive newly diagnosed cases of primary lung cancer seen in 20 Italian general hospitals between January and June 1987. At diagnosis most patients (78%) had one or more symptoms related to the tumor, and in an additional 9 % symptoms were related to the presence of distant metastases. The median diagnostic time lag between first symptoms and final diagnosis was 50 days with a significantly longer delay in patients first seen by their general practitioner compared with those who sought first care in hospital outpatient departments. The diagnostic process was satisfactorily carried out in fewer than two-thirds of the patients leading to complete ascertainment of disease stage and histology in 58% cases with significantly better performance in more specialized institutions. Analysis of the first-line treatment profile indicated a rather aggressive therapeutic attitude In the case of patients with non-small cell lung cancer – 28% of them had chemotherapy despite the lack of any proof of efficacy in controlled clinical trials – and a failure to identify among the patients with small cell disease those amenable to more aggressive treatment. The lack of progress in the treatment of lung cancer over the last decades seems to have resulted in widely varying practice patterns where a mixture of aggressive and laissez-faire attitudes does not take into account that in the absence of effective therapies a more conservative attitude would at least have some advantage in terms of quality of remaining life for many patients.

No Gender Differences in Egocentric and Allocentric Environmental Transformation After Compensating for Male Advantage by Manipulating Familiarity

The present study has two-fold aims: to investigate whether gender differences persist even when more time is given to acquire spatial information; to assess the gender effect when the retrieval phase requires recalling the pathway from the same or a different reference perspective (egocentric or allocentric). Specifically, we analyse the performance of men and women while learning a path from a map or by observing an experimenter in a real environment. We then asked them to reproduce the learned path using the same reference system (map learning vs. map retrieval or real environment learning vs. real environment retrieval) or using a different reference system (map learning vs. real environment retrieval or vice versa). The results showed that gender differences were not present in the retrieval phase when women have the necessary time to acquire spatial information. Moreover, using the egocentric coordinates (both in the learning and retrieval phase) proved easier than the other conditions, whereas learning through allocentric coordinates and then retrieving the environmental information using egocentric coordinates proved to be the most difficult. Results showed that by manipulating familiarity, gender differences disappear, or are attenuated in all conditions.

Fibroblast proliferation over dialysis membrane: an experimental model for “tissue” biocompatibility evaluation

The present study reports on a biological model based on fibroblast proliferation applied to 3 different types of flat-plate dialysis membrane, in order to ascertain whether the artificial materials currently used in hemodialysis cause in vitro cellular proliferation. The study plan we followed involved plate membrane isolation from non-used dialyzers and used dialyzers, observed through scanning electron microscopy (SEM) both before and after testing with human fibroblasts by means of cell culture. Fibroblast growth was assessed by phase contrast light microscopy examination and cytometric DNA content evaluation. Our investigations proved that the artificial materials we considered interact with fibroblast cultures. Noticeable proliferative response was observed both after contact with unused material and on mediation by the protein layer absorbed on the membrane surface at the end of dialysis sessions. In this last case fibroblast proliferative activity appeared higher than that observed with unused membranes, showing that the soluble molecules entrapped in the protein layer appeared able to exert a biological activity even in in vitro tests

[Neurology]

Ocrelizumab (Ocrevus), an anti-CD20 monoclonal antibody, has been approved for the treatment of multiple sclerosis. Eculizumab (Soliris) has been approved in several countries for refractory forms of generalized seropositive severe myasthenia gravis. A form of gene therapy, patisiran, has shown positive results in transthyretin familial amyloidosis. In the treatment of headaches, particularly migraines, non-pharmacological approaches have shown some interesting results. The criteria for Lewy body dementia have been revised. Generic use of lamotrigine does not result in recrudescence of epileptic seizures or adverse effects.

Prognostic Factors for Enteroatmospheric Fistula in Open Abdomen Treated with Negative Pressure Wound Therapy: a Multicentre Experience

BACKGROUND

Reductions in mortality were reported with negative pressure wound therapy for laparostomy. However, some authors have voiced concern over an increased risk of enteroatmospheric fistulae. In this retrospective study, we hypothesized that surgical and metabolic derangements could increase the incidence of enteroatmospheric fistulae. We aimed to assess our experience and report long-term outcomes.

METHODS

A multicentre review of all patients with a laparostomy managed with negative pressure wound therapy between 2005 and 2015 was undertaken. Features associated with enteroatmospheric fistulae were included in multivariate logistic regression.

RESULTS

Fifty-seven patients were treated according to uniform protocol. Fourteen per cent (8/57) presented enteroatmospheric fistulae. Mesenteric ischaemia and preoperative arterial serum lactate >3.5 mmol/L were associated with a significantly increased risk of enteroatmospheric fistulae. Preoperative arterial serum lactate >3.5 mmol/L was an independent predictor of enteroatmospheric fistulae with an odds ratio of 12.41 (95% CI 1.54-99.99). All mesenteric ischaemia patients with anastomosis (5/15) presented enteroatmospheric fistulae. In-hospital mortality was 26.3% (15/57). One-year mortality was 33.3% (19/57). Incisional hernia rate was 5.2% (2/38) after 14.2 (2.4-56.3) months of follow-up.

DISCUSSION

Mesenteric ischaemia increases the risk of enteroatmospheric fistulae. Anastomosis should only be created in revascularized patients. When mesenteric vascularization is not restored, diversion is advised.

Anastomotic leakage after laparoscopic single-port sigmoid resection: combined transanal and transabdominal minimal invasive management

BACKGROUND

Laparoscopic colorectal surgery has become the gold standard in the therapy of benignant and malignant colorectal pathologies. Anastomotic leakage is still a reason for laparotomy; applying a diverting stoma or performing a Hartman's procedure is common [1, 2]. Laparoscopic treatment of an early-detected anastomotic leakage is suggested from other authors [3, 4]. In our video we demonstrate a combined minimal invasive transabdominal and transanal treatment concept in patients with early-detected anastomotic leakage.

METHODS

Two consecutive patients developing an anastomotic leakage after single-port laparoscopic sigmoid resection for stage II/III diverticulitis (Hanson & Stock) were treated with a combined minimal invasive approach. Anastomotic leakage was diagnosed by triple contrast computed tomography on postoperative day 4 in patient one and on postoperative day 7 in patient two. Operative treatment was performed immediately on the same day without delay.

RESULTS

In both patients a combined transanal and transabdominal approach was performed. First step was a diagnostic laparoscopy in order to exclude fecal peritonitis. Using a single-port device (SILS Port Covidien), transanal inspection of the anastomosis was also performed: In both patients anastomotic tissue margins were vital, and the leakage affected only a quarter of the anastomotic circumference. Transanal stitches were placed to close the anastomotic leakage. Laparoscopic transabdominal irrigation was performed, and two suction drainages were placed in the pelvis. Postoperative antibiotic treatment and a gradual return to slid food were carried out. Functional result at follow-up of 102 and 112 days (with rectoscopy) showed no residual leak and no stricture of the anastomosis, and both of patients had a normal rectal function.

Transarterial embolization in acute colonic bleeding: review of 11 years of experience and long-term results

BACKGROUND

Lower gastrointestinal bleeding represents 20 % of all gastrointestinal bleedings. Interventional radiology has transformed the treatment of this pathology, but the long-term outcome after selective embolization has been poorly evaluated. The aim of this study is thus to evaluate the short-term and long-term outcomes after selective embolization for colonic bleeding.

METHODS

From November 1998 to December 2010, all acute colonic embolizations for hemorrhage were retrospectively reviewed and analyzed. The risk factors for post-embolization ischemia were also assessed.

RESULTS

Twenty-four patients underwent colonic embolization. There were 6 men and 18 women with a median age of 80 years (range, 42-94 years). The underlying etiologies included diverticular disease (41.9 %), post-polypectomy bleeding (16.7 %), malignancy (8.2 %), hemorrhoid (4.1 %), and angiodysplasia (4.1 %). In 23 patients, bleeding stopped (95.8 %) after selective embolization. One patient presented a recurrence of bleeding with hemorrhagic shock and required urgent hemorrhoidal ligature. Four patients required an emergent surgical procedure because of an ischemic event (16.7 %). One patient died of ileal ischemia (mortality, 4.1 %). The level of embolization and the length of hypoperfused colon after embolization were the only risk factors for emergent operation. Mean hospital stay was 18 days (range, 9-44 days). After a mean follow-up of 28.6 months (range, 4-108 months), no other ischemic events occurred.

CONCLUSION

In our series, selective transarterial embolization for acute colonic bleeding was clinically effective with a 21 % risk of bowel ischemia. The level of embolization and the length of the hypoperfused colon after embolization should be taken into consideration for emergent operation.

Perforated duodenal diverticulum, a rare complication of a common pathology: A seven-patient case series

Duodenal diverticula (DD) are frequently encountered and are usually asymptomatic, with an incidence at autopsy of 22%. Perforation of DD is a rare complication (around 160 cases reported) with potentially dramatic consequences. However, little evidence regarding its treatment is available in the literature. The aim of this study was to review our experience of perforated DD, with a focus on surgical management. Between January 2001 and June 2011, all perforated DD were retrospectively reviewed at a single centre. Seven cases (5 women and 2 men; median age: 72.4 years old, rang: 48-91 years) were found. The median American Society of Anesthesiologists’ score in this population was 3 (range: 3-4). The perforation was located in the second portion of duodenum (D2) in six patients and in the third portion (D3) in one patient. Six of these patients were treated surgically: five patients underwent DD resection with direct closure and one was treated by surgical drainage and laparostomy. One patient was treated conservatively. One patient died and one patient presented a leak that was successfully treated conservatively. The median hospital stay was 21.1 d (range: 15-30 d). Perforated DD is an uncommon presentation of a common pathology. Diverticular excision with direct closure seems to offer the best chance of survival and was associated with a low morbidity, even in fragile patients.

Diagnosis and treatment of lymph node metastases of a rectal carcinoid tumor using In111-octreotide-scintigraphy and intraoperative gamma probe detection

Carcinoids represent 1-2% of the rectal cancer. We report the case of a woman with a rectal carcinoid and a hypogastric node metastasis. We propose a less invasive treatment of the metastase using In11-octreotide-scintigraphy and intraoperative gamma-probe detector.

Pulse wave amplitude drops during sleep are reliable surrogate markers of changes in cortical activity

BACKGROUND

During sleep, sudden drops in pulse wave amplitude (PWA) measured by pulse oximetry are commonly associated with simultaneous arousals and are thought to result from autonomic vasoconstriction. In the present study, we determine whether PWA drops were associated with changes in cortical activity as determined by EEG spectral analysis.

METHODS

A 20% decrease in PWA was chosen as a minimum for a drop. A total of 1085 PWA drops from 10 consecutive sleep recordings were analyzed. EEG spectral analysis was performed over 5 consecutive epochs of 5 seconds: 2 before, 1 during, and 2 after the PWA drop. EEG spectral analysis was performed over delta, theta, alpha, sigma, and beta frequency bands. Within each frequency band, power density was compared across the five 5-sec epochs. Presence or absence of visually scored EEG arousals were adjudicated by an investigator blinded to the PWA signal and considered associated with PWA drop if concomitant.

RESULTS

A significant increase in EEG power density in all EEG frequency bands was found during PWA drops (P<0.001) compared to before and after drop. Even in the absence of visually scored arousals, PWA drops were associated with a significant increase in EEG power density (P<0.001) in most frequency bands.

CONCLUSIONS

Drops in PWA are associated with a significant increase in EEG power density, suggesting that these events can be used as a surrogate for changes in cortical activity during sleep. This approach may prove of value in scoring respiratory events on limited-channel (type III) portable monitors.

Aminoterminal B-type natriuretic peptide (NT-proBNP) in the therapy of patent ductus arteriosus

BACKGROUND

NT-proBNP is a reliable index in case of cardiac diseases.

OBJECTIVE

To evaluate the diagnostic usefulness of NT-proBNP as index of the closure of patent ductus arteriosus (PDA) in ELBW.

METHODS

Considered 73 ELBW (mGA 26+3 weeks; mBW 789 g) with echocardiographical diagnosis of PDA. The closure of the duct was spontaneous in 22%, pharmacological in 49.3% and by surgical ligation in 28.7%. Plasma NT-proBNP levels were measured on day 3 in 35 preterm infants; in 20 of them concentrations of the peptide were assayed on day 3 and on closure of the duct.

RESULTS

On day 3 the median of NT-proBNP levels was 13718 pg/ml (range 1918-70000). Peptide concentrations did not differ between pharmacological treatment and surgical ligation (respectively 13718 and 12342 pg/ml; p = 0.33). Concentrations of NT-proBNP were significantly lower on the closure of the duct (p < 0.0001) compared to concentrations on day 3 (median 12666 at day 3 versus 2443.5 pg/ml at closure), with a decrease of 80.71%.

CONCLUSIONS

ELBW showed high variability of NT-proBNP concentrations both on day 3 and on closure of PDA. Although NT-proBNP high levels were indicative of the presence of hsPDA, due to the extreme heterogeneity of the values it was not possible to determine an absolute cut-off concentration of NT-proBNP below which closure of the duct occurred, while a decrease of NT-proBNP > or =80% was a reliable index of PDA closure.

[What's new in neurology]

This article summarize principal news about treatments in the different specialities in neurology. We don't pretend to be exhaustive and to make a detailed analyse of all treatments, and preferred to present pertinent therapeutic advances, with an evidence-based point of view. We also mentioned some negative studies, to balance our purpose.

Outbreak of Bacterial Blossom Blight Caused by Pseudomonas viridiflava on Actinidia chinensis Kiwifruit Plants in Italy

During the springs from 2006 to 2008, a new disease was observed on 4- to 5-year-old Actinidia chinensis (cv. Jin Tao) trees in different commercial kiwifruit-production areas in northern Italy (Lombardy). Initially, disease occurrence was sporadic but later became widespread. Symptoms on flowers appeared as a dark brown rot of anthers, filaments, sepals, and whole buds. Blossoms abscised prematurely from buds. Symptoms appeared as confluent brown spots often present on rolled margins. Bacteria were isolated from symptomatic tissue on nutrient agar medium supplemented with 5% sucrose. The isolated bacteria were aerobic; produced a diffusible fluorescent pigment on King's B medium; levan, oxidase, and arginine dihydrydrolase negative, and catalase positive; rotted potato tuber tissue; caused a hypersensitive response on tobacco; and failed to reduce nitrate or utilize sucrose and were ice nuclease-positive at -5°C, suggesting the organism was P. viridiflava (1,3). Inoculation of 2-year-old A. chinensis cv. Jin Tao plants were carried out in the greenhouse under controlled environmental conditions (15 to 27°C, night/day; relative humidity up to 70%) by spraying five plants in bloom with a suspension (1 × 10⁸ CFU/ml) of isolated bacteria with a hand-held sprayer that produced large spray droplets. Symptoms, similar to those in nature, were observed on flowers and buds 3 to 5 days after inoculation and on leaves after 7 to 10 days. Using the same tests described above with the original strains, the strains that were isolated from symptomatic tissue were identified as Pseudomonas viridiflava. Seven bacterial strains (PV508-PV1108) were identified by sequencing 1,481 bp of their 16S rDNA region (2) and using BlastN (4) for the most similar sequences in the INSD (GenBank, EMBL, and DDBJ). Our sequences shared 99.53% (1,474 of 1,481 bp) to 99.9% (1480 of 1,481 bp) identity with the analogous sequences of P. viridiflava available in the database. To our knowledge, this is the first report of an outbreak of blossom blight caused by P. viridiflava on A. chinensis cv. Jin Tao kiwifruit plants in Italy. Previously, it was reported on A. deliciosa cv. Hayward (3). Because of the risk of bacterial contamination among the different cultivars of kiwifruit, further investigation and development of control measures are in progress. References: (1) R. A. Lelliott and D. E. Stead. Methods for the Diagnosis of Bacterial Diseases of Plants. Blackwell Scientific, Oxford, UK, 1987. (2) E. R. B. Moore et al. Syst. Appl. Microbiol. 19:478, 1996. (3) L. Varvaro et al. Inf. Fitopatol. 6:49, 1990. (4) Z. Zhang et al. J. Comput. Biol. 7(1-2):203, 2000.

Susceptibility trends of Bacteroides fragilis group isolates from Buenos Aires, Argentina

The aim of this study was to analyze the susceptibility trends to seven antibiotics of Bacteroides fragilis group isolates based on three survey studies performed by the Committee of Anaerobic Bacteria between 1989 and 2002. Fifty three, 82 and 65 B. fragilis group isolates were collected during each period. The antimicrobial agents included were: ampicillin, ampicillin-sulbactam (2:1), cefoxitin, piperacillin, imipenem, clindamycin, and metronidazole. Minimal inhibitory concentrations (MICs) were determined according to the reference agar dilution method described by the Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS). The most active antibiotics for B. fragilis and non-B. fragilis species throughout the three periods were: imipenem with 99.1 and 100% of activity, respectively, and metronidazole with 100% of activity. The susceptibility to ampicillin-sulbactam showed a decrease, from 100% to 90.3% and to 82.4 % in the last period, for both B. fragilis and non-B. fragilis species, respectively. The overall susceptibility rates for cefoxitin, piperacillin, and clindamycin were significantly different between B. fragilis and non-B. fragilis species (84.2% vs. 56.5%; 85.9% vs. 66.7% and 88.8% vs. 64.7%, respectively, p < 0.05). Cefoxitin was the antibiotic that showed more variations as regards periods and species. The susceptibility rates for clindamycin were low, about 60%, for non-B. fragilis species during the last two periods. The variations observed in the susceptibility patterns of the B. fragilis group isolates emphasize the need to continue monitoring the emergence of resistance in order to guide the election of the most appropriate antibiotic therapy scheme for anaerobic infections.

Pregnancy in immigrant women

OBJECTIVE

We wanted to study how foreign women face pregnancy and childbirth in a society quite different from their own.

METHODS

In 2004 we studied 328 pregnant women at the Department of Gynaecology at the "General Hospital Umberto I" in Rome. Information on patients' personal lives and experiences was collected.

RESULTS

Women were classified into six (6) groups based on nationality, race, religion and culture.

CONCLUSIONS

Arabian women had the most natural childbirths. African women had a longer duration of gestation. Women from Eastern Europe underwent frequent tests and examinations, but had the highest chance of having preterm births. Chinese women did not usually undergo many examinations and were able to tolerate pain during childbirth quite well.

["In vitro" activity of ten antimicrobial agents against anaerobic bacteria. A collaborative study, 1999-2002]

The antimicrobial activity of ampicillin, ampicillin-sulbactam, cefoxitin, ceftriaxone, imipenem, piperacillin, piperacillin-tazobactam, clindamycin, metronidazole, and azitromycin was assesed against 166 strains of anaerobic bacteria recovered from eight hospitals in Buenos Aires. The strains studied were Bacteroides fragilis group (65), Fusobacterium spp. (26), Prevotella spp. (21), Porphyromonas spp. (10), Clostridium difficile (10), other clostridia (12), and gram-positive cocci (22). The MICs were determined by the agar dilution method according to NCCLS document M11-A5. Metronidazole and piperacillin-tazobactam were the most active antimicrobial agents tested and exhibited MIC90 values of < or = 2 microg/ml and < or = 4 microg/ml against gram-negative organisms, and < or = 2 microg/ml, and < or = 8 microg/ml against gram-positive organisms, respectively. Among beta-lactams the activity against gram-negative rods was in the following order: imipenem > piperacillin > cefoxitin > ceftriaxone > ampicillin. Among the gram-positive bacteria the decreased activity was: piperacillin > imipenem > cefoxitin > ceftriaxone > ampicillin. The majority of the species studied showed different degrees of resistance to clindamycin and azitromycin. Nevertheless, 90% of Fusobacterium nucleatum and Porphyromonas spp. isolates were inhibited by 0.125 mg/ml of clindamycin and azitromycin, respectively.

Assessment of inhaled BDP-dose dependency of exhaled nitric oxide and local and serum eosinophilic markers in steroids-naive nonatopic asthmatics

The aim of the present study was to assess the dose-dependency from inhaled steroids of changes of airways inflammation [eosinophils count and eosinophil cationic protein (ECP)] measures in induced sputum and in serum, as well as that of exhaled nitric oxide. Twenty steroid-naive patients with nonatopic asthma of mild to moderate degree [forced expiratory volume in 1 s (FEV1) = 70% of predicted] and with negative response to the standard tests for allergy were selected; after a 1-week run-in period they were randomized to receive a 12-week treatment period of inhaled beclomethasone dipropionate dry powder given with the Pulvinal inhaler (Clenil P, Chiesi Farmaceutici S.p.A., Parma, Italy) in two different dose regimens, 400 microg bid (high dose) or 200 microg bid (low dose), over a double blind, parallel groups design. The following outcome measures were assessed in baseline and after 1, 6 and 12 weeks of treatment: FEV1 (l), eosinophils count in sputum (%), is ECP (microg/l), serum eosinophils count (%), serum ECP (microg/l) and exhaled NO (ppb). The results showed that all the considered parameters improved in both groups: the increase over baseline of FEV1 and the decrease of NO were significant at any time in the high-dose group and only at week 12 in the low-dose group (NS between groups), whereas the markers of eosinophilic activity showed more consistent reductions in the high-dose than in the low-dose group when measured in induced sputum (P < 0.05 between groups after 6 and 12 weeks for eosinophils count and after 12 weeks for ECP). Decreases over baseline of markers measured in serum were more rapid in the high-dose group, without differences between groups. A marked trend towards a negative correlation was found between FEV1 and ECP, (r = -0.72, P < 0.05), between FEV1 and eosinophils in sputum (r = -0.31, NS) and between FEV1 and exhaled NO (r = -0.38, NS), all of them only in the high-dose group. The results of the study demonstrate that changes of levels of eosinophilic activity in the airways are dependent from the daily dose of inhaled steroids when measured in induced sputum and that the local assessment can therefore represent a practical and noninvasive method to monitor the extent of airways inflammation.

Effects on lung function, symptoms, and bronchial hyperreactivity of low-dose inhaled beclomethasone dipropionate given with HFA-134a or CFC propellant

The aim of this study was to compare the efficacy of BDP 200 microg bid via metered dose inhaler, using HFA-134a (Chiesi Farmaceutici S.p.A., Parma, Italy) versus CFC (Becotide, Allen & Hanburys, U.K.) as a propellant. 172 adult patients (86 in each group) with stable mild persistent asthma who completed a 7-day run-in period were randomized to receive a 6-week treatment in a double-blind, double dummy, parallel-group design; 164 patients completed the study. Morning and evening PEFR, use of rescue salbutamol, number of day-time and night-time asthma attacks, number of night-time awakenings and clinical symptoms were recorded daily on a diary card. Pulmonary function tests (FEV(1), FVC, PEFR, and MEF(50)) were measured at the clinic before and after the 1-week run-in period, and after 3 and 6 weeks of treatment. A challenge test with inhaled methacholine was completed at baseline and at the end of the treatment period to assess potential bronchial hyper-reactivity in a subgroup of subjects (n = 65; 34 HFA, 31 CFC). In accordance with asthma of mild severity (FEV(1) predicted over 90% in both groups), a small improvement in lung function compared to baseline was seen for both treatments, significantly for FEV(1) in BDP HFA and MEF(50) in both groups. The two formulations of BDP had similar efficacy for the primary outcome variable morning PEFR (ITT population mean difference 5.8 L/min; C.I. -4.9 to +16.5) as well as for the secondary outcomes of evening PEFR and clinic FEV(1). There were small improvements in methacholine PD(20) and PC20 in both groups, with no significant difference between treatments. A total of 22 and 19 drug-related adverse events were reported in the BDP HFA and CFC groups, respectively; most events were of seasonal nature or were local effects due to the use of inhaled corticosteroids. It can be concluded that the newly developed formulation of BDP given via HFA-134a seems to provide similar asthma control, compared with the same low daily dose of the active drug delivered via CFC. Further studies are needed using higher doses in moderate to severe asthma to confirm these preliminary findings.

Equivalent efficacy and safety of a new HFA-134a formulation of BDP compared with the conventional CFC in adult asthmatics

The present study demonstrates the equivalent efficacy for BDP 500 microg bid given via MDI with the new HFA-134a propellant (Chiesi Farmaceutici S.p.A., Parma) compared to a conventional CFC propellant (Becotide, Allen & Hanburys, UK). One hundred and sixteen adult patients with stable mild to moderate asthma (FEV1 > or = 60% of predicted normal) entered a 2-week run-in period where they maintained their own inhaled corticosteroids and were then assigned to a 12-week treatment with the test drug in a randomized, multicentre, double-blind, double-dummy, parallel-group design. Ninety-one patients completed the study period. Morning and evening peak expiratory flow rate (PEFR), use of rescue salbutamol, number of daytime and nighttime asthma attacks, number of nighttime awakenings, and clinical symptoms were recorded daily by patients on a diary card. Pulmonary function tests (FEV1, FVC, PEFR, MEF50 and FEF25) were completed at study entry, at the start of treatment and every 2 weeks thereafter. Morning (08.00-10.00 AM) serum cortisol was measured at the start and at the end of treatment. Adverse events were collected for the total study period. Equivalence between groups was demonstrated for the primary end-point morning PEFR, as well as for evening PEFR and FEV1 (the 95% CI of the treatments' difference was within the 5% of the LSM of BDP CFC). The other secondary pulmonary function tests measured at the clinic visit showed a satisfactory asthma control, albeit without statistically significant differences between groups. Decreases in the use of rescue salbutamol and in clinical symptoms were also reported in both groups, with no differences between them. Adverse events were reported in 81.4% of patients in the BDP HFA group and in 82.5% in the CFC group. There were 73 and 59 adverse drug reactions in the two groups, respectively; the difference was mainly due to differences in taste. No drug-related serious adverse events were reported in either group. No difference was seen for morning serum cortisol between baseline and end of treatment, or between groups. In conclusion, the BDP-HFA 134a formulation proved to be statistically equivalent to the standard BDP CFC product over 12 weeks in adult patients with mild to moderate asthma.

Comparison of once- versus twice-daily use of beclomethasone dipropionate aqueous nasal spray in the treatment of allergic and non-allergic chronic rhinosinusitis

The aim of the study was to assess the efficacy and safety of nasal aqueous beclomethasone dipropionate (BDP), 400 micro g/day, given via a metered pump in a once-daily or twice-daily regimen following a double-blind, parallel group design over a 12-week period. Adult patients (n=112) with allergic or non-allergic chronic rhinosinusitis recorded their nasal and ocular symptoms for the 7-day run-in period and for the first 4 weeks of treatment. At baseline and after 4 weeks the airways' resistance via active anterior rhinomanometry and the volume and area section via acoustic rhinometry were measured. Morning serum cortisol was measured at baseline and at week 12. Adverse events were to be reported at each visit. Of the 112 randomised patients, three did not enter the ITT analysis and another 13 in total discontinued the treatment. Significant improvements over the baseline were reported in both groups for the primary variable sum of nasal scores (-53.7% in the once-daily group and -59.7 in the twice-daily group), as well as for each nasal and ocular symptoms, without differences between the groups. Because of a wider variability than expected, the 95% confidence interval (C.I.) for the difference between the least square means exceeded the pre-defined limit of +/-10% of the reference mean. Similar improvements in both groups were also reported for the nasal airway patency's parameters. The total number of drug-related adverse events was 26 in the once-daily group and 32 in the twice-daily group, with most of the events consisting of local effects at the site of application. No signs of adrenal suppression were observed, and serum morning cortisol values did not significantly change. The once-daily BDP dosing (400 micro g/day) therefore has a similar efficacy and safety profile as the same daily dose given in a twice-daily regimen.

The reversed ipsilateral acoustic reflex: clinical features and kinetic analysis

OBJECTIVE

The reversed ipsilateral acoustic reflex (RIAR) has been the subject of few studies in the past literature and the nature of this "reflex" response is not yet completely understood. It can be observed in different diseases, all of which result from inactivity of the stapedial reflex (SR). We aimed to investigate the occurrence of the RIAR in different diseases.

MATERIAL AND METHODS

An extensive clinical investigation of the RIAR was carried out.

RESULTS

The RIAR was found to be present in 100% of ears lacking an effective SR arc. Its amplitude is modulated by the air pressure level in the external ear canal whilst its sign is constantly positive and never reverses.

CONCLUSION

Kinetic analysis of the RIAR suggests the existence of a single underlying phenomenon while the interaction of the RIAR with the SR may explain the complex morphology frequently observed in the normal ipsilateral acoustic reflex.