Diabetes as a risk factor for pneumococcal disease and severe related outcomes and efficacy/effectiveness of vaccination in diabetic population. Results from meta-analysis of observational studies

AIMS

To collect all available evidence on the effect of diabetes mellitus (DM) as a risk factor for pneumococcal disease incidence and related complications, and on the efficacy/effectiveness of vaccines in patients with DM.

METHODS

Two distinct systematic searches on MEDLINE, Cochrane, ClinicalTrials.gov and EMBASE databases were performed, one for each meta-analysis, collecting all observational (cohort and case-control) studies and randomized clinical trials performed on humans up to June 1st, 2023.

RESULTS

We retrieved 36 observational studies comparing risk for pneumococcal disease and related complications in people with or without DM, and 11 studies (1 randomized clinical trial and 10 observational studies) assessing conjugated and polysaccaridic vaccines efficacy/effectiveness on preventing such outcomes. People with DM were at higher risk for Invasive Pneumococcal Disease (unadjusted OR 2.42 [2.00; 2.92]); Case-Fatality Rate (unadjusted OR 1.61 [1.25; 2.07], Pneumococcal pneumonia (unadjusted OR 2.98 [2.76; 3.22), and Intensive care unit admission for pneumococcal disease (unadjusted OR 2.09 [1.20; 3.66]). In diabetic individuals vaccinated with conjugated vaccine, incidence of pneumonia specific for vaccine type in a clinical trial (OR 0.237 [0.008; 0.704]), and hospitalization for overall pneumonia during the year following the polysaccharide vaccination in observational studies (unadjusted OR 0.63 [0.45-0.89]) were significantly lower in comparison with unvaccinated DM subjects, with no significant differences for other outcomes.

CONCLUSIONS

People with diabetes mellitus are at higher risk for less favourable course of pneumococcal disease and should be therefore targeted in vaccination campaigns; more evidence needs to be collected on vaccination outcomes in people with diabetes.

Exosomal miR-17-5p, miR-146a-3p, and miR-223-3p Correlate with Radiologic Sequelae in Survivors of COVID-19-Related Acute Respiratory Distress Syndrome

We investigated the association between circulating microRNAs (miRNAs) potentially involved in the lung inflammatory process and fibrosis development among COVID-19-related acute respiratory distress syndrome (ARDS) survivors. At 4 ± 2 months from clinical recovery, COVID-19-related ARDS survivors matched for age, sex, and clinical characteristics underwent chest high-resolution computerized tomography (HRCT) and were selected based on imaging pattern evolution into fully recovered (N = normal), pulmonary opacities (PO) and fibrosis-like lesions (FL). Based on the previous literature, we performed plasma miRNA profiling of exosomal miRNAs belonging to the NLRP3-inflammasome platform with validated (miR-17-5p, miR-223-3p) and putative targets (miR-146a-5p), miRNAs involved in the post-transcriptional regulation of acute phase cytokines (miR128-3p, miR3168, miR125b-2-3p, miR106a-5p), miRNAs belonging to the NLRP4-inflammasome platform (miR-141-3p) and miRNAs related to post-transcriptional regulation of the fibrosis process (miR-21-5p). miR-17-5p, miR-223-3p, and miR-146a-5p were significantly down-regulated in patients with FL when compared to patients with PO. miR-146a-5p was also down-regulated in patients with FL than in N. The expression of the remaining miRNAs did not differ by group. In patients with long-term pulmonary radiological sequelae following COVID-19-related ARDS, a down-regulation of miR-17-5p, miR-146a-3p, and miR-223-3p correlated to fibrosis development in patients showing persistent hyper-reactivity to inflammatory stimulation. Our results support the hypothesis that NLRP3-Inflammasome could be implicated in the process of fibrotic evolution of COVID-19-associated ARDS.

Unraveling Barriers to a Healthy Lifestyle: Understanding Barriers to Diet and Physical Activity in Patients with Chronic Non-Communicable Diseases

Although the important contribution of nutrition and physical activity to people's health is known, it is equally well known that there are many barriers to adherence to healthy habits (i.e., of an organizational, economic, and/or psychological nature) experienced by the general population, as well as by people with non-communicable diseases. Knowledge of these barriers seems essential to the implementation of the activities and strategies needed to overcome them. Here, we aim to highlight the most frequent barriers to nutrition and exercise improvement that patients with chronic-degenerative diseases experience. Drawing from the Pubmed database, our analysis includes quantitative or mixed descriptive studies published within the last 10 years, involving adult participants with non-communicable diseases. Barriers of an organizational nature, as well as those of an environmental, economic, or psychological nature, are reported. The study of patients' barriers enables healthcare and non-health professionals, stakeholders, and policymakers to propose truly effective solutions that can help both the general population and those with chronic pathologies to adhere to a healthy lifestyle.

Handgrip strength is associated with adverse outcomes in patients hospitalized for COVID-19-associated pneumonia

Handgrip strength (HGS), a simple tool for the evaluation of muscular strength, is independently associated with negative prognosis in many diseases. It is unknown whether HGS is prognostically relevant in COVID-19. We evaluated the ability of HGS to predict clinical outcomes in people with COVID-19-related pneumonia. 118 patients (66% men, 63 ± 12 years), consecutively hospitalized to the "Santa Maria" Terni University Hospital for COVID-19-related pneumonia and respiratory failure, underwent HGS measurement (Jamar hand-dynamometer) at ward admission. HGS was normalized to weight^2/3 (nHGS) The main end-point was the first occurrence of death and/or endotracheal intubation at 14 days. Twenty-two patients reached the main end-point. In the Kaplan-Meyer analysis, the Log rank test showed significant differences between subjects with lower than mean HGS normalized to weight^2/3 (nHGS) (< 1.32 kg/Kg^2/3) vs subjects with higher than mean nHGS. (p = 0.03). In a Cox-proportional hazard model, nHGS inversely predicted the main end-point (hazard ratio, HR = 1.99 each 0.5 kg/Kg^2/3 decrease, p = 0.03), independently from age, sex, body mass index, ratio of partial pressure arterial oxygen and fraction of inspired oxygen (PaO₂/FiO₂ ratio), hypertension, diabetes, estimated glomerular filtration rate and history of previous cardiovascular cardiovascular disease. These two latter also showed independent association with the main end-point (HR 1.30, p = 0.03 and 3.89, p < 0.01, respectively). In conclusion, nHGS measured at hospital admission, independently and inversely predicts the risk of poor outcomes in people with COVID-19-related pneumonia. The evaluation of HGS may be useful in early stratifying the risk of adverse prognosis in COVID-19.

Indexing of Fatty Acids in Poultry Meat for Its Characterization in Healthy Human Nutrition: A Comprehensive Application of the Scientific Literature and New Proposals

Chicken meat is becoming the most consumed in the world for both economic and nutritional reasons; regarding the latter, the lipid profile may play positive or negative roles in the prevention and treatment of diseases. In this study, we define the state of the art of lipid-based nutritional indexes and used the lipid content and fatty acid profile (both qualitative and quantitative) of breast meat of two poultry genotypes with different growth rates and meat traits. Further, we summarize and review the definitions, implications, and applications of nutritional indexes used in recent years and others of our own design to provide a useful tool to researchers working in the field of meat quality (not only in poultry) to select the most appropriate index for their own scientific purposes. All indexes show advantages and disadvantages; hence, a rational choice should be applied to consider the nutritional effect of meat on human health and for a possible assessment of the most suitable rearing systems (genotype, feeding, farming system or postmortem handling).

TGF – beta 2 enriched formula as oral nutritional supplement in patients hospitalized for COVID-19: A preliminary observational study

BACKGROUND: SARS-COV 2 turned in a global epidemic since January 2020. It is able to directly stimulate the release of proinflammatory cytokines (cytokine storm) and, affecting enterocytis, dysregulates intestinal permeability likewise Inflammatory Bowel Diseases. According to Guidelines, nutritional support in COVID-19 patients is relevant in a perspective of a fast recovery. Aim of this study is to propose in SARS-COV2 patients an early nutritional support using a polymeric - TGF-beta2 containing formula, with immunoregulatory properties specific for bowel disease, evaluating its effects on systemic inflammation and protein energy malnutrition. METHODS: COVID-19 patients hospitalized in Santa Maria Hospital of Terni and in Madonna delle Grazie Hospital of Matera (March - December 2020) were enrolled. The protocol consists in supplying 150 gr of nutritional formula powder (750 kcal/day). Values of serum prealbumin, transferrin, C-reactive protein and Lymphocyte count were collected at baseline and every week. Data were compared to a untreated sample of inpatients. RESULTS: TGF-beta2 containing formula use seems to be associated to a lower needing and longer time free from steroid therapy, increasing of prealbumin and transferrin values and overall with a better outcome in exposed patients; higher values of serum prealbumin seemed to be associated with lower CRP. It does not induce gastrointestinal discomfort or worsen gastrointestinal symptoms. CONCLUSIONS: TGF-beta2 containing formula represents a valid nutritional support in COVID-19, preventing sarcopenia associated to hypercatabolic status and modulating inflammatory response probably thanks to specific properties of its nutritional components. This is only a preliminary observation: further investigations are on-going, involving several Italian Centers.

Adipokines: A Rainbow of Proteins with Metabolic and Endocrine Functions

Obesity represents one of the most important health problems worldwide with increasing morbidity and mortality. Widespread prevalence of this disease justifies its actual definition of a "global epidemic". Adipose tissue is nowadays considered a complex organ with lots of endocrine and metabolic functions. In addition to fulfilling its task for energy storage and thermal regulation, by virtue of its constituent white and brown cells, adipose tissue represents, considering its size, the biggest endocrine gland in the body. Both adipocytes and surrounding resident cells (macrophages, endothelial cells and others) produce a huge number of molecules, or adipokines, with endocrine or paracrine functions, that regulate various aspects of metabolism whose clinical relevance is emerging. By balancing pro-inflammatory and anti-inflammatory effects, the adipokines control insulin sensitivity and related glucose metabolism changes, lipid accumulation in the liver and other organs, and finally gonadal function. Collectively, literature data remains cloudy because of still conflicting results of pre-clinical and clinical studies. The aim of this review was to summarize scientific evidence about adipokines' effects on human metabolism, by focusing on their role on either Metabolic Syndrome and NAFLD, or insulin-resistance in pregnancy, or finally, reproductive function disorders.

Radial head prosthesis: surgical tips and tricks

Radial head prostheses (RHP) have been developed to decrease the complications rate following a radial head resection surgery. The aim of the RHP is to replicate the physiological radiocapitellar tracking, reproducing the mechanical function of the native radial head: to stabilize the elbow and to shear the forces passing through the elbow along with the other stabilizers. The currently used RHP models try to achieve this target with three different prosthesis' strategies: (a) loose fit stem, (b) bipolar radial head or (c) anatomical radial head. Even if the radial head fixation is the preferred technique in every possible case and the resection can be still considered a possible option, in the last years there has been a growing worldwide consensus in using the radial head replacement in patients with unfixable radial head fractures, especially if associated with complex elbow instability. However, complications after a RHP are not uncommon, and their rate is raising as long as the implants number are increasing. The main difficulties are due to the implantation technique that needs to be performed with the same attention and precision used for the replacement of all the other joints, and to the concurrent treatment of the associated lesions. A personalized postoperative rehabilitation program is essential for obtaining good results and decreasing the complications rate. Concern exists for the young age of the patients that often require a RHP: personal experience and literature analysis suggest that if the clinical and radiographic results are positive after a 6-12-month follow-up, good outcomes can be also expected at a medium- or long-term follow-up.

Pattern of care and effectiveness of treatment for glioblastoma patients in the real world: Results from a prospective population-based registry. Could survival differ in a high-volume center?

BACKGROUND

As yet, no population-based prospective studies have been conducted to investigate the incidence and clinical outcome of glioblastoma (GBM) or the diffusion and impact of the current standard therapeutic approach in newly diagnosed patients younger than aged 70 years.

METHODS

Data on all new cases of primary brain tumors observed from January 1, 2009, to December 31, 2010, in adults residing within the Emilia-Romagna region were recorded in a prospective registry in the Project of Emilia Romagna on Neuro-Oncology (PERNO). Based on the data from this registry, a prospective evaluation was made of the treatment efficacy and outcome in GBM patients.

RESULTS

Two hundred sixty-seven GBM patients (median age, 64 y; range, 29-84 y) were enrolled. The median overall survival (OS) was 10.7 months (95% CI, 9.2-12.4). The 139 patients ≤aged 70 years who were given standard temozolomide treatment concomitant with and adjuvant to radiotherapy had a median OS of 16.4 months (95% CI, 14.0-18.5). With multivariate analysis, OS correlated significantly with KPS (HR = 0.458; 95% CI, 0.248-0.847; P = .0127), MGMT methylation status (HR = 0.612; 95% CI, 0.388-0.966; P = .0350), and treatment received in a high versus low-volume center (HR = 0.56; 95% CI, 0.328-0.986; P = .0446).

CONCLUSIONS

The median OS following standard temozolomide treatment concurrent with and adjuvant to radiotherapy given to (72.8% of) patients aged ≤70 years is consistent with findings reported from randomized phase III trials. The volume and expertise of the treatment center should be further investigated as a prognostic factor.

Cartilage repair procedures associated with high tibial osteotomy in varus knees: clinical results at 11 years' follow-up

BACKGROUND AND AIM

In this study, the authors retrospectively compared the clinical outcome of middle-aged active patients affected by a varus knee with medial unicompartmental osteoarthritis: the treatment was isolated high tibial osteotomy (HTO) for one group or HTO associated with a cartilage repair procedure, that was autologous chondrocyte implantation (ACI) for one group (HTO+ACI) and microfracture (MFX) for the other group (HTO+MFX). The purpose of this study was to analyse the clinical outcomes at long-term follow-up. The hypothesis was that a cartilage repair procedure may add some benefit to isolated axial correction.

METHODS

56 patients affected by medial osteoarthcritis in a varus knee were retrospectively investigated: 20 patients were treated by HTO, 18 by HTO+ACI and 18 by HTO+MFX. All patients underwent clinical assessment following HSS and WOMAC rating scores and a radiographic study was performed preoperatively and at follow-up. The statistical analysis confirmed that the three groups of patients were homogeneous regarding clinical, radiographical and anatomopathological patterns; differences have been reported in body mass index (BMI).

RESULTS

At final follow-up, improvements in clinical and radiographical results were obtained in all patients. HTO and HTO+ACI series showed significantly higher scores compared to the HTO+MFX series.

CONCLUSIONS

At more than 11 years of follow-up, isolated HTO and HTO+ACI treatments showed satisfactory results similar to those reported in the literature with no evidence of superiority of the addition of ACI to isolated HTO. MFX associated with HTO provided the worst results in the series.

Ankle surgery: focus on arthroscopy

BACKGROUND

The ankle joint can be affected by several diseases, with clinical presentation varying from mild pain or swelling to inability, becoming in some cases a serious problem in daily life activities. Arthroscopy is a widely performed procedure in orthopedic surgery, due to the low invasivity compared to the more traditional open field surgery. The ankle joint presents anatomical specificities, like small space and tangential view that make arthroscopy more difficult.

METHODS

From 2000 more than 600 ankle arthroscopies were performed at our institution. The treated pathologies were mostly impingement syndrome and osteochondral lesions, and in lower percentage instabilities and ankle fractures.

RESULTS

In the impingement, the AOFAS scores at FU showed an increase compared to scores collected preoperatively, with improvement of symptoms in most of the cases, good or excellent results in 80 % of cases. In ligament injuries, AOFAS score significatively improved at the maximum follow-up. In fractures all patients had an excellent AOFAS score at maximum follow-up, with complete return to their pre-injury activities. In osteochondral injuries, the clinical results showed a progressive improvement over time with  the different performed procedures. Control MRI and bioptic samples showed a good regeneration of the cartilage and bone tissue in the lesion site.

CONCLUSIONS

The encouraging obtained clinical results, in line with the literature, show how the arthroscopic technique, after an adequate learning curve, may represent a precious aid for the orthopedic surgeon and for the patient's outcome.

LEVEL OF EVIDENCE

Case series, Level IV.

Monitoring environmental Aspergillus spp. contamination and meteorological factors in a haematological unit

The opportunistic pathogens belonging to the Aspergillus genus are present in almost all seasons of the year, and their concentration is related to meteorological conditions. The high density of Aspergillus spp. conidia in a haematological hospital ward may be a significant risk factor for developing invasive fungal diseases in immunocompromised patients. Aim of the present study was to evaluate the variability of airborne Aspergillus spp. conidia contamination in a Haematological Unit (HU) within a period of 16 months in relation with some meteorological parameters. An environmental Aspergillus surveillance was conducted in the HU in four rooms and their bathrooms, in the corridor and in three external sites using an agar impact sampler. During each sampling, temperature and relative humidity at each site were recorded and current wind speed and rainfall events were taken from the official weather service. Aspergillus spp. conidia concentration differed significantly across the sampling sites. Internal Aspergillus spp. loads were significantly dependent on temperature, internal relative humidity and rain. External conidia concentrations were significantly influenced by outdoor temperature and relative humidity. A suitable indicator was introduced to evaluate the seasonal distribution of Aspergillus spp. conidia in the sampling sites, and a significant dependence on this indicator was observed inside the HU. Seventeen different fungal species belonging to the Aspergillus genus were detected during the sampling period. Aspergillus fumigatus was the most frequently isolated species and its distribution depended significantly on the seasonal indicator both inside and outside the hospital ward.

Bone marrow concentrated cell transplantation: rationale for its use in the treatment of human osteochondral lesions

Bone marrow is one of the best characterized stem cell microenvironments that contains Mesenchymal Stem Cells (MSCs), a rare population of non-hematopoietic stromal cells. MSCs have been indicated as a new option for regenerative medicine because of their ability to differentiate into various lineages such as bone, cartilage and adipose tissue. However, isolation procedures are crucial for the functional activity of the transplanted cells. The use of concentrated bone marrow cells (BMCs) enables a cell population surrounded by its microenvironment (niche) to be implanted while avoiding all the complications related to the in vitro culture. The cells of the niche are able to regulate stem cell behavior through direct physical contact and secreting paracrine factors. The aim of this study was to characterize BMCs in vitro to evaluate their ability to differentiate toward mature cells and try to understand whether there are differences in the chondrogenic and osteogenic potential of cells from patients of different ages. Mononuclear Cells (MNCs) isolated by Ficoll were used as control. Both cell populations were grown in monolayers and differentiated with specific factors and analyzed by histological and molecular biology assays to evaluate the expression of some specific extracellular matrix molecules. The present investigations revealed the ability of BMCs to act as isolated cells. They are able to form colonies and differentiate toward chondrogenic and osteogenic lineages, the latter pathway appearing to be influenced by donor age. The results obtained by this study support the use of BMCs in clinical practice for the repair of osteochondral damage, which might be particularly useful for the one-step procedure allowing cells to be directly implanted in operating room.

Clinical and molecular evidence for association of SLE with parvovirus B19

In addition to genetic and environmental factors, viruses have been suspected as causes and/or contributors to human autoimmune diseases, although direct evidence for the association is generally lacking. Parvovirus B19, the cause of Fifth disease in childhood, and possible trigger in the spectrum of autoimmune diseases in adults, has emerged as one of the central viral candidates within the last few years. In this article we propose a possible model for parvovirus B19 association with systemic lupus erythematosus (SLE). The basis for our model is the secretion of hydrolyzing anti-ssDNA autoantibodies in 30-70% of cases with SLE, which in turn can either hydrolyze viral B19 ssDNA in blood and other fluids, or intranuclear, replicated viral ssDNA after re-activation and translocation of the virus into the nucleus of the host permissive cells. Both mechanisms contribute to perpetuation and maintenance of a 'vicious cycle' with concomitant flares in SLE, and involve inevitable TLR9 sensitization and genetic switch for anti-ssDNA autoantibody production from activated B cells in individuals prone to triggering. This model strongly suggests a major potential impact upon early prevention (vaccination) and targeted therapy of this subclass within the SLE spectrum of diseases. Incorporated in this new concept is an innovative idea for developing the tool for more precise (individualized) diagnosis, prevention, and therapy.

A computational model to compare different investment scenarios for mini-stereotactic frame approach to deep brain stimulation surgery

Deep brain stimulation (DBS) alleviates symptoms of many neurological disorders by applying electrical impulses to the brain by means of implanted electrodes, generally put in place using a conventional stereotactic frame. A new image guided disposable mini-stereotactic system has been designed to help shorten and simplify DBS procedures when compared to standard stereotaxy. A small number of studies have been conducted which demonstrate localization accuracies of the system similar to those achievable by the conventional frame. However no data are available to date on the economic impact of this new frame.

AIM

The aim of this paper was to develop a computational model to evaluate the investment required to introduce the image guided mini-stereotactic technology for stereotactic DBS neurosurgery.

METHODS

A standard DBS patient care pathway was developed and related costs were analyzed. A differential analysis was conducted to capture the impact of introducing the image guided system on the procedure workflow. The analysis was carried out in five Italian neurosurgical centers.

RESULTS

A computational model was developed to estimate upfront investments and surgery costs leading to a definition of the best financial option to introduce the new frame. Investments may vary from Euro 1.900 (purchasing of Image Guided [IG] mini-stereotactic frame only) to Euro 158.000.000. Moreover the model demonstrates how the introduction of the IG mini-stereotactic frame doesn't substantially affect the DBS procedure costs.

Migrainous infarction: association with vascular risk factors in a male subject

Migraine with aura (MA) is associated with an increased risk of ischemic stroke, especially in young women with vascular risk factors (smoke, contraceptive pill). Patent foramen ovale (PFO) has also been associated with MA. We describe a 41-year-old man, in good health, with MA since 16, familiar history of diabetes, heavy smoker (30 cigarettes/day). Frequency (1-2 attacks/year) and clinical features of migraine have been unchanged since the onset. A few days before our examination he suffered a typical migraine attack. In the following hours, however, the headache became more and more throbbing and the aura symptoms (regressed as usual in 30 min) reappeared and persisted, so he went to an Emergency Department. The CT-scan (without contrast) was normal. The following days he had visual disturbances and spatial disorientation. We found a normal neurological examination and fundus oculi. He referred persisting visual troubles. We prescribed MR + angioMR which confirmed a migrainous infarction and ruled out others pathological conditions. Further tests found out dyslipidemia, hyperhomocysteinemia, impaired glucose tolerance. Transcranial Doppler showed right to left shunting. We also prescribed the screening tests for vasculitis (normal). In our opinion this case highlights the relevance of vascular risk factors in MA complications also in male subjects.

A survey of Italian cases of dystonia treated by deep brain stimulation

AIM

The aim of this study was to report on Italian cases of dystonia treated by deep brain stimulation up to the end of 2005.

METHODS

Retrospective survey. Presentation of data collection among all Italian neurosurgical institutions.

RESULTS

Seven out of 123 Italian neurosurgical centres were enrolled. Sixty-nine patients were operated. According to different classification criteria, cases were grouped as follows: 37 primary and 32 secondary dystonia; 61 generalized and 8 focal dystonia; 16 patients aged at onset <2 years, 22 aged 3-12 years, 14 aged 13-20 years, 17 aged >20 years. Primary dystonia (DYT) mutation 1 was identified in 21% of primary generalized dystonia. Age at surgery was <15 years in 21.7% of cases (N.=15). Mean time between clinical onset and surgery was 17 years. Globus pallidus internus (GPi) was chosen for implantation in all cases. Type of anesthesia, method of target localization, lead and implanted pulse generator (IPG) model differed among centres. Surgical complications occurred in 19% of patients, but at a higher rate (33%) in the pediatric subgroup. Stimulation parameters varied among centres, but the main scheme was 90-120 micros and 130 Hz. Follow-up duration ranged from 3 to 84 months (longer than 24 months in 50% of patients). Mean Burke-Fahn-Marsden scale (BFM) improvement was 42% for both severity and disability score, ranging from 0% to 92%. Improvement of at least 50% in BFM severity score has been reached by 45% of primary and 37% of secondary dystonia. Clinical results were better in the DYT1 subgroup, with 60% of cases improving more than 50%. Among secondary dystonia, the drug-induced group had very good results too. On the contrary delayed surgery and presence of comorbidity were negatively correlated to the outcome.

CONCLUSION

In this series, primary generalized dystonia has a better outcome, especially if associated to DYT1 mutation. Among secondary dystonia, the drug-induced group has very good

RESULTS

Correlation analysis of time to surgery and associated comorbidity suggests that earlier surgery is advisable.

Evaluation of acute perihematomal regional apparent diffusion coefficient abnormalities by diffusion-weighted imaging

In this study, we investigated 40 patients (18 male, 22 female; mean age = 64.5 +/- 11.0; GCS = 9 to 14) with acute supratentorial spontaneous intracerebral hemorrhage (SICH) at admission by using a 1-tesla magnetic resonance imaging (MRI) unit equipped for single-shot echo-planar spin-echo isotropic diffusion-weighted imaging (DWI) sequences. All DWI studies were obtained within 48 hours after symptom onset. Regional apparent diffusion coefficient (rADC) values were measured in 3 different regions of interest (ROIs) drawn freehand on the T2-weighted images at b 0 s/mm2 on every section in which hematoma was visible: 1) the perihematomal hyperintense area; 2) 1 cm of normal appearing brain tissue surrounding the perilesional hyperintense rim; 3) an area mirroring the region including the clot and perihematomal hyperintense area placed in the contralateral hemisphere. rADC mean values were higher in perihematomal hyperintense and in contralateral than in normal appearing areas (p < 0.001), with increased rADC mean levels in all regions examined. Our findings show that rADC values indicative of vasogenic edema were present in the perihematomal area and in normal appearing brain tissue located both ipsilateral and contralateral to the hematoma, with lower levels in non-injured areas located in the T2 hyperintense rim around the clot.

Comparison between two perception tests in patients with severe and profoundly severe prelingual sensori-neural deafness

Patients with severe and profoundly severe bilateral sensorineural prelingual deafness constitute a group of particular interest in the organization of the National Health Service; every patient must, in fact, follow a prosthetic-rehabilitative-educational programme lasting many years and organized under different areas to compensate for his/her communicative difficulties, especially with regard to the speech canal. No reliable data providing details of the efficacy and efficiency of any of these points is available. A critical point in the rehabilitation process is that of auditory perception training. Of the few auditory perception tests presently available in Italian, the following were examined: namely, EARS (Evaluation of Auditory Responses to Speech) battery, on the one hand, and the Italian version of the ESP (Early Speech Perception), GASP (Glendonald Auditory Screening Procedure). NU-CHIPS (Northwestern University Children's Perception of Speech) and WIPI (Word Intelligibility by Picture Identification) tests on the other. A group of 10 patients presenting severe and profoundly severe bilateral sensori-neural prelingual deafness received the two tests at the beginning and after six months of auditory perception rehabilitation. The findings emerging from the two different test sessions were analysed and compared. The EARS battery was seen to have enabled even very early and highly developed stages of auditory perception to be detected in comparison with the other battery, which, however, was more accurate in evaluating the ability to discriminate and identify words on the basis of their spectral characteristics. The Authors propose the combined use of the two test batteries to evaluate the efficacy and efficiency of auditory perception training in patients with severe and profoundly severe bilateral sensori-neural prelingual deafness.

Macular edema induced by phacoemulsification

PURPOSE

To characterise the association between lens phacoemulsification and the development of macular edema.

METHODS

We studied 15 patients who underwent lens phacoemulsification in our clinic between January and April 1998 performed by the same surgeon. Ultrasound power and cumulative time was noted. Follow-up was performed at 1 day, 1 week, 1, 3 and 6 months after operation. On each visit corneal thickness, best corrected visual acuity, biomicroscopy and fluorescein angiography were performed. Patients with systemic diseases and/or retinal diseases were not included.

RESULTS

Visual acuity was inversely related to the amount of energy delivered during phacoemulsification. In patients who had received more than 1 Joule of energy, fluorescein angiography revealed a higher incidence of blood retinal barrier breakdown. Corneal thickness was not correlated with the ultrasound energy used.

CONCLUSIONS

Excessive use of power during phacoemulsification may hamper the postoperative evolution of cataract surgery.

Identifying the indications for laparoscopically assisted vaginal hysterectomy: a prospective, randomised comparison with abdominal hysterectomy in patients with symptomatic uterine fibroids

OBJECTIVE

To compare laparoscopically assisted vaginal hysterectomy (LAVH) and total abdominal hysterectomy (TAH) in patients with uterine fibroids.

DESIGN

A prospective randomised study.

SETTING

The San Paolo Hospital, Milan.

POPULATION

Sixty-two patients, who were not suitable for a vaginal hysterectomy, requiring treatment for uterine fibroids.

METHODS

Randomisation between LAVH and TAH. Comparison of outcomes on the whole series, patients with uteri < or = 500 g (Group 1) and patients with uteri > 500 g (Group 2).

MAIN OUTCOME MEASURES

To establish operating time, blood loss, complications, febrile morbidity, analgesics administration and hospital stay for both treatment approaches.

RESULTS

Median uterine weight was 400 g in both LAVH and TAH group. Median operating time was longer for LAVH (135 min compared with 120 min for TAH; P = 0.001), but patients undergoing LAVH had less analgesics administration (23% compared with 77%, P < 0.001) and a shorter median hospital stay (3.8 compared with 5.8 days; P < 0.001). LAVH, when compared with TAH in the two weight subgroups, required a significantly longer operating time only in Group 2, significantly reduced analgesics administration only in Group 1, and significantly reduced hospital stay in both groups. Conversions of LAVH to laparotomy were significantly more frequent in Group 2 (3/11) than in Group 1 (0/20) (P = 0.04).

CONCLUSIONS

Compared with TAH, LAVH has advantages in removing uteri weighing < or = 500 g, with comparable operating time, less post-operative pain and shorter recovery. Among uteri weighing > 500 g LAVH showed a shorter recovery, but longer operating time than TAH and a 27% rate of conversion to laparotomy.

[Raynaud's phenomenon. Practical considerations on the forms secondary to immunomediated systemic diseases]

Raynaud's phenomenon is a frequent asphyxial vascular syndrome interesting the 4% of general population. In most of cases it is a functional problem (Raynaud's disease). Less frequently it has an organic cause (Raynaud's syndrome). The pathogenesis of primitive Raynaud's phenomenon remains an enigma. In secondary Raynaud phenomenon the attacks of vasospasm can be explained by the physiopathologic events characterizing the underlying disease. For example, multiple cytokines, transforming grow factor beta, serum immunocomplexes are of great importance in the contest of connective diseases. Clinical examination, some usual laboratory and roentgenographic investigations and nailfold capillary microscopy are of particular importance in orientating the diagnosis.

Intracranial tumors during the 1st year of life

Twenty-eight patients with intracranial tumors symptomatic during the 1st year of life were managed from January 1970 to March 1988. Supratentorial location (19 cases) was dominant over the infratentorial. The most common histological type was astrocytoma; choroid plexus papilloma and ependymal tumors followed in frequency. Twenty-two infants (78.6%) had associated hydrocephalus. Macrocrania, vomiting, delayed milestones, and behavioral disturbances were the chief clinical manifestations. Four patients were admitted in extremely deteriorated condition and died preoperatively. Twenty cases underwent surgery for tumor removal with a 1-month mortality rate of 20%. Tumor excision provided permanent relief of hydrocephalus in the majority of the surviving cases. Five patients received conventional radiotherapy. Stereotactic brachytherapy yielded an excellent result in 1 case. Overall 13 cases are currently alive; 6 of them have survived longer than 6 years. Fourteen of the 15 patients who were dead at follow-up succumbed within 1 year after diagnosis.

Extradural hematomas of the posterior cranial fossa. Observations on a series of 32 consecutive cases treated after the introduction of computed tomography scanning

A series of 32 patients with posterior fossa epidural hematoma treated after the introduction of computed tomography scanning between 1975 and March 1988 is presented. Sixteen patients harbored "pure" epidural hematomas, whereas 16 had other infratentorial or supratentorial traumatic lesions. Glasgow Coma Scale on admission was 7 or less in 10 patients, 8-12 in 11, and 13-14 in 11. Only six patients had a lucid interval. Thirty patients were treated surgically; two patients with small hematomas were treated conservatively. Overall mortality was 15.6%, with 0% for "pure" and 31.2% for "complicated" posterior fossa epidural hematomas. The value of routine computed tomography scanning is emphasized in cases with occipital skull fracture or when such fracture is found in patients undergoing emergency evacuation of supratentorial hematomas. The pertinent literature is addressed with special regard to the delayed occurrence, associated lesions, and mortality of posterior fossa epidural hematomas and to the role of computed tomography scanning.

Surgical treatment of syringomyelia: favorable results with syringosubarachnoid shunting

The authors review the clinical course of 29 patients who underwent syringosubarachnoid shunting for syringomyelia. Twenty-two patients presented hindbrain-related syringomyelia; seven patients had non-hindbrain-related syringomyelia secondary to trauma (four cases) and to spinal arachnoiditis (three cases). The surgical technique is described in detail. All patients showed postoperative deflation or collapse of the syrinx at follow-up magnetic resonance imaging evaluation. Symptoms stabilized in 17 cases (59%); 9 cases (31%) showed improvement in the neurological function; 3 cases (10%) presented delayed neurological deterioration, probably owing to spinal cord ischemia.

Univariate and multivariate analysis of associated factors of retinopathy in 894 Italian adult diabetics

The prevalence of diabetic retinopathy and the evaluation of its risk factors is poorly known in Italian population. Therefore, we have studied 894 diabetic outpatients (420 males, 474 females, 27.6% IDDs, 38.1% insulin-treated) in order to investigate the effect of clinical and metabolic characteristics on the frequency of diabetic retinopathy, classified into six different classes. In univariate analyses age, duration of disease, systolic and diastolic blood pressure, blood urea nitrogen, 24 hr proteinuria and fasting glycemia significantly correlated (p less than 0.001) with severity of retinopathy. The significance was confirmed in multivariate analysis for duration, age and systolic blood pressure (p less than 0.001). Stratification by type of diabetes showed that undefined onset of diabetes probably reduced in NID patients the power of duration as an associated factor of retinopathy. Worsening of this complication in three clinical classes of therapy (diet, oral and insulin-treatment) is evident too. Finally, our 11 variables in the step-wise multiple-regression analysis explain only 16.8% of diabetic retinopathy in all patients, but 36.6% in selected ID subjects.

Histiocytosis-X: a rare cause of radiculopathy

A rare case of histiocytosis-X of the spine is presented. The clinical and histological features of histiocytosis-X are reviewed. Complete neurological recovery was exhibited by the patient after surgical treatment and radiotherapy. The literature dealing with the eight cases previously reported is reviewed.

Distal ulnar neuropathy from carpal ganglia: a clinical and electrophysiological study

The clinical and electrophysiological observations in two cases of distal ulnar neuropathy from carpal ganglia are reported. In the first case, the ganglion was compressing the ulnar nerve just proximal to its division; in the second case, the ganglion was compressing the deep branch of the ulnar nerve just at its origin. In both cases, both axonal degeneration and segmental demyelination were present. A clinical classification of the compression syndromes of the deep ulnar branch is proposed.

The Neu-COFS (cerebro-oculo-facio-skeletal) syndrome: report of a case

A newborn female with a phenotype intermediate between the Neu and the COFS syndromes is described. The hypothesis of the two conditions representing different degrees of severity of the same autosomal recessive mutation in the homozygote state is discussed.

Content analysis approach to visual scanning theory in dreams

No relationship between dream content and density of REMs preceding dream reports obtained for data based on 15 night sessions for 1 S.