Intracranial germ cell tumors in Adolescents and Young Adults: European and North American consensus review, current management and future development

The incidence of intracranial germ cell tumors (iGCT) is much lower in European and North American (E&NA) than in Asian population. However, E&NA cooperative groups have simultaneously developed with success treatment strategies with specific attention paid to long-term sequelae. Neurological sequelae may be reduced by establishing a diagnosis with an endoscopic biopsy and/or cerebrospinal fluid (CSF) and/or serum analysis, deferring the need to perform a radical surgery. Depending on markers and/or histological characteristics, patients are treated as either germinoma or non-germinomatous germ cell tumors (NGGCT). Metastatic disease is defined by a positive CSF cytology and/or distant drops in craniospinal MRI. The combination of surgery and/or chemotherapy and radiation therapy is tailored according to grouping and staging. With more than 90% 5-year event-free survival (EFS), localized germinomas can be managed without aggressive surgery, and benefit from chemotherapy followed by whole ventricular irradiation with local boost. Bifocal germinomas are treated as non-metastatic entities. Metastatic germinomas may be cured with craniospinal irradiation. With a 5-year EFS over 70%, NGGCT benefit from chemotherapy followed by delayed surgery in case of residual disease, and some form of radiotherapy. Future strategies will aim at decreasing long-term side effects while preserving high cure rates.

Computational Tools for the Reliability Assessment and the Engineering Design of Procedures and Devices in Bariatric Surgery

Obesity is one of the main health concerns worldwide. Bariatric Surgery (BS) is the gold standard treatment for severe obesity. Nevertheless, unsatisfactory weight loss and complications can occur. The efficacy of BS is mainly defined on experiential bases; therefore, a more rational approach is required. The here reported activities aim to show the strength of experimental and computational biomechanics in evaluating stomach functionality depending on bariatric procedure. The experimental activities consisted in insufflation tests on samples of swine stomach to assess the pressure-volume behaviour both in pre- and post-surgical configurations. The investigation pertained to two main bariatric procedures: adjustable gastric banding (AGB) and laparoscopic sleeve gastrectomy (LSG). Subsequently, a computational model of the stomach was exploited to validate and to integrate results from experimental activities, as well as to broad the investigation to a wider scenario of surgical procedures and techniques. Furthermore, the computational approach allowed analysing stress and strain fields within stomach tissues because of food ingestion. Such fields elicit mechanical stimulation of gastric receptors, contributing to release satiety signals. Pressure-volume curves assessed stomach capacity and stiffness according to the surgical procedure. Both AGB and LSG proved to reduce stomach capacity and to increase stiffness, with markedly greater effect for LSG. At an internal pressure of 5 kPa, outcomes showed that in pre-surgical configuration the inflated volume was about 1000 mL, after AGB the inflated volume was slightly lower, while after LSG it fell significantly, reaching 100 mL. Computational modelling techniques showed the influence of bariatric intervention on mechanical stimulation of gastric receptors due to food ingestion. AGB markedly enhanced the mechanical stimulation within the fundus region, while LSG significantly reduced stress and strain intensities. Further computational investigations revealed the potentialities of hybrid endoscopic procedures to induce both reduction of stomach capacity and enhancement of gastric receptors mechanical stimulation. In conclusion, biomechanics proved to be useful for the investigation of BS effects. Future exploitations of the biomechanical methods may largely improve BS reliability, efficacy and penetration rate.

Trans-sulcal versus trans-parenchymal approach in supratentorial cavernomas. A multicentric experience

OBJECTIVES

Cavernous malformations (CM) are low-flow vascular lesions that can cause significant symptoms and neurological deficits. Different intraoperative surgical approaches have been developed. Aim of the present investigation is the comparison between the trans-sulcal approach (TS) and the trans-parenchymal neuronavigation-assisted approach (TPN) in a surgical series from two neurosurgical centers. The technique and clinical outcomes are discussed, with a specific focus on seizure outcome.

PATIENTS AND METHODS

Clinical and radiological data from two neurosurgical centers ("A. Gemelli" Hospital in Rome and A.O.U. Città della Salute e della Scienza in Turin) were retrospectively reviewed in order to evaluate the different outcome of TS and TPN approach for cavernous malformation treatment.

RESULTS

A total of 177 patients underwent surgical intervention for supratentorial CM, 130 patients with TPN approach and 47 with TS approach. TS approach was associated with higher rate of seizure in early post-operative period both in epileptic patients (p < 0,001) and in patients without history of seizures before surgery (p = 0,002). Moreover, length of incision (p < 0,001), area of craniotomy (p < 0,001) and corticectomy (p < 0,001) were bigger in TS than in TPN approach. Brain contusion (p < 0,001) and fluid collection (p < 0,001) were more likely to be discovered after TS approach.

CONCLUSIONS

TPN is a valuable approach for resection of CM. Minor complications are significantly lower in TPN approach when compared with TS approach. In addition, it is associated with lower rate of early post-operative seizure and shorter length of stay.

Final height in growth hormone-deficient childhood cancer survivors after growth hormone therapy

PURPOSE

Growth hormone deficiency (GHD) is the most prevalent hypothalamic-pituitary (HP) disorder found in childhood cancer survivors (CCS). The published studies assessing GHD in CCS concluded that recombinant human GH (rhGH) does not restore final height (FH) to that predicted from mid-parental height (MPH). Thus, wider analyses on final height outcomes after rhGH in CCS are needed.

METHODS

Retrospective study on final height (FH) in 87 CCS treated with rhGH. Patients were divided into: Group A (n =48) who underwent cranial radiotherapy or had non-irradiated tumours of HP area, and B (n =39) who were treated with craniospinal or total body irradiation (TBI). 19/87 patients with central precocious/early puberty also received GnRH analogues.

RESULTS

Height (HT) gain after 1 and 2 years of rhGH was 0.38 ± 0.35 SDS and 0.18 ± 0.30 SDS, respectively (P < 0.0001); mean FH was in the normal range (- 0.85 ± 1.34 SDS), though not significantly different from HT SDS at baseline. 67% overall failed to reach MPH especially in Group B (P < 0.0001). However, height loss (HT SDS-MPH SDS) at FH improved or remained stable compared to baseline in 26/45 patients (58%). On stepwise regression analysis, major determinants of FH were HT at baseline (P < 0.0001) and delay before start of rhGH (P = 0.012). There was no significant difference in FH when GnRHa was added to rhGH.

CONCLUSION

rhGH and GnRH analogues therapy, when indicated, though failing to induce catch-up growth, prevented further height loss leading to a FH within the normal range but still below MPH, this latter being statistically significant in children who received craniospinal and TBI.

Quality and reporting of guidelines on the diagnosis and management of dystonia

BACKGROUND AND PURPOSE

The quality of clinical practice guidelines on dystonia has not yet been assessed. Our aim was to appraise the methodological quality of guidelines worldwide and to analyze the consistency of their recommendations.

METHODS

We searched for clinical practice guidelines on dystonia diagnosis/treatment in the National Guideline Clearinghouse, PubMed, National Institute for Health and Care Excellence, Guidelines International Network and Web of Science databases. We also searched for guidelines on homepages of international neurological societies. We asked for guidelines from every Management Committee member of the BM1101 Action of the Cooperation between Science and Technology European framework and every member of the International Parkinson and Movement Disorders Society with special interest in dystonia.

RESULTS

Fifteen guidelines were evaluated. Among guidelines on treatment, only one from the American Academy of Neurology could be considered as high quality. Among guidelines on diagnosis and therapy, the guideline from the European Federation of Neurological Societies was recommended by the appraisers. Clinical applicability and reports of editorial independence were the greatest shortcomings. The rigor of development was poor and stakeholder involvement was also incomplete in most guidelines. Discrepancies among recommendations may result from the weight given to consensus statements and expert opinions due to the lack of evidence, as well as inaccuracy of disease classification.

CONCLUSIONS

The quality of appraised guidelines was low. It is necessary to improve the quality of guidelines on dystonia, and the applied terminology of dystonia also needs to be standardized.

Shiga toxin-producing Escherichia coli (STEC) O22:H8 isolated from cattle reduces E. coli O157:H7 adherence in vitro and in vivo

PROBLEM ADDRESSED

Shiga toxin-producing Escherichia coli (STEC) are a group of bacteria responsible for food-associated diseases. Clinical features include a wide range of symptoms such as diarrhea, hemorrhagic colitis and the hemolytic uremic syndrome (HUS), a life-threatening condition.

OBJECTIVE

Our group has observed that animals naturally colonized with STEC strains of unknown serotype were not efficiently colonized with E. coli O157:H7 after experimental infection. In order to assess the basis of the interference, three STEC strains were isolated from STEC persistently-colonized healthy cattle from a dairy farm in Buenos Aires, Argentina.

METHODS AND RESULTS

The three isolated strains are E. coli O22:H8 and carry the stx1 and stx2d genes. The activatable activity of Stx2d was demonstrated in vitro. The three strains carry the adhesins iha, ehaA and lpf_O113. E. coli O22:H8 formed stronger biofilms in abiotic surface than E. coli O157:H7 (eae+, stx2+) and displayed a more adherent phenotype in vitro towards HeLa cells. Furthermore, when both serotypes were cultured together O22:H8 could reduce O157:H7 adherence in vitro. When calves were intragastrically pre-challenged with 10⁸ CFU of a mixture of the three STEC strains and two days later challenged with the same dose of the strain E. coli O157:H7 438/99, the shedding of the pathogen was significantly reduced.

CONCLUSIONS

These results suggest that E. coli O22:H8, a serotype rarely associated with human illness, might compete with O157:H7 at the bovine recto-anal junction, making non-O157 carrying-calves less susceptible to O157:H7 colonization and shedding of the bacteria to the environment.

The Italian Dystonia Registry: rationale, design and preliminary findings

The Italian Dystonia Registry is a multicenter data collection system that will prospectively assess the phenomenology and natural history of adult-onset dystonia and will serve as a basis for future etiological, pathophysiological and therapeutic studies. In the first 6 months of activity, 20 movement disorders Italian centres have adhered to the registry and 664 patients have been recruited. Baseline historical information from this cohort provides the first general overview of adult-onset dystonia in Italy. The cohort was characterized by a lower education level than the Italian population, and most patients were employed as artisans, builders, farmers, or unskilled workers. The clinical features of our sample confirmed the peculiar characteristics of adult-onset dystonia, i.e. gender preference, peak age at onset in the sixth decade, predominance of cervical dystonia and blepharospasm over the other focal dystonias, and a tendency to spread to adjacent body parts, The sample also confirmed the association between eye symptoms and blepharospasm, whereas no clear association emerged between extracranial injury and dystonia in a body site. Adult-onset dystonia patients and the Italian population shared similar burden of arterial hypertension, type 2 diabetes, coronary heart disease, dyslipidemia, and hypothyroidism, while hyperthyroidism was more frequent in the dystonia population. Geographic stratification of the study population yielded no major difference in the most clinical and phenomenological features of dystonia. Analysis of baseline information from recruited patients indicates that the Italian Dystonia Registry may be a useful tool to capture the real world clinical practice of physicians that visit dystonia patients.

Efficacy of pallidal stimulation in isolated dystonia: a systematic review and meta-analysis

The aim of this review was to provide strong clinical evidence of the efficacy of deep brain stimulation (DBS) of the globus pallidus internus (GPi) in isolated inherited or idiopathic dystonia. Eligible studies were identified after a systematic literature review of the effects of bilateral GPi‐DBS in isolated dystonia. Absolute and percentage changes from baseline in the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS) motor and disability scores were pooled, and associations between treatment effect and patient characteristics were explored using meta‐regression. In total, 24 studies were included in the meta‐analysis, comprising 523 patients. The mean absolute and percentage improvements in BFMDRS motor score at the last follow‐up (mean 32.5 months; 24 studies) were 26.6 points [95% confidence interval (CI), 22.4–30.8] and 65.2% (95% CI, 59.6–70.7), respectively. The corresponding changes in disability score at the last follow‐up (mean 32.9 months; 14 studies) were 6.4 points (95% CI, 5.0–7.8) and 58.6% (95% CI, 50.3–66.9). Multivariate meta‐regression of absolute scores indicated that higher BFMDRS motor and disability scores before surgery, together with younger age at time of surgery, were the main factors associated with significantly better DBS outcomes at the latest follow‐up. Reporting of safety data was frequently inconsistent and could not be included in the meta‐analysis. In conclusion, patients with isolated inherited or idiopathic dystonia significantly improved after GPi‐DBS. Better outcomes were associated with greater dystonia severity at baseline. These findings should be taken into consideration for improving patient selection for DBS.

Novel Evidence of PLC δ2 Involvement in the Regulation of the Differential Evolution of Aneurysms

The biological and molecular mechanisms which are responsible for the formation and possible evolution of human aneurysms are unknown. Previous investigations have pointed to the possible involvement of inositol specific-phospholipase C (PLC) in the mechanisms related to the formation or evolution of intracranial aneurysms, but, thus far, a relationship of one or more PLC isoforms with the biological signals influencing the fate of this lesion has not been demonstrated. The aim of this study was to investigate the expression, activity and possible modification of PLC isoforms in intracranial aneurysms in patients undergoing elective surgical repair after casual identification of unruptured aneurysms, or during emergency surgical repair of ruptured aneurysms. PLC and proliferating cell nuclear antigen (PCNA) expressions were detected by immunoistochemical analysis; PLC activity was obtained by measuring its hydrolytic activity on labelled PIP2; PKC activity was measured by total kinase activity assay. Results indicated no substantial differences between controls and aneurysms, with the only exception being PLC 52 which was nearly absent in controls and ruptured aneurysms, while strongly expressed and functionally active in almost all unruptured aneurysms. In addition, its expression always correlated with the proliferation cell marker PCNA, while its specific activity always correlated to PKC activity. PLC δ2 distribution, regulation and role in human tissues are still unknown Therefore, although preliminary, these data provide a novel insight into the signalling machinery influencing the aneurismal progression.

Excessively High Magnetic Resonance Signal in Preterm Infants and Neuropsychobehavioural Follow-up at 2 Years

The diffuse excessive high-signal intensity (DEHSI) findings in the T2 weighted scans of white matter (WM), besides the corresponding low signal in the T1 weighted images, are usually more evident around the periventricular regions. It is not clear whether the DEHSI should be considered as a diffuse WM injury rather than a sign of delayed maturation of the WM. Eighty nine preterm infants at the full-term equivalent age (FEA) were studied using conventional Magnetic Resonance (MR) imaging of the brain. Based on the MR findings, the infants studied were divided into three groups: the control group presenting normal WM, the DEHSI group and the group with other WM lesions. Ten newborns were not included in the statistical analysis because they presented evidence of precedent germinal matrix hemorrhage (GMH-IVH) which cannot be considered as WM lesions. Seventy nine infants were enrolled in a program of neuropsychobehavioural study follow-up until 24 months of age. Each infant was evaluated for those variables which mostly affect the occurrence of neuropsychomotor disability. In the DEHSI infant group, significantly lower mean pH and mean base excess (BE) values were found in comparison to controls, while the mean birth weight (BW) was significantly higher. No significant difference was observed between the mean 1st minute Apgar Score, mean birth gestational age (GA) and assisted ventilation mean duration of controls and DEHSI groups. Finally, no significant difference between the parameters studied was found by comparing the WM lesion infants group to the DEHSI infants one. Our observations, together with follow-up studies, even up to school age, confirm that DEHSI has a clinical significance and cannot be considered as a simple indicator of delayed WM maturation.

Management of dystonia in Europe: a survey of the European network for the study of the dystonia syndromes

BACKGROUND AND PURPOSE

Dystonia is difficult to recognize due to its large phenomenological complexity. Thus, the use of experts in dystonia is essential for better recognition and management of dystonia syndromes (DS). Our aim was to document managing strategies, facilities and expertise available in various European countries in order to identify which measures should be implemented to improve the management of DS.

METHODS

A survey was conducted, funded by the Cooperation in Science and Technology, via the management committee of the European network for the study of DS, which is formed from representatives of the 24 countries involved.

RESULTS

Lack of specific training in dystonia by general neurologists, general practitioners as well as other allied health professionals was universal in all countries surveyed. Genetic testing for rare dystonia mutations is not readily available in a significant number of countries and neurophysiological studies are difficult to perform due to a lack of experts in this field of movement disorders. Tetrabenazine is only readily available for treatment of dystonia in half of the surveyed countries. Deep brain stimulation is available in three-quarters of the countries, but other surgical procedures are only available in one-quarter of countries.

CONCLUSIONS

Internationally, collaboration in training, advanced diagnosis, treatment and research of DS and, locally, in each country the creation of multidisciplinary teams for the management of dystonia patients could provide the basis for improving all aspects of dystonia management across Europe.

Clinical reappraisal of SHORT syndrome with PIK3R1 mutations: toward recommendation for molecular testing and management

SHORT syndrome has historically been defined by its acronym: short stature (S), hyperextensibility of joints and/or inguinal hernia (H), ocular depression (O), Rieger abnormality (R) and teething delay (T). More recently several research groups have identified PIK3R1 mutations as responsible for SHORT syndrome. Knowledge of the molecular etiology of SHORT syndrome has permitted a reassessment of the clinical phenotype. The detailed phenotypes of 32 individuals with SHORT syndrome and PIK3R1 mutation, including eight newly ascertained individuals, were studied to fully define the syndrome and the indications for PIK3R1 testing. The major features described in the SHORT acronym were not universally seen and only half (52%) had four or more of the classic features. The commonly observed clinical features of SHORT syndrome seen in the cohort included intrauterine growth restriction (IUGR) <10th percentile, postnatal growth restriction, lipoatrophy and the characteristic facial gestalt. Anterior chamber defects and insulin resistance or diabetes were also observed but were not as prevalent. The less specific, or minor features of SHORT syndrome include teething delay, thin wrinkled skin, speech delay, sensorineural deafness, hyperextensibility of joints and inguinal hernia. Given the high risk of diabetes mellitus, regular monitoring of glucose metabolism is warranted. An echocardiogram, ophthalmological and hearing assessments are also recommended.

Impulse control behaviours in patients with Parkinson's disease after subthalamic deep brain stimulation: de novo cases and 3-year follow-up

OBJECTIVE

To document the occurrence of impulse control behaviours (ICBs) in patients with Parkinson's disease after 3 years of continuous deep brain stimulation (DBS) of the subthalamic nucleus (STN).

METHODS

Detailed neurological and ICB assessments were performed before STN DBS and up to 3 years after implant.

RESULTS

13 out of 56 patients (23.2%) had ICBs at baseline; they took higher doses of dopamine agonists (DAA). Three years after implant 11 had fully remitted with a 60.8% reduction of DAA medication; the remaining two, who had a similar medication reduction, had only compulsive eating, having recovered from hypersexuality. Six of the 43 patients without ICBs at baseline (14%) developed transient de novo ICBs after implant; none of them had ICBs at the 3-year observation.

CONCLUSIONS

ICBs were abolished in patients 3 years after STN DBS and DAA dosages were lowered. New ICBs may occur after implant and are transient in most cases. Compulsive eating may be specifically related to STN stimulation.

Tauroursodeoxycholic acid in the treatment of patients with amyotrophic lateral sclerosis

Background and purpose

Tauroursodeoxycholic acid (TUDCA) is a hydrophilic bile acid that is produced in the liver and used for treatment of chronic cholestatic liver diseases. Experimental studies suggest that TUDCA may have cytoprotective and anti‐apoptotic action, with potential neuroprotective activity. A proof of principle approach was adopted to provide preliminary data regarding the efficacy and tolerability of TUDCA in a series of patients with amyotrophic lateral sclerosis (ALS).

Methods

As a proof of principle, using a double‐blind placebo controlled design, 34 ALS patients under treatment with riluzole who were randomized to placebo or TUDCA (1 g twice daily for 54 weeks) were evaluated after a lead‐in period of 3 months. The patients were examined every 6 weeks. The primary outcome was the proportion of responders [those subjects with improvement of at least 15% in the Amyotrophic Lateral Sclerosis Functional Rating Scale Revised (ALSFRS‐R) slope during the treatment period compared to the lead‐in phase]. Secondary outcomes included between‐treatment comparison of ALSFRS‐R at study end, comparison of the linear regression slopes for ALSFFRS‐R mean scores and the occurrence of adverse events.

Results

Tauroursodeoxycholic acid was well tolerated; there were no between‐group differences for adverse events. The proportion of responders was higher under TUDCA (87%) than under placebo (P = 0.021; 43%). At study end baseline‐adjusted ALSFRS‐R was significantly higher (P = 0.007) in TUDCA than in placebo groups. Comparison of the slopes of regression analysis showed slower progression in the TUDCA than in the placebo group (P < 0.01).

Conclusions

This pilot study provides preliminary clinical data indicating that TUDCA is safe and may be effective in ALS.

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Protective effect of external ventricular drainage on cerebral vasospasm. A retrospective study on aneurysmal SAH treated endovascularly

OBJECTIVE

Cerebral vasospasm (VS) is one of the factors that can most significantly worsen the prognosis after aneurysmal subarachnoid hemorrhage (SAH). A substantial body of evidence supports the idea that CSF diversion could prevent VS, even if this issue is still much debated. External ventricular drainage (EVD) is the recommended procedure for post-hemorrhagic hydrocephalus. In this study we analyzed whether EVD, placed for acute hydrocephalus, is effective in reducing the incidence of clinical and radiological cerebral vasospasm in patients who underwent endovascular treatment for aneurysmal SAH.

PATIENTS AND METHODS

We retrospectively studied the incidence of radiologically confirmed VS in 141 patients treated endovascularly for aneurysmal SAH: 80 underwent EVD for hydrocephalus, 61 did not undergo EVD.

RESULTS

VS occurred in 8.75% of cases (7 patients) in the first groups, while in 22.95% (14 patients) in the second group. In addition, patients not treated with EVD display a prevalence of VS in lower Fisher grades compared to the other group.

CONCLUSION

Our data indicate that CSF drainage reduces the risk of vasospasms in patients with endovascular treatment for aneurysmal SAH.

Anatomical variants of the basal vein of Rosenthal: prevalence in idiopathic subarachnoid hemorrhage

BACKGROUND

Spontaneous, non traumatic subarachnoid hemorrhage (SAH) is a significant clinical problem that occurs most commonly as a result of aneurysm rupture. In approximately 15 % of cases, nor aneurysm or other vascular malformation can be identified by cerebral angiography as origin of the hemorrhage, and these are commonly defined as idiopathic SAH (ISAH). Because of the negative angiography, limited extension of the bleeding with prevalent prepontine pattern and the benign prognosis, the venous causes has been preferred rather than the arterial ones. In the literature recent studies have suggested a possible contribution by primitive variants of Basal vein of Rosenthal (BVR) in its the pathogenesis of ISAH, commonly grouped according Watanabe classification (type A, B and C). In this paper we evaluated the prevalence of anatomical variants of BVR in ISAH.

METHODS

Venous drainage at angiography was retrospectively analyzed in 40 patients with ISAH and in 40 with unruptured aneurysms as controls.

RESULTS AND CONCLUSIONS

Previous studies displayed a significant prevalence of BVR type C variants in ISAH. Conversely in our study we recognized variant B as prevalent, in which the BVR bifurcates to drain anteriorly into the uncal vein and posteriorly into the Galenic system. Similarly to variant C (in which the BVR drains via perimesencephalic "bridging" veins into cavernous, sphenoparietal, petrosal sinus or directly into transverse sinus) also variant B might be subjected to those stress mechanisms and intrinsic system 'fragility' and for reasons yet to determine, sets off a consequent hemorrhage with clinical and radiological features typical of ISAH.

Alpha lipoic acid and superoxide dismutase in the treatment of chronic low back pain

BACKGROUND

Neuropathic mechanisms largely contribute to low back pain (LBP) and oxidative stress is acknowledged as one of the causes of nerve damage typical of neuropathic pain: antioxidant agents may be a useful choice in the multimodal treatment strategy for chronic LBP patients.

AIM

The aim of this study was to detect changes in perceived pain, functional activity and in the assumption of analgesics in patients with chronic LBP treated with a combination of alpha-lipoic acid (ALA) and superoxide dismutase (SOD).

DESIGN

Prospective non-randomized open-label study.

SETTING

Outpatient at TAMMEF (Therapeutic Application of Musically Modulated Electromagnetic Fields) Centre of the University of Siena.

POPULATION

The study enrolled 98 adult patients with chronic (≥12 weeks) LBP with or without radiculopathy and without neoplastic or inflammatory pathologies.

METHODS

Patients were treated for 60 days with 600 mg ALA and 140 UI SOD/die. The Roland Morris Disability Questionnaire and Pain Rating Scale were used and concomitant use of medications (with particular attention to analgesics) and adverse events (toxicity) were recorded during treatment. Differences between all the study time points were calculated for the scores of the two tools and for the need of concomitant treatment with analgesics.

RESULTS

At the end of the study only 8% of patients still used analgesics versus 73.5% registered at baseline (P<0.01). Regarding self-reported tools, a statistically significant improvement both for perceived pain and functional disabilities occurred: pain ameliorated after 40 days of therapy and the improvement was significant both statistically (P<0.05) and clinically. Only 4 patients stopped the treatment due to unacceptable pain (not related to the treatment).

CONCLUSION

Oral treatment with ALA and SOD improves functionality and reduces the use of analgesics in chronic LBP patients.

CLINICAL REHABILITATION IMPACT

Oral combination of ALA and SOD may be a powerful adjuvant in multimodal therapy of chronic LBP patients.

Transcriptional profile characterization for the identification of peripheral blood biomarkers in patients with cerebral aneurysms

We tried to identify molecular markers in peripheral blood to predict high risk of aneurysm rupture. Extraction of the total population of peripheral blood mononuclear cell (PBMC) from total blood volume, total RNA extraction from PBMC and Agilent One Color Gene-expression Oligo-Microarray were performed on peripheral venous blood samples from 45 patients with ruptured, unruptured cerebral aneurysms and control group (15). Mean foreground/ background signal intensities and A (log2(R*G)/2) values were calculated for each spot. Genes with absolute fold change (FC) greater than or equal to plus or minus 1.5 and p-value less than 0.05 were considered differentially expressed in the 3 groups (Student T-test). Genes coding for MMPs were strongly underexpressed in ruptured aneurysms group, suggesting a possible role in aneurysms development more than their rupture. Genes coding for adhesine proteins of the extracellular matrix (ICAM1) and cytoskeleton (WIPF1,TUBA4A) were underexpressed in ruptured aneurysms. Genes coding proteins involved in the regulation of apoptotic processes may be important in aneurysm development and rupture, resulting into an increased rate of remodeling processes in the arterial wall. Fas coding gene, SUMO1, ZFAT, BCL2, CCR5 genes were all over-represented in unruptured aneurysms. The coexisting over-representation of pro-apoptotic genes and the underexpression of cytoskeleton and extracellular matrix genes confirms that aneurysms development and evolution are part of a degenerative process of the arterial wall not involved in aneurysms rupture. MMPs may be involved in repairing chronic damages to the arterial walls and preventing SAH. Unexpectedly, Heat Shock Proteins (HSP90AA1, HSPA1A, HSPB1), G and RAS proteins, generally activated by stress situations were under-represented in aneurysmal walls. Further PCR and Western Blotting studies are needed to confirm such findings and to identify diagnostic and prognostic markers in order to define screening protocols for intracranial aneurysms.

Therapeutic Application of Musically Modulated Electromagnetic Fields in the Treatment of Musculoskeletal Disorders

Different studies have demonstrated the efficacy of extremely low frequency electromagnetic fields (ELF EMFs) in the treatment of pain. In particular, the positive effects of ELF EMFs seems to depend on their respective codes, such as frequency, intensity and waveform, even if the exact mechanism of interaction is still debated. The most commonly used for extremely low frequency magnetotherapy is a 100Hz sinusoidal field (ELF) with a mean of induction of few Gauss. This article reviews the therapeutic application of a musically modulated electromagnetic field (TAMMEF), a new-generation of electromagnetic field used for extremely low frequency magnetotherapy characterized by variable frequencies, intensities and waveforms. Both clinical and experimental studies, performed by authors of the present review, have demonstrated the efficacy of ELF and the new TAMMEF systems in several musculoskeletal disorders such as osteoarthritis, rheumatoid arthritis, carpal tunnel syndrome, shoulder periarthritis and cervical spondylosis. Moreover, it has been demonstrated that ELF and TAMMEF systems are not only effective, but also safe, from clinical and experimental point of view. In fact, clinical trials did not reported any undesired side effect, while in vitro studies showed that ELF EMFs did not induce uncontrolled cell proliferation, did not affect cell viability and did not induce apoptosis. With their efficacy and safety, ELF and even more the new TAMMEF systems represent a valid complementary or alternative treatment to standard pharmacological therapies in reducing both pain and inflammation of patients affected by musculoskeletal disorders.

Three-dimensional rotational angiography for craniotomy planning and postintervention evaluation of intracranial aneurysms

PURPOSE

The authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.

MATERIALS AND METHODS

A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.

RESULTS

Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.

CONCLUSIONS

3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.

Nanotechnology and vascular neurosurgery: an in vivo experimental study on microvessels repair using laser photoactivation of a nanostructured hyaluronan solder

Sealing tissues by laser in neurosurgical procedures may overcome problems related to the use of conventional suturing methods which can be associated with various degrees of vascular wall damage. Despite the significant experimental and clinical achievements of the past, a standardized clinical application of laser-welding technology has not yet been implemented. The main problem is related to the use of common organic chromophores. A substantial breakthrough in the laser welding of biological tissues may come from the advent of nanotechnologies. In this paper we describe an experimental study, to confirm the feasibility of an innovative laser-assisted vascular repair (LAVR) technique based on diode laser irradiation and subsequent photoactivation of a hyaluronan solder embedded with near infrared (NIR) absorbing gold nanorods (GNRs), and to analyze the induced closuring effect in a follow-up study performed in animal model. Twenty New Zealand rabbits underwent closure of a 3-mm longitudinal incision performed on the common carotid artery (CCA) by means of 810 nm diode laser irradiation, in conjunction with the topical application of an optimized GNR composite. Effective closure of the arterial wound was accomplished by using very low laser intensity (30 W/cm2). The average CCA occlusion time was as low as 50 sec. Animals underwent different follow-up periods (2, 8, 30 days). After follow-up, they were re-anesthetized, the patency of the treated vessels was tested (Doppler analysis) and then the irradiated vessels were excised and subjected to histological evaluations. Morphological examinations of the samples documented the integrity of the vascular wall. No host reaction to nanoparticles occurred. Collagen and elastic fibers returned to their normal architecture 30 days after treatment. A Scanning Electron Microscopy (SEM) examination and immuno-histochemical analysis demonstrated a full re-endothelization of the vessel walls. We thus confirmed that a laser-based approach is technically easy to perform, and provides several advantages, such as a simplification of the surgical procedure, a reduction in the operative time, and the suppression of bleeding. The use of GNRs improves the selectivity of welding and minimizes the surgical trauma to vessels, resulting in an optimal healing process.

Demographic and behavioural profiles of patients with common oral mucosal lesions by a homogeneity analysis

OBJECTIVE

The aim of this study is to assess the main oral mucosal lesions (OMLs) within a hospital base and to provide an anamnestic, diagnostic model based on homogeneity analysis of some variables.

METHODS

The demographic and behavioural data (i.e. gender, age, smoking status, alcohol consumption and therapeutic drug usage) of 1753 patients with at least one OML were considered. Multiple correspondence analysis (MCA) and multivariate tests of the simultaneous marginal homogeneity hypothesis (SMH) were used to analyse the evidence of any differences between the demographic and behavioural profiles relating to OMLs diagnoses. Statistical significance of P < 0.05 was chosen.

RESULTS

With respect to the model used, patients affected by oral squamous cell carcinoma (n = 65; 3.5%) and oral leukoplakia (n = 73; 4.0%) differed significantly for demographic and behavioural characteristics analyzed, in particular with respect to gender (63.9%vs 50.1% males) and alcohol consumption (29.1%vs 12.1%). Patients affected by burning mouth syndrome (n = 134; 7.3%) and bisphosphonate-related osteonecrosis of the jaw (n = 40; 2.2%) differed significantly for chronic use of drugs (45.7%vs 71.6%). Finally, patients with halitosis (n = 60; 3.3%) and recurrent aphthous stomatitis (n = 103; 5.6%) showed similar profile, mainly in terms of men (47.6%), drinker (4.8%), drug user (34.9%), ≥60 years old (20.8%) and smoker (6.4%).

CONCLUSION

Knowledge of some similarities in patients' profile could help in positing the likely presence of OML when making diagnosis process by either general physicians or dentists, especially those without extensive experience in the field of oral medicine.

[Is viscoelastic the corneal tissue?]

PURPOSE

To compare the known viscoelastic properties of soft tissues with singular published observations on the behaviour of corneal tissue.

MATERIALS AND METHODS

The behaviour of the maxwellian element, typical viscoelastic biomechanical model, is compared with that of various previously studied soft tissues of animals. The same comparison can be made between stress-strain curves of riboflavin and UVA treated and untreated strips of human and porcine corneal tissue, stretched at constant velocity, from the literature.

RESULTS

The asymptotic stress-strain curves of the various soft tissues previously examined could be faithfully simulated by the Maxwell viscoelastic element. The exponential stress-strain curves of samples of corneal tissue were clearly different.

CONCLUSIONS

The observed divergence demonstrates incompatibility between the alleged behaviour of corneal tissue and the viscoelastic properties attributed to it. Thus there are two possibilities: either corneal tissue is viscoelastic and the experiment showing exponential behaviour suffers from some technical problem, or the data is correct and corneal tissue is not viscoelastic. In either case further research is necessary for correct interpretation of the mechanism of cross-linking and for consequent therapeutic choices.

In vitro exposure of human osteoarthritic chondrocytes to ELF fields and new therapeutic application of musically modulated electromagnetic fields: biological evidence

Osteoarthritis (OA) is the most frequently occurring rheumatic disease, caused by metabolic changes in chondrocytes, the cells that maintain cartilage. Treatment with electromagnetic fields (MF) produces benefits in patients affected by this pathology. Isolated human osteoarthritic (OA) chondrocytes were cultured in vitro under standard conditions or stimulated with IL-1beta or IGF-1, to mimic the imbalance between chondroformation and chondroresorption processes observed in OA cartilage in vivo. The cells were exposed for a specific time to extremely low frequency (ELF; 100-Hz) electromagnetic fields and to the Therapeutic Application of Musically Modulated Electromagnetic Fields (TAMMEF), which are characterized by variable frequencies, intensities, and waveforms. Using flow cytometry, we tested the effects of the different types of exposure on chondrocyte metabolism. The exposure of the cells to both systems enhances cell proliferation, does not generate reactive oxygen species, does not cause glutathione depletion or changes in mitochondrial transmembrane potential and does not induce apoptosis. This study presents scientific support to the fact that MF could influence OA chondrocytes from different points of view (viability, ROS production and apoptosis). We can conclude that both ELF and TAMMEF systems could be recommended for OA therapy and represent a valid non-pharmacological approach to the treatment of this pathology.

Motor features and response to oral levodopa in patients with Parkinson's disease under continuous dopaminergic infusion or deep brain stimulation

BACKGROUND

Subthalamic nucleus deep brain stimulation (STN DBS) and continuous dopaminergic infusions (jejunal levodopa or subcutaneous apomorphine) are indicated in complicated Parkinson's disease (PD), although it remains unsettled how they compare to each other.

METHODS

We investigated the daytime motor condition in patients with advanced PD under monotherapy with jejunal levodopa, subcutaneous apomorphine, or STN DBS and also measured the motor changes produced by an additional standard morning dose of levodopa. Motor performance was assessed with the UPDRS-III, hand taps, the AIMS dyskinesia score and patients' diaries. Outcome measures were time to best motor 'on' after start of morning treatment, daytime variability of motor condition, motor scores.

RESULTS

The time to 'on' was longest in the jejunal levodopa group. DBS and jejunal levodopa treatments produced stable motor conditions without appreciable 'off' episodes. Continuous apomorphine infusion was associated with the worst motor scores (UPDRS-III and taps) and the most frequent off-states. Jejunal levodopa infusion was associated with the highest AIMS scores. Addition of a levodopa dose produced shortening of time to 'on' and a transient motor improvement in the jejunal levodopa group without increase in dyskinesias; in the DBS and apomorphine groups, there was an increase in dyskinesias without changes in UPDRS-III or taps.

CONCLUSIONS

STN DBS provided adequate trade-off between motor improvement and dyskinesia control, although dyskinesias could be elicited by adding oral levodopa. Jejunal levodopa infusion produced adequate motor improvement with slow time to 'on' and moderate dyskinesias. Apomorphine infusion produced insufficient motor control and negligible dyskinesias.