Adverse Effects and Surgical Complications in Pediatric Patients Undergoing Vagal Nerve Stimulation for Drug-Resistant Epilepsy

Vagal nerve stimulation (VNS) is an effective treatment for drug-resistant epilepsy that is not suitable for resective surgery, both in adults and in children. Few reports describe the adverse effects and complications of VNS. The aim of our study was to present a series of 33 pediatric patients who underwent VNS for drug-resistant epilepsy and to discuss the adverse effects and complications through a review of the literature.The adverse effects of VNS are usually transient and are dependent on stimulation of the vagus and its efferent fibers; surgical complications of the procedure may be challenging and patients sometimes require further surgery; generally these complications affect VNS efficacy; in addition, hardware complications also have to be taken into account.In our experience and according to the literature, adverse effects and surgical and hardware complications are uncommon and can usually be managed definitely. Careful selection of patients, particularly from a respiratory and cardiac point of view, has to be done before surgery to limit the incidence of some adverse effects.

Venous outflow as a criterion of impairment of cerebral vascular reserve

AIM

The purpose of this work is to evaluate if the asymmetry of venous outflow between the two hemispheres is a reliable criterion of impairment of the cerebral vascular reserve among symptomatic patients harbouring a spontaneous atherosclerotic occlusion of internal carotid artery.

METHODS

From January 1995 to December 2007, 7 symptomatic patients, affected from occlusion of internal carotid artery, were submitted to a low-flow by-pass between the superficial temporal artery and the middle cerebral artery owing to the presence of an impairment of cerebral vascular reserve diagnosed by TC-Doppler, SPECT or perfusion-CT with acetazolamide challenge. Conventional angiography was always performed. Angiographic studies of these patients were reviewed in order to find out the presence of asymmetry of the venous outflow. In the same period 35 patients harbouring an occlusion of the carotid artery in the neck and a normal cerebral reserve underwent cerebral angiography in our departments in Monza. Angiographic studies, of this latter group of patients, were also retrospectively analyzed with the same purpose.

RESULTS

All patients, with a poor cerebral reserve, showed an asymmetry of venous outflow >3 s omolateral at the carotid occlusion. Patients, with a normal cerebral reserve, showed an asymmetry of venous outflow <2 s.

CONCLUSIONS

Asymmetry of venous outflow were correlated to an impaired cerebral reserve also in chronic conditions as atherosclerotic spontaneous occlusion of internal carotid artery. Our data are a further support to the reliability of this criterion in case of therapeutic sacrifice of internal carotid artery.

Effects of low- or high-dose hormone therapy on fasting and post-methionine homocysteine levels in postmenopausal women

OBJECTIVE

To evaluate the effect of two different hormone therapy (HT) doses on fasting and post-methionine homocysteine levels, an independent risk factor for cardiovascular and thromboembolic diseases.

METHODS

Forty-eight women in natural postmenopause randomly received calcium 1 mg/day (control group; n = 12) or calcium plus low dose (1 mg estradiol plus 0.5 mg norethisterone; n = 18) or high dose (2 mg estradiol plus 1 mg norethisterone; n = 18) HT in a 6-month randomized, controlled, prospective study.

RESULTS

Folate levels did not vary in any group, while levels of vitamin B12 significantly decreased after low- (-12.2 +/- 6.6%; p < 0.04) or high-dose HT (-13.9 +/- 6.1%; p < 0.01). Fasting homocysteine was reduced by either HT dose in a way that was inversely related to pretreatment homocysteine levels (-0.675x; r = 0.644; p < 0.0001). Modification of post-load homocysteine increase was influenced by the HT dose and inversely related to the homocysteine response to methionine observed at baseline. The regression slope observed with the low-dose HT (-1.637x; r = 0.57; p < 0.02) was significantly steeper (p < 0.001) than that observed with the high-dose HT (-0.304x; r = 0.554; p < 0.03) dose.

CONCLUSIONS

Low- or high-dose HT similarly influences fasting homocysteine levels. Low-dose HT seems to be more effective than high-dose HT in reducing the post-methionine homocysteine increase.

Early outcome of myomectomy by laparotomy, minilaparotomy and laparoscopically assisted minilaparotomy. A randomized prospective study

BACKGROUND

To compare in the first 7 days after surgery the outcome of myomectomy performed by three laparotomic approaches: laparotomy (LT), minilaparotomy (MLT) and laparoscopically assisted minilaparotomy (LA-MLT).

METHODS

Fifty-one women with 5-15 cm total myoma diameter were randomized blindly using a computer randomization list, to LT (n = 17), MLT (n = 17) or LA-MLT (n = 17).

RESULTS

Mean operation length was similar in the three groups. Mean (+/- SEM) time of paralytic ileus (55.0 +/- 4.5 versus 33.4 +/- 3.4 h; P < 0.01) and discharge (141.6 +/- 5.2 versus 81.5 +/- 8.2 h; P < 0.01) was longer in LT than LA-MLT or even MLT. In comparison with LA-MLT, LT induced a greater haemoglobin decline (-3.07 +/- 0.3 versus -1.8 +/- 0.15 mg/dl; P < 0.025), and a greater post-operative stress, as documented by increased prolactin (+15.1 +/- 3.8 versus +0.16 +/- 4.5 ng/ml; P < 0.03) and decreased insulin sensitivity (fasting glucose/insulin; -7.5 +/- 2.6 versus -0.7 +/- 2.1; P < 0.02). Seven days after surgery, abdominal pain (P < 0.05) was higher after LT (3.0 +/- 0.6) than MLT (0.5 +/- 0.2) and LA-MLT (0.9 +/- 0.4).

CONCLUSIONS

In selected cases, myomectomy by LA-MLT offers some advantages versus LT and, to a smaller extent, MLT.

Synthesis of a 11-deoxyprostanoid in the area of preclavulones: (+-)-8,12-trans-(5Z-14Z)-9-oxo-prosta-5,14-dienoic acid from 2-allyl-2-cyclopenten-1-one

Following our research on the arachidonic acid metabolites and their derivatives with potential biological activity, we describe the synthesis of the (+-)-8,12-trans-(5Z, 14Z)-9-oxo-prosta-5,14-dienoic acid, a 11-deoxyprostanoid correlated to the class of Preclavulones, one of the unusual families of marine eicosanoids from the coral Clavularia Viridis with considerable biological interest.

A route to the total synthesis of iso-LTB4 system

The convergent synthesis of the iso-Leukotriene B4 (XVI) (as diastereoisomeric mixture with the desired geometry), by Wittig's condensation of the two precursor synthons at 6 (VI) and 14 C (XIV), starting from the common cyclic acrylaldehyde dimer (I), is reported.

Synthesis of (+/-) 8,12-trans-delta5-en-cis-9-keto-13,14-en-trans-15-R,S-hydroxyprostanoic acid methyl ester

The synthesis of the title compound (X) is easily achieved by suitable transformations of the lateral chains of the 1-ethylenedioxy-2-allyl--trans-3-cyclopentane acetic acid (II).

[Synthesis of n-hexanoylmethylene triphenylphosphorane]

An efficient synthesis of n.hexanoylmethylenetriphenylphosphorane (II), a fundamental intermediate for obtaining prostanoic products, is described. The crucial intermediate in the synthesis is the 2-keto-n.heptyltriphenylphosphonium chloride (VII), which is prepared via a very precise procedure.

[Synthesis of n-pentanoylmethylenetriphenylphosphorane]

An efficient synthesis of n.pentanoylmethylenetriphenylphosphorane (II), useful intermediate for achievement of prostanoic derivatives, is described. The procedure affords the desired product at a remarkable degree of purity.

The synthesis of (+/-)-1-ethylenedioxy-trans-2-(beta-R,S-hydroxypropyl)-3-(beta-acetoxyethyl)cyclopentane

The synthesis of (+/-)-1-ethylenedioxy-trans-2-(beta-R,S-hydroxypropyl)-3-(beta-acetoxyethyl)cyclopentane (IV), starting from (+/-)-1-ethylenedioxy-trans-2-propargyl-3-(beta-hydroxyethyl)cyclopentane (I) by indirect hydration with mercuric acetate and hydrogen sulphide, is reported.

Synthesis of (+/-)-8,12-trans-delta5-en-cis-9-KETO-14,15-en-trans-16-R,S-hydroxyprostanoic acid methyl ester

A new synthesis of (+/-)-8,12-trans-delta5-en-cis-9-keto-14,15-en-trans-16-R,S-hydroxyprostanoic acid methyl ester (VII) from 2-allyl-2-cyclopentenone (I) is described, for which a lateral chain link process, opposite to that previously reported (4), is adopted.

Synthesis of (+/-)-8,12-trans-delta5-en-cis-11-KETO-14,15-trans-en-16-R,S-hydroxyprostanoic acid methyl ester

The synthesis of (+/-)-8,12-trans-delta5-en-cis-11-keto-14,15-trans-en-16-R,S-hydroxyprostanoic acid methyl ester (XIII) from 2-allyl-2-cyclopentenone (I) is described. The key products are the conjugate enone (IX) or the acetylenic secondary alcohol (X) derived from 2-propargyl-2-cyclopentenone (II).

[Synthesis of long chain alkyne and alkene ketoalcohols and their derivatives]

A description is given of the synthesis of the acetylenic alcohol with 16 carbon atoms (V) starting from 6-ethylendioxy-4,4-dimethyl-2-heptyne (III) and valeraldehyde followed by reduction with Raney-nickel and lithium in liquid ammonia.

An easy synthesis of ((+/-)-8,12-trans-delta5-en-cis-11-keto-14,15-yn-16-R,S-hdroxyprostanoic acid methyl ester

A convenient synthesis of (+/-)-8,12-trans-delta5-en-cis-11-keto-14,15-yn-16-R, S-hydroxyprostanoic acid methyl ester (XI) starting from 2-propargyl-2-cyclopentenone (I) is described.