Acquired bilateral facial palsy: a systematic review on aetiologies and management

OBJECTIVE

To systematically review the published cases of bilateral facial palsy (BFP) to gather evidence on the clinical assessment and management of this pathology.

METHODS

Following PRISMA statement recommendations, 338 abstracts were screened independently by two authors. Inclusion criteria were research articles of human patients affected by BFP, either central or peripheral; English, Italian, French or Spanish language; availability of the abstract, while exclusion criteria were topics unrelated to FP, and mention of unilateral or congenital FP. Only full-text articles reporting the diagnostic work-up, the management, and the prognosis of the BFP considered for further specific data analysis.

RESULTS

A total of 143 articles were included, resulting a total of 326 patients with a mean age of 36 years. The most common type of the paralysis was peripheral (91.7%), and the autoimmune disease was the most frequent aetiology (31.3%). The mean time of onset after first symptoms was 12 days and most patients presented with a grade higher than III. Associated symptoms in idiopathic BFP were mostly non-specific. The most frequently positive laboratory exams were cerebrospinal fluid analysis, autoimmune screening and peripheral blood smear, and the most performed imaging was MRI. Most patients (74%) underwent exclusive medical treatment, while a minority were selected for a surgical or combined approach. Finally, in more than half of cases a complete bilateral recovery (60.3%) was achieved.

CONCLUSIONS

BFP is a disabling condition. If a correct diagnosis is formulated, possibilities to recover are elevated and directly correlated to the administration of an adequate treatment.

Overcoming Challenges in Chemical Glycosylation to Achieve Innovative Vaccine Adjuvants Possessing Enhanced TLR4 Activity

Lipopolysaccharide (LPS) mimicry leading to toll-like receptor 4 (TLR4) active compounds has been so far based mainly on reproducing the lipid A portion of LPS. Our work led to a series of structurally simplified synthetic TLR4 agonists in preclinical development as vaccine adjuvants called FPs. FPs bind MD2/TLR4 similarly to lipid A, inserting the lipid chains in the MD2 lipophilic cavity. A strategy to improve FPs' target affinity is introducing a monosaccharide unit in C6, mimicking the first sugar of the LPS core. We therefore designed a panel of FP derivatives bearing different monosaccharides in C6. We report here the synthesis and optimization of FPs' C6 glycosylation, which presented unique challenges and limitations. The biological activity of glycosylated FP compounds was preliminarily assessed in vitro in HEK-Blue cells. The new molecules showed a higher potency in stimulating TLR4 activation when compared to the parent molecule while maintaining TLR4 selectivity.

Clear cell sarcoma-like/malignant gastrointestinal neuroectodermal tumor of the tongue: a clinicopathologic and molecular case report

Malignant gastrointestinal neuroectodermal tumor (M-GNET) and clear cell sarcoma (CCS) of soft tissue represent closely related, extremely rare, malignant mesenchymal neoplasm of uncertain differentiation. Both entities are characterized genetically by the same molecular alterations represented by the presence of EWSR1-ATF1 and, more rarely, EWSR1-CREB1 fusion genes. The latter translocation seems to be more represented in M-GNET that, despite significant morphologic overlap with CCS, tends to lack overt features of melanocytic differentiation. Most M-GNET occur in the lower gastrointestinal tract, whereas occurrence in the upper tract has been reported only exceptionally. The differential diagnosis represents a major challenge, and accurate diagnosis impact significantly on therapeutic planning. We herein report the clinicopathologic features of a molecularly confirmed M-GNET that arose at the base of the tongue and review the pertinent literature.

P2599Echo color doppler evaluation of renal hemodynamic during acute heart failure

Background

Acute heart failure (AHF) is often accompanied by impairment in renal function. A profound derangement of normal abdominal haemodynamic is always present during this clinical phase.

Methods

14 patients (6 F – mean age 80 – mean EF 0.39) admitted for acute heart failure underwent cardiac and renal Echo Doppler examination at day 1-3-5 of Hospital stay. Parameters of arterial and venous flow within cortical right kidney were recorded. Venous Doppler Profile (VDP) was classified as: continuous (C), pulsatile (P), biphasic (B) or monophasic (M) according to the growing degree of derangement. Arterial resistive index (RI) >0.8 was considered elevated. Correlation between renal hemodynamic (and its changes) with biohumoral and echo parameters was sought.

Outcome

At day 1 VDP was M or B in 8 patients (57%) and in four (50%) of them dropped to C or P at day 5. RI was elevated in 8 patients at day 1 while only in 4 at day 5. VDP and RI were not related to EF or BNP values. One patient died before day 5, no other worsening heart failure episodes occurred. Two patients (14%) developed acute kidney injury but their VDP and RI were normal and did not change. Three patients (21%) did not improve their BNP (decrease >30%) but this was not associated with VDP or RI changes. Elevated derived pulmonary artery systolic pressure (>40 mmHg) was present in 6 out of 8 patients (75%) with M or B VDP and in all 4 patients with both elevated RI and M or B VDP.

Venous Pattern Day 1 Day 3 Day 5 Continous 2 8 5 Pulsatile 4 2 4 Biphasic 2 1 2 Monophasic 6 3 2 Arterial RI >0.8 8 6 4 BNP, pg/ml 1060±1180* 372±281* 424±213* Creatinine, mg/dl 1.4±0.6 1.5±0.6 1.3±0.6 Hb, g/dl 12.1±2.3 12.3±3.6 13.2±2.3 *p>0.05.

Conclusions

This is the first study exploring changes in renal hemodynamic by echo Doppler during AHF. With respect to previous studies among stable patients, our preliminary data shows a higher proportion of deranged renal venous and/or arterial pattern. After diuretic therapy a trend towards improvement in VDP was recorded. No clear association with other clinical and hemodynamic parameters seems evident.

Interactions between commonly used left and right ventricular function indexes in stable patients

AIM

Aim of this study was to better understand interactions between left ventricular (LV) and right ventricular (RV) systolic and diastolic function echocardiographic indexes in stable cardiovascular diseased patients and in subjects with cardiovascular risk factors.

METHODS

The study enrolled 683 stable patients who were submitted to standard transthoracic echocardiography with evaluation of left ventricular ejection fraction (LVEF) (Simpson biplane method), LV and RV systolic peak on Doppler tissue imaging (LVSys and RVSys), tricuspid annulus plane systolic excursion (TAPSE), pulmonary artery systolic pressure (PASP), and multiparameter evaluation of LV and RV diastolic function utilizing E and A peak, their ratio, E peak deceleration time, E' and A' peak on Doppler tissue imaging, their ratio, and E/E' ratio.

RESULTS

Part of the considered indexes had interactions but only LVEF and TAPSE were related to all the others (LVEF P<0.001 with all the considered parameters; TAPSE P<0.001 with all parameters except with PASP=0.003). Unexpectedly TAPSE seems to have, such as LVEF, a pivotal position among LV and RV function.

CONCLUSION

The study demonstrates the existence of interactions between LV and RV function indexes; these results may be considered as a piece of evidence in favor of heart seen as a single structure.

Trichodina nobilis Chen, 1963 and Trichodina reticulata Hirschmann et Partsch, 1955 from ornamental freshwater fishes in Brazil

In the present work Trichodina reticulata and T. nobilis (Ciliophora: Trichodinidae) are morphologically characterised from ornamental freshwater fish culture in the State of Santa Catarina, Brazil. The prevalence of infection and a list of comparative measurements are discussed. We examined "southern platyfish" Xiphophorus maculatus (n = 35), "goldfish" Carassius auratus (n = 31), "guppy" Poecilia reticulata (n = 20), "sailfin molly" Poecilia latipinna (n = 6), "beta" Betta splendens (n = 2) and "spotted headstander" Chilodus punctatus (n = 1). After being anesthetised in a benzocaine solution, fishes were examined for parasitological evaluation. A total of 51.57% fishes were parasitised by Trichodina spp. Carassius auratus was the most parasitised species, followed by X. maculatus and P. reticulata. Beta splendens, C. punctatus and P. latipinna were not parasitised by any trichodinid species. Two species of Trichodina were collected from the skin of fish: T. nobilis was found in C. auratus, P. reticulata and X. maculatus and T. reticulata was only observed in C. auratus. The importance of adequate handling in ornamental fish culture are also discussed.

Ranitidine bismuth citrate plus clarithromycin 7-day regimen is effective in eradicating Helicobacter pylori in patients with duodenal ulcer

BACKGROUND

No clinical study has been performed to-date to evaluate the efficacy of the dual therapy of ranitidine bismuth citrate (RBC) plus clarithromycin (C) 500 mg b.d. given for 7 days for the eradication of H. pylori.

AIM

To assess the eradication rates achieved by treatment with RBC 400 mg b.d. for 28 days combined with clarithromycin 500 mg b.d. for 7 days in H. pylori-positive duodenal ulcer patients.

METHODS

One hundred and twelve H. pylori-positive patients with endoscopically proven active duodenal ulcer were included in a multicentre, open, randomized trial. H. pylori infection was initially detected by CLO-test and histology on antral and corpus biopsies, and by 13C-urea breath test (UBT). Patients were included if at least two of the tests were positive for H. pylori infection. Patients were randomized to receive RBC 400 mg b.d. for 4 weeks combined with clarithromycin 500 mg b.d. for the first 7 days (Group A) or 14 days (Group B). A second endoscopy was performed at least 28 days after the end of therapy for the assessment of ulcer healing and H. pylori infection. Eradication was assumed if all the tests (CLO-test, histology and UBT) were negative for H. pylori.

RESULTS

Fifty patients in Group A and 55 in Group B were assessed for H. pylori eradication and ulcer healing. The eradication rates according to intention-to-treat analysis were 75% in Group A and 80% in Group B. Considering only those patients with evaluable data at least 28 days after the end of therapy, H. pylori eradication was achieved in 84% and 82% in Group A and B, respectively. No statistically significant difference in eradication was found between the two groups by Mantel-Haenszel test. Only one patient, in Group A, was withdrawn because of adverse events (epigastric pain and pruritus).

[The oral strontium load test in the assessment of intestinal calcium absorption]

A close correlation between calcium and strontium intestinal absorption has been described. In this study, a test using Stable Strontium has been assessed in women without abnormal calcium or bone metabolism, with no history of drugs which might affect calcium or bone metabolism. Decreasing values of Strontium intestinal absorption, according to the length of the postmenopausal period, have been observed. Besides, the Stable Strontium Test has been given in postmenopausal women with osteoporotic femur fractures. In comparison with age matched healthy women, this latter group showed a significantly lower Strontium intestinal absorption. Analogous behaviour has been reported for Calcium intestinal absorption.

Heparin prevents stasis-induced thrombosis through protection of the venous endothelial cells: an electron microscopic study in rabbits

This study was performed to see whether or not protection of the endothelial cells contributes to the antithrombotic effects of heparin. New Zealand albino rabbits were subjected to jugular vein stasis by single caudal ligation for 2 h. Three treatments were given: saline (control group), heparin (0.2 mg/kg) 5 or 45 min before ligature of the vein. Groups of 6-8 animals were killed at 0, 5, 15, 30 and 120 min. The following parameters were determined: (1) involution and damage of the endothelial cells by scanning and transmission electron microscopy; (2) incidence and weight of thrombi in the lumens of the veins after 2 h stasis, and (3) effects of heparin on APTT and anti-Xa activity. In the control group, stasis caused a considerable involution of the endothelial cells in the first 30 min, followed by fibrin deposition and thrombus generation. Heparin strongly reduced the damage to the endothelial cells, with very evident protection of the cell membranes, and prevented thrombus generation: there were significant decreases in both incidence and weight of thrombi. These effects of heparin were evident both shortly after (maximal anticoagulant effect) and long after (no anticoagulant effect) pretreatment. We think that, under the experimental conditions we used, heparin prevented venous thrombosis at least partially by protection of the endothelial cells, through unknown mechanisms.

Lactose malabsorption in adult patients with Crohn's disease

In order to evaluate, in adult patients with Crohn's disease (CD), the prevalence of lactose malabsorption and intolerance, and the percentage who can tolerate a physiologic amount of milk in their diet, we tested 37 patients with CD (19 with intestinal resection, and 18 without) and 67 healthy controls (C) with the H2-breath test after they had ingested increasing loads of lactose as 10% solution (12.5 g, 25 g, and 50 g). Patients with malabsorption after the 12.5-g dose were tested further with 250 ml of milk. In the total group of patients and in the subgroup of those with resection, the prevalence of malabsorption was higher than in controls at all lactose loads; in patients who had not undergone resection, no significant difference was observed with the 12.5-g dose. Eleven of 18 patients who were malabsorbers with the 12.5-g dose had malabsorption also with 250 ml milk; however, only three of them (8% of the total group) experienced symptoms of intolerance. We conclude that, in adult patients with CD, 1) the prevalence of lactose malabsorption is increased, 2) in patients who have undergone intestinal resection, malabsorption occurs at a lower dose of the sugar than in patients who did not, and 3) since only 8% of patients experienced symptoms of intolerance after the ingestion of milk 250 ml, this amount can be empirically inserted in the daily diet of an adult with CD.

Efficacy of addition of exogenous lactase to milk in adult lactase deficiency

The efficacy of lactase by Kluyveromyces lactis in hydrolyzing milk lactose and reducing milk intolerance symptoms was tested in 52 proved lactose malabsorbers. The enzyme was added to milk administered to the patients, and H2 breath excretion (as an index of carbohydrate malabsorption), was determined by gas chromatograph technique, and milk intolerance symptoms were recorded. H2 mean excretion was 78.3 +/- 5.49 ppm after administration of intact whole milk 500 ml (test A), 43.5 +/- 4.99 ppm when lactase 2000 U was added to milk 500 ml immediately before administration (test B); 36.7 +/- 5.01 ppm when milk 500 ml was incubated for 12 h with lactase 1000 U (test C), and 29.7 +/- 4.35 ppm when the incubation was prolonged for 24 h (test D). Symptoms score was: test A = 5.85 +/- 0.56, test B = 3.71 +/- 0.45, test C = 2.77 +/- 0.63, test D = 1.7 +/- 0.68. A correlation index of r = 0.44 (p less than 0.01) was obtained between reduction in H2 mean excretion and reduction in symptoms score of a single individual. The addition of this lactase to milk seems to be effective in correcting lactose malabsorption, thus representing a convenient approach in milk intolerance.

Effect of chemically defined formula diets on pancreatic mass in the rat

To establish the effect of chemically defined formula diets on pancreatic mass, 58 male Wistar rats, weighing approximately 200 g, were fed orally one of the following diets for 20 days: standard diet; partially hydrolyzed diet; elemental diet. The diets were isocaloric and provided 73 cal/day per rat. At the end of the experiment, the rats were killed and pancreas removed to assess wet weight and DNA and RNA content. Compared to the controls, the elemental diet caused a reduction in pancreatic wet weight (p less than 0.005), pancreatic DNA (p less than 0.001), and RNA content (p less than 0.001). In the group fed partially hydrolyzed diet, only pancreatic DNA content showed an highly significant reduction when compared with the reference group (p less than 0.001), whereas the value of RNA failed to reach the statistical significance. We found an increase of the ratio mg RNA/mg DNA in the partially hydrolyzed and elemental diet groups. These results suggest that long-term nutrition with the partially hydrolyzed diet, and more strongly with the elemental diet, may induce pancreatic hypoplasia.

A single-specimen fecal chymotrypsin test in the diagnosis of pancreatic insufficiency: correlation with secretin-cholecystokinin and NBT-PABA tests

An investigation of fecal chymotrypsin activity on spot fecal specimens was carried out in three groups of subjects, divided as follows: 45 healthy controls (group C); 36 patients with gastroenterological diseases of extrapancreatic origin (group VP); and 42 patients with chronic pancreatitis (group CP). Nineteen patients of group CP underwent pancreozymin-secretin and NBT-PABA tests. The following results, expressed as mg of chymotrypsin/g of feces, were obtained: C = 0.610 +/- 0.203; CP = 0.291 +/- 0.154, p less than 0.001; VP = 0.560 +/- 0.234. FCT showed a sensitivity rate of 78.5% and a specificity rate of 71.6%. The fecal output of chymotrypsin correlated well with the pancreatic secretion of chymotrypsin (r = 0.59, p less than 0.01) and with the percentage of recovery of urinary PABA (r = 0.44, p less than 0.05). We conclude that chymotrypsin assay by the described method on spot stool specimens is a simple, reliable technique which may be considered a good screening test for pancreatic insufficiency. The test will not detect minimal pancreatic disease or minimal pancreatic dysfunction.

Intestinal morphological changes during oral refeeding in a patient previously treated with total parenteral nutrition for small bowel resection

This report describes a patient who, after a subtotal resection of small intestine for an embolic obstruction of the superior mesenteric artery, was maintained on total parenteral nutrition for 30 days and then refed. Cytoproliferative analysis of the intestinal mucosa, evaluated by peroral biopsies performed on days 1, 5, 14 and 30 after oral refeeding, demonstrated an increase in cell proliferation from 1 to 14 days after refeeding, followed by a return to starting values after 30 days. On days 1 and 5, we saw an intestinal hypoplasia that became a hyperplasia after 14 days of oral refeeding. Our data confirm the importance of oral nutrition for the small intestinal response after resection.