Nerve ultrasound in Friedreich's Ataxia: enlarged nerves as a biomarker of disease severity

OBJECTIVE

In Friedreich's ataxia research, the focus is on discovering treatments and biomarkers to assess disease severity and treatment effects. Our study examines high-resolution nerve ultrasound in these patients, seeking correlations with established clinical markers of disease severity.

METHOD

Ten patients with Friedreich's Ataxia underwent a comprehensive clinical assessment with established scales (SARA, FARS, mFARS, INCAT, ADL 0-36, IADL). Additionally, they underwent nerve conduction studies and high-resolution nerve ultrasound. Quantitative evaluation of nerve cross-sectional area, conducted at 24 nerve sites using high-resolution nerve ultrasound, was compared with data obtained from 20 healthy volunteers.

RESULTS

All the patients had a severe sensory axonal neuropathy. High-resolution nerve ultrasound showed significant increase, in cross sectional area, of median and ulnar nerves at the axilla and arm. The cumulative count of affected nerve sites was directly associated with clinical disability, as determined by SARA, FARS, mFARS, ADL 0-36, and INCAT score, while displaying an inverse correlation with IADL.

CONCLUSIONS

Our study shows that high-resolution ultrasound reveals notable nerve abnormalities, primarily in the upper limbs of patients diagnosed with Friedreich's Ataxia. The observed correlation between these nerve abnormalities and clinical disability scales indicates the potential use of this technique as a biomarker for evaluating disease severity and treatment effects.

SIGNIFICANCE

Nerve Ultrasound is a potential biomarker of disease severity in Friedreich's Ataxia.

Predicting value for incomplete recovery in Bell's palsy of facial nerve ultrasound versus nerve conduction study

OBJECTIVE

This longitudinal study aims at assessing the predictive value of facial nerve high-resolution ultrasound (HRUS) for incomplete clinical recovery in patients with Bell's palsy, the most common facial nerve disease.

METHODS

We prospectively enrolled 34 consecutive patients with Bell's palsy. All patients underwent neurophysiological testing (including facial nerve conduction study) and HRUS evaluations 10-15 days (T1), one month (T2), and three months (T3) after the onset of Bell's palsy. Patients who did not experience complete recovery within three months were also evaluated after six months (T4). We have then compared the accuracy of HRUS with that of the facial nerve conduction study in predicting incomplete clinical recovery at three and six months.

RESULTS

At T1, the facial nerve diameter, as assessed with HRUS, was larger on the affected side than on the normal side, particularly in patients with incomplete recovery at T2, T3 and T4. ROC curve analysis, however, showed that the facial nerve diameter at T1 had a lower predictive value than the facial nerve conduction study for an incomplete clinical recovery at three (T3) and six (T4) months. Still, the facial nerve diameter asymmetry, as assessed with HRUS, had a relatively high negative predictive value (thus indicating a strong association between normal HRUS examination and a good prognosis).

CONCLUSIONS

Although HRUS shows abnormally increased facial nerve diameter in patients in the acute phase of Bell's palsy, the predictive value of this technique for incomplete clinical recovery at three and six months is lower than that of the nerve conduction study.

SIGNIFICANCE

Nerve ultrasound has a low predictive value for incomplete clinical recovery in patients with Bell's Palsy.

Modulation of the spinal N13 SEP component by high- and low-frequency electrical stimulation. Experimental pain models matter

OBJECTIVE

The N13 component of somatosensory evoked potential (N13 SEP) represents the segmental response of cervical dorsal horn neurons. Neurophysiological studies in healthy participants showed that capsaicin-induced central sensitization causes an increase of the N13 SEP amplitude. Consequently, in human research, this spinal component may serve as a valuable readout of central sensitization. In this study, we wanted to verify if the sensitivity of the N13 SEP for detecting central sensitization is consistent across different experimental pain models inducing central sensitization and secondary hyperalgesia, namely high and low-frequency electrical stimulation (HFS and LFS).

METHODS

In 18 healthy participants, we recorded SEP after bilateral ulnar nerve stimulation before and after secondary hyperalgesia was induced through HFS and LFS applied on the ulnar nerve territory of the hand of one side. The area of secondary hyperalgesia was mapped with a calibrated 128-mN pinprick probe, and the mechanical pain sensitivity with three calibrated 16-64-256-mN pinprick probes.

RESULTS

Although both HFS and LFS successfully induced secondary hyperalgesia only LFS increased the amplitude of the N13 SEP.

CONCLUSIONS

These findings suggest that the sensitivity of the N13 SEP for detecting dorsal horn excitability changes may critically depend on the different experimental pain models.

SIGNIFICANCE

Our results indicate that LFS and HFS could trigger central sensitization at the dorsal horn level through distinct mechanisms, however this still needs confirmation by replication studies.

The diagnostic accuracy of the Small Fiber Neuropathy Symptoms Inventory Questionnaire (SFN-SIQ) for identifying pure small fiber neuropathy

BACKGROUND AND AIMS

A definite diagnosis of pure small fiber neuropathy (SFN) relies on specific diagnostic testing, such as skin biopsy, quantitative sensory testing (QST), and nociceptive evoked potentials, which require considerable resources that may not be widely available. Accordingly, diagnostic tools with easy implementation in non-specialist centers are warranted to identify patients who require second-level diagnostic tests. In this study, we aimed to test the accuracy of the Small Fiber Neuropathy Symptoms Inventory Questionnaire (SFN-SIQ) in diagnosing pure SFN.

METHODS

We enrolled 86 patients with suspected pure SFN. In these patients, we calculated the diagnostic accuracy of the SFN-SIQ using a combination of clinical examination, quantitative sensory testing, and skin biopsy as a reference standard.

RESULTS

We found that the SFN-SIQ showed an excellent ability to discriminate between patients with and without pure SFN, with 86% sensitivity and 70% specificity in the diagnosis of pure SFN.

INTERPRETATION

Our study providing the diagnostic yield of the SFN-SIQ for pure SFN diagnosis suggests that this questionnaire might be used to screen patients with suspected SFN and identify those requiring second-level diagnostic tests such as QST, skin biopsy, or nociceptive evoked potentials. This article is protected by copyright. All rights reserved.

How different experimental models of secondary hyperalgesia change the nociceptive flexion reflex

OBJECTIVE

In this neurophysiological study in healthy humans, we assessed how central sensitization induced by either high-frequency stimulation (HFS) or topical capsaicin application modulates features of the RIII reflex response. The ability of these stimuli to engage the endogenous pain modulatory system was also tested.

METHODS

In 26 healthy participants we elicited an RIII reflex using suprathreshold stimulation of the sural nerve. Subsequently HFS or capsaicin were applied to the foot and the RIII reflex repeated after 15 minutes. Contact heating of the volar forearm served as the heterotopic test stimulus to probe activation of the endogenous pain modulatory system.

RESULTS

HFS significantly reduced the pain threshold by 29% and the RIII reflex threshold by 20%. Capsaicin significantly reduced the pain threshold by 17% and the RIII reflex threshold by 18%. Both HFS and capsaicin left RIII reflex size unaffected. Numerical Rating Scale (NRS) pain scores elicited by the heterotopic noxious heat stimulus were unaffected by capsaicin and slightly increased by HFS.

CONCLUSIONS

HFS and capsaicin similarly modulated the pain threshold and RIII reflex threshold, without a concomitant inhibitory effect of the endogenous pain modulatory system.

SIGNIFICANCE

Our neurophysiological study supports the use of the RIII reflex in investigating central sensitization in humans.

Modulation of the N13 component of the somatosensory evoked potentials in an experimental model of central sensitization in humans

The N13 component of somatosensory evoked potential (N13 SEP) represents the segmental response of dorsal horn neurons. In this neurophysiological study, we aimed to verify whether N13 SEP might reflect excitability changes of dorsal horn neurons during central sensitization. In 22 healthy participants, we investigated how central sensitization induced by application of topical capsaicin to the ulnar nerve territory of the hand dorsum modulated N13 SEP elicited by ulnar nerve stimulation. Using a double-blind placebo-controlled crossover design, we also tested whether pregabalin, an analgesic drug with proven efficacy on the dorsal horn, influenced capsaicin-induced N13 SEP modulation. Topical application of capsaicin produced an area of secondary mechanical hyperalgesia, a sign of central sensitization, and increased the N13 SEP amplitude but not the peripheral N9 nor the cortical N20-P25 amplitude. This increase in N13 SEP amplitude paralleled the mechanical hyperalgesia and persisted for 120 min. Pregabalin prevented the N13 SEP modulation associated with capsaicin-induced central sensitization, whereas capsaicin application still increased N13 SEP amplitude in the placebo treatment session. Our neurophysiological study showed that capsaicin application specifically modulates N13 SEP and that this modulation is prevented by pregabalin, thus suggesting that N13 SEP may reflect changes in dorsal horn excitability and represent a useful biomarker of central sensitization in human studies.

Biomarkers and new therapeutic targets in renal cell carcinoma

OBJECTIVE

Renal Cell Carcinoma (RCC) is the most common malignancy in adult kidneys. The American Cancer Society estimated 62,700 new cases and 14,240 deaths in 2018. Although early detection has improved in recent years, the treatment remains a challenge and reliable biomarkers for poor outcomes become necessary for the prevention of metastases and improve the quality of patients' life during and after treatment. Then, the current status of the search for new RCC biomarkers was discussed, as well as the latest discoveries in the RCC risk and metastatic treatment were discussed in this review.

MATERIALS AND METHODS

Extensive research was carried out in the online databases and full-free text articles published in the last 5 years, or more when convenient, were evaluated. Articles were included that addressed the proposed theme and were published in the English language.

RESULTS

The present state of knowledge on biomarkers for RCC carcinogenesis and progression is still much to be understood about RCC risk factors and molecular pathways resulting in metastatic progression. Newest RCC target therapies were discussed, mainly in relation to immunological therapy, and vaccines that have been tested in numerous trials with different cancer types.

CONCLUSIONS

The development of targeted therapies has revolutionized the treatment of advanced and metastatic cancers or non-responder patients. Combined therapy between classical chemotherapy and adjuvant immunotherapies has been modifying the cancer patients prognosis and bringing the hope of a cure in many cases.

Constraints on Sub-GeV Dark-Matter-Electron Scattering from the DarkSide-50 Experiment

We present new constraints on sub-GeV dark-matter particles scattering off electrons based on 6780.0 kg d of data collected with the DarkSide-50 dual-phase argon time projection chamber. This analysis uses electroluminescence signals due to ionized electrons extracted from the liquid argon target. The detector has a very high trigger probability for these signals, allowing for an analysis threshold of three extracted electrons, or approximately 0.05 keVee. We calculate the expected recoil spectra for dark matter-electron scattering in argon and, under the assumption of momentum-independent scattering, improve upon existing limits from XENON10 for dark-matter particles with masses between 30 and 100  MeV/c^{2}.

Low-Mass Dark Matter Search with the DarkSide-50 Experiment

We present the results of a search for dark matter weakly interacting massive particles (WIMPs) in the mass range below 20  GeV/c^{2} using a target of low-radioactivity argon with a 6786.0 kg d exposure. The data were obtained using the DarkSide-50 apparatus at Laboratori Nazionali del Gran Sasso. The analysis is based on the ionization signal, for which the DarkSide-50 time projection chamber is fully efficient at 0.1  keVee. The observed rate in the detector at 0.5  keVee is about 1.5  event/keVee/kg/d and is almost entirely accounted for by known background sources. We obtain a 90% C.L. exclusion limit above 1.8  GeV/c^{2} for the spin-independent cross section of dark matter WIMPs on nucleons, extending the exclusion region for dark matter below previous limits in the range 1.8-6  GeV/c^{2}.

Therapeutic Plasma Adsorption. A Review

Alternative techniques to the traditional plasma exchange are emerging in clinical practice for the treatment of different pathological conditions, particularly autoimmune diseases. Filtration is a technique used to separate blood cells from plasma, which may be further “treated” with other filters or columns. The case for cascade filtration and absorption onto a column is becoming stronger and stronger and the patient population is increasing. Alongside the “historical” techniques of adsorption onto a column, new systems (pairs of self-regenerating columns) and new products (columns with dextran sulphate, tryptophane, anti-human lipoprotein antibodies) are now available. Protein A in particular seems to open up new horizons; in therapeutic plasmapheresis, there are two versions, one Swedish and the other American, based on different theoretical premises and obtaining different results, with different biocompatibilities but good clinical results.

Plasma Exchange in Systemic Lupus Erythematosus. Experience in Thirty-seven Patients

Thirty-seven (37) SLE patients submitted to therapeutic plasmapheresis were examined. The results were good in the active stage of the disease. Various types of antibody, anti-DNA, anti nucleus, anti-cardiolipine, I.C. (Clq and C3d) were removed. The values of IgG, coagulation factors, creatinine and proteinuria were assessed.

Close collaboration with the clinicians is urged, with the aim of applying immunosuppressive therapy immediately after P.E. to consolidate the results obtained.

Persistence with denosumab therapy in women affected by osteoporosis with fragility fractures: a multicenter observational real practice study in Italy

BACKGROUND

Persistence is commonly considered a key factor for the successful management of osteoporosis and fragility fractures. Denosumab is the first biologic agent developed for the treatment of osteoporosis with satisfying data regarding the persistence with this therapy.

AIM

The purpose of this multicenter observational real practice study was to evaluate the persistence with denosumab treatment in post-menopausal women affected by osteoporosis.

MATERIAL/SUBJECTS AND METHODS

Women were recruited in four specialized centers for the management of osteoporosis in North, Center and South of Italy. We included women with a diagnosis of post-menopausal osteoporosis, aged >50 years, able to obtain a prescription according to the Italian reimbursement criteria in force during the study period for anti-osteoporotic pharmacological treatment. They initiated a treatment with subcutaneous denosumab (Prolia^®) 60 mg/every 6 months between November 2011 and May 2016. Women who had received aromatase inhibitors were excluded. Patients were assessed at baseline and every 6 months for all treatment length. Persistence data were evaluated for a total of 36 months.

RESULTS

Eight hundred seventy women were enrolled; mean aged 70 years, with a mean body mass index of 24.8 ± 4.1 kg/m². At the Dual-energy X-ray absorptiometry assessment, the mean lumbar spine T-score was -2.76 ± 1.14 standard deviations (SD) and the mean femoral neck T-score was -2.49 ± 0.80 SD. During the study, the total persistence was 91.4%. Total dropouts were 75 (8.6%), higher within the initial 6-month period of treatment.

CONCLUSIONS

Persistence to denosumab treatment in our observational real practice study was very high. These results suggest that factors such as frequency of visits, pharmacological schedule, and opportunity to call the doctor might play an important role in the persistence and adherence to treatment to obtain maximum therapeutic effect and avoid further fragility fractures.

Association of the GSTT1 polymorphism in upper aerodigestive tract cancer with tobacco smoking

Polymorphisms in genes encoding xenobiotic-metabolizing enzymes might explain differences in the susceptibility to upper aerodigestive tract (UADT) cancers in individuals exposed to tobacco or other carcinogens. The present study aimed to evaluate the association of polymorphisms in the glutathione S-transferase (GST) candidate genes GSTM1, GSTT1, and GSTP1 with the risk of UADT cancers. GST gene polymorphisms were determined in 116 individuals with UADT cancer and 224 healthy controls using polymerase chain reaction-based methods. The GSTT1-null polymorphism was found to be a protective factor for UADT cancer [(odds ratio (OR) = 0.5, 95% confidence interval (CI) = 0.27-0.93)], although this association was not confirmed when adjusted for gender, age, smoking, alcoholism, and self-reported skin color in the multivariate logistic regression model (OR = 0.61, 95%CI = 0.29-1.28). The combined effect of GSTT1-positive genotypes with either the GSTP1 wild-type genotype (Ile/Ile) or the GSTP1 variant genotypes (Ile/Val or Val/Val) increased the risk for UADT cancer (OR = 4.34, 95%CI = 1.06-17.78 and OR = 4.55, 95%CI = 1.12-18.42, respectively). A significant interaction was observed among moderate smokers carrying the GSTT1-positive genotype. In this population, the significant gene-gene and gene-environment interactions of GST polymorphisms may confer a substantial risk to UADT cancers.

Sarcopenia in women with vertebral fragility fractures

We performed a pilot study with the purpose to evaluate the prevalence of sarcopenia in osteoporotic women with vertebral fractures. Dual-energy X-ray absorptiometry (DXA) was used to measure the whole and regional body composition. Appendicular lean mass (aLM) was calculated as the sum of lean mass in arms and legs. We calculated the skeletal muscle mass index (aLM/h(2)), and we measured bone mineral density and T scores by DXA scan at total-body and at femoral neck. Participants were divided according to the number of vertebral fractures (single or multiple fractures). A total of 67 women were included. Thirty-five women (52.23%) had a vertebral fracture, of them 8 (22.85%) were sarcopenic and 32 women (47.76%) had multiple vertebral fractures, of them 14 (43.75%) were sarcopenic. Our results suggest that sarcopenia is common among osteoporotic women increasing along with the number of vertebral fragility fractures.

Vitamin D supplementation in fractured patient: how, when and why

Vitamin D, through its action on calcium metabolism, is essential for bone physiology. It's also required in a wide range of biological systems to act modulating the proliferation and inducing terminal differentiation of a variety of normal cells. Actually vitamin D deficiency can impact muscle function and increases fall risk in elderly, while severe vitamin D deficiency (< 30 nmol/L) is common in patients with fragility fractures. Vitamin D and calcium supplementation, in addition to antiosteoporosis treatment after surgery or conservative treatment, can ensure optimal recovery and survival, especially in hip fractured patients.

Drop-out rate in eating disorders: could it be a function of patient-therapist relationship?

OBJECTIVE

The factors influencing drop-out in eating disorders (ED) are still unclear. The aim of the present study was to determine whether compliance is strongly related to the patient-therapist relationship.

MATERIALS AND METHODS

During 14 months all new patients affected by EDs referring to our Specialist Service Center, were assessed and followed up, they underwent EAT 40, EDI II, and computerized case history for ED. Moreover, we collected data from therapist using the GCI scale, and we recorded as the patient perceived his weight (PPW).

RESULTS

We found that out of the 100 patients enrolled, 53 withdraw and when probability was predicted according to a digit model, it was not influenced by EDI-II subscales, age, sex, education, EAT-40 score, duration of the disorder and diagnosis while it significantly decreased when GCI scores increased and decreased when the PPW was altered.

CONCLUSION

These results seem to confirm that some psychological factors related to patient-therapist relationship can play a key role for a stable and continuous therapeutic program.

Vasculogenic mimicry by bone marrow macrophages in patients with multiple myeloma

Bone marrow macrophages of patients with active and nonactive multiple myeloma (MM), monoclonal gammopathies of undetermined significance (MGUS) and benign anemia (controls) were stimulated for 7 days with vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF), and analysed for the expression of endothelial cell (EC) markers by reverse transcription (RT)-PCR, real-time RT-PCR, western blot and immunofluorescence. Their vasculogenic ability was investigated in vitro in a Matrigel assay and in vivo on bone marrow biopsies through dual immunofluorescence and confocal laser microscopy. Active MM macrophages exposed to VEGF and bFGF acquired EC markers and formed capillary-like structures mimicking paired bone marrow ECs (multiple myeloma patient-derived endothelial cells, MMECs), with major responsiveness compared to macrophages from nonactive MM, MGUS or controls. Bone marrow biopsies of active MM harbored 'mosaic' vessels, being formed by MMECs, EC-like macrophages and macrophages themselves. These figures were rare in nonactive MM and absent in MGUS or controls. Our data indicate that macrophages contribute to build neovessels in active MM through vasculogenic mimicry, and this ability proceeds parallel to progression of the plasma cell tumors. Macrophages may be a target for the MM antivascular treatment.

Simulation of real-time deformable soft tissues for computer assisted surgery

The simulation of realistic surgical procedures requires specialized optimized algorithms for the models of organs and tissues, which should comply both with accuracy of results and run-time computation. This paper provides a general survey of methods and approaches used for the simulation of soft tissues in Computer Assisted Surgery, discussing the technological challenges to achieve realistic simulation of deformation.An application example is presented, referring to the simulation of a gastroenterology procedure, abdominal paracentesis for the treatment of ascites.

Crosstalk between angiogenesis and lymphangiogenesis in tumor progression

Extensive studies have identified reliable markers of lymphatic endothelial cells, and mechanisms and molecules that regulate development and growth of the lymphatic vessels. Vascular endothelial growth factors (VEGF)-C and VEGF-D, and their cognate receptor tyrosine kinase, VEGF receptor-3 (VEGFR-3), are critical regulators of lymphangiogenesis. By binding to its endothelial cell surface receptors VEGFR-1 and VEGFR-2, VEGF-A mediates vascular leakage, endothelial proliferation and migration. Angiopoietin-2 (Ang-2) is expressed at sites of blood vessel remodeling and invasion, and factors that induce angiogenesis in vivo, such as VEGF-A, upregulate Ang-2 in endothelial cells. In this review, we summarize the literature concerning the crosstalk between angiogenesis and lymphangiogenesis in tumor progression, that is, involvement of VEGF-C, VEGF-D and VEGFR-3 in angiogenesis, and the role played by VEGF-A and Ang-2 in lymphangiogenesis, respectively.

Psychiatric comorbidity in a population of outpatients affected by tinnitus

The aim of this study was to outline the psychopathological characteristics of a population of outpatients affected by tinnitus and to consider its impact on their mental state and ability to function in major areas of their lives. Seventy-five consecutive tinnitus patients were enrolled on their first visit to the outpatients clinic of the Audiology Department of the 'Federico II' University of Naples, for audiological and psychiatric evaluation. A series of audiometric and vestibular tests was performed for tinnitus rating assessment, and further information was obtained from the patient via a semi-structural interview. For the psychopathological examination, patients underwent the Mini International Neuropsychiatric Interview (MINI), by means of which a multiaxial diagnosis (five axes) was expressed, according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). For a better understanding of the personality aspects, the Minnesota Multiphasic Personality Inventory (MMPI) test was administered to a subgroup of 55 subjects whose cultural background permitted their full cooperation. The results of the study show that 58 subjects (77% of the total) met the criteria for psychiatric disorder diagnosis, according to the DSM-IV system: Axis I comprises anxiety, affective and somatoform disorders and psychoses; Axis II comprises personality disorders. Multiple diagnoses were expressed in some subjects. The findings of the examination via MMPI show a high percentage of depression, hysteria, and hypochondria. Although we are not seeking to establish a cause-effect relationship between the unpleasant experience of tinnitus and psychopathological disorders, our findings are consistent with those of other authors. Tinnitus can indeed have severe consequences for the subject's ability to function in many areas of their life. In this paper, the implications of such results for the diagnosis and therapy of tinnitus are discussed.

What happens to eating disorder outpatients who withdrew from therapy?

OBJECTIVE

Dropouts are frequent among eating disorder (ED) patients, but less is known about their natural history. This paper assesses the outcome of outpatients who dropped out from a therapy programme and its possible causes.

MATERIAL AND METHODS

From 1992 to 1994, we assessed 222 ED subjects. Psychiatrists expert in EDs evaluated these subjects by defining baseline parameters and diagnosis was made according to the 3rd revisioned edition of the Diagnostic and Statistical Manual of Mental Disorders. One hundred and twenty-eight subjects (57%) dropped out during the treatment. In 1997, we contacted them, reassessed the same baseline parameters and asked for a self-judgment about their social and clinical condition during the previous 2-5 years. Patients were classified as "improved" and "not improved" (stationary or worse) according to their social, physical and psychological condition. The relation between baseline condition and outcome was determined statistically.

RESULTS

Seventy-one percent of subjects were "improved" and no deaths were recorded. A significant correlation was found between "duration of illness" and no treatment following a dropout.

DISCUSSION

The high percentage of improvement among dropouts was unexpected. Shorter duration of illness and lack of specific therapy in the improved patients suggest the existence of a subset of ED patients with acute onset and a spontaneous tendency to improve. This point obviously requires further investigation.

Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. Role of the posterior longitudinal ligament

Among unusual abnormalities of the lumbar spine reported since the introduction of Computed Tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.

Trigeminal pain caused by a cerebellopontine-angle lipoma. Case report and review of the literature

A 16-year-old girl complained of 2-year history of right facial pain, episodic vertigo and progressive hearing loss in the right ear. The facial pain was described as an episodic lancinating event confined to the second and third branch of the right trigeminal nerve. Computed tomography and magnetic resonance imaging revealed a 2 cm lesion in the right cerebellopontine-angle. At surgery, a soft, yellowish mass was found incorporating the 7th and 8th cranial nerves. The anterior-inferior cerebellar artery (AICA) was displaced medially and pushed into the sensory portion of the trigeminal nerve root, causing vascular compression. The hearing loss remained unchanged. The trigeminal pain disappeared over a period of several weeks. Patients can be harmed in an attempt to remove these neurovascular nonmalignant, generally non growing, fatty vascular lumps. Only a partial, meticulous removal should be performed with a maximum effort to decompress the affected nerve.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

The Gatehouse Project: a systematic approach to mental health promotion in secondary schools

OBJECTIVE

The objective of this paper is to outline the conceptual background and strategy of intervention for a systematic and sustainable approach to mental health promotion in secondary schools.

METHOD

The conceptual origins of the Gatehouse Project are described in terms of the epidemiology of adolescent mental health problems, attachment theory, education reform research and health promotional theory and practice. The elements of health promotional work are described in terms of structural change and priority setting; implementation at multiple levels within the participating schools is described.

RESULTS

The conceptual framework of the Gatehouse Project emphasises healthy attachments with peers and teachers through the promotion of a sense of security and trust, effective communication and a sense of positive self-regard based on participation in varied aspects of school and community life. A school social climate profile is derived from a questionnaire survey of students. An adolescent health team uses this information to set priorities for change within the school. Interventions may focus on the promotion of a positive social climate of the whole school or in the classroom. Curriculum-based health education is also used and based on materials that are relevant to the normal developmental experiences of teenagers. These are integrated into the mainstream curriculum and incorporate a strong component of teacher professional development. Lastly, the intervention promotes linkage between the school and broader community with a particular emphasis on the needs of young people at high risk of school drop-out.

CONCLUSIONS

Educational environments are complex systems undergoing continuous and simultaneous changes. The Gatehouse Project will provide unique information on the relationship between the social environment and the emotional wellbeing of young people. More importantly it outlines a sustainable process for building the capacity of schools to promote the social and emotional development of young people.

[Adrenal medullary hyperplasia: a rare etiology of arterial hypertension--report of a case]

Adrenal medullary hyperplasia is often misdiagnosed. The clinical features may resemble those of pheochromocytoma, with paroxysmal hypertension and elevated urinary catecholamine and metanephrine levels. Pathologic study shows diffuse or nodular adrenal medullary hyperplasia, determined by morphometric analysis: increased adrenal gland weight, increased relative medullary volume, increased relative medullary weight, decreased cortico-medullary ratio. Adrenal medullary hyperplasia may be primary or sporadic, but is often associated with multiple endocrine neoplasia (MEN) type II.

[Collagen diseases and the involvement of the mouth in childhood]

In the review, the authors describe the lesions of the oral cavity, which are present in lupus erythematosus, scleroderma, dermatomyositis. They underline the importance of their knowledge for the dentist and for the pediatrician, because the last recognition can influence prognosis negatively.

Fournier's gangrene: Clinical and therapeutical remarks on 5 new cases and review of the literature

Fournier's gangrene is an uncommon disease. It is characterised by superficial cellulitis involving the external genitalia, with a quick necrotic evolution. The origin of infection is often unclear. Generally the disease has a good prognosis, without systemic toxicity or compromising the patient's life. Many cases of Fournier's gangrene with bad prognosis, sepsis, have been described, however, in literature. In these cases the infection propagates from the colorectum, the periurethral glands or the urethra. We believe that these cases must be described as urinous phlegmon which unlike Fournier's gangrene, is a deep cellulitis. The 5 cases that we report, confirm our opinion.

A case of idiopathic myelofibrosis with alloimmunization to HLA-identical platelet transfusions not responsive to antibody absorption over protein-A columns

A case of idiopathic myelofibrosis has been treated with HLA-identical platelet apheresis concentrates. After a short period the patient also developed refractoriness to the haploidentical siblings. Protein A columns were used to absorb the platelet antibodies with no result. Now two apheresis platelet concentrates are used every month, crossmatched negative products produce good results maintaining cell counts between 20 and 30 x 10(9)/L. The immune mechanism involved is difficult to understand.

Atypical McLeod syndrome manifested as X-linked chorea-acanthocytosis, neuromyopathy and dilated cardiomyopathy: report of a family

We report a family with three members affected by a typically X-linked McLeod syndrome. In the proband a very weak positivity for antigens of the Kell group was detected. His sister showed a normal antigenic pattern. We emphasize the prominent neurological picture characterized by a choreic syndrome with atrophy of the caudate nucleus on MRI, psychiatric disturbances, peripheral nerve and muscle biopsy findings indicating slight neuromuscular involvement, and cardiac abnormalities. The differential diagnosis is discussed.

Therapeutic plasma adsorption. A review

Alternative techniques to the traditional plasma exchange are emerging in clinical practice for the treatment of different pathological conditions, particularly autoimmune diseases. Filtration is a technique used to separate blood cells from plasma, which may be further "treated" with other filters or columns. The case for cascade filtration and absorption onto a column is becoming stronger and stronger and the patient population is increasing. Alongside the "historical" techniques of adsorption onto a column, new systems (pairs of self-regenerating columns) and new products (columns with dextran sulphate, tryptophane, anti-human lipoprotein antibodies) are now available. Protein A in particular seems to open up new horizons; in therapeutic plasmapheresis, there are two versions, one Swedish and the other American, based on different theoretical premises and obtaining different results, with different biocompatibilities but good clinical results.

Plasma exchange in systemic lupus erythematosus. Experience in thirty-seven patients

Thirty-seven (37) SLE patients submitted to therapeutic plasmapheresis were examined. The results were good in the active stage of the disease. Various types of antibody, anti-DNA, anti nucleus, anti-cardiolipine, I.C. (Clq and C3d) were removed. The values of IgG, coagulation factors, creatinine and proteinuria were assessed. Close collaboration with the clinicians is urged, with the aim of applying immunosuppressive therapy immediately after P.E. to consolidate the results obtained.

[High-resolution computed tomography in the diagnosis of branchial otodysplasias. A report on 10 cases (15 ears)]

Computed Tomography (CT) is not yet widely employed in the evaluation of temporal bone diseases in pediatric patients. Our experience is reported in the study of branchial otodysplasias (10 cases, 15 ears) by means of a high-resolution program. Indications, advantages, limitations and risks of this technique are discussed. Some technical details are reported, such as number and type of scans, length of data acquisition, thickness and feed of slices, electronic image reconstruction, and radiation doses given to the lens. The method employed to immobilize younger patients is also described. CT findings in the single cases are summarized in the tables. The most significant images of 5 cases are also reproduced. A careful analysis of the cases in our series highlights the advantages provided by the use of high-resolution CT in the evaluation of the temporal bone in pediatric patients, especially as far as dysplasias are concerned.