Incidence of pain at rest and during nursing procedures in ICU patients: a longitudinal observational study

AIM

To evaluate pain monitoring in surgical and no-surgical ICU patients and to observe the presence of pain at rest and during nursing procedures.

METHODS

A longitudinal, observational study was conducted at an intensive care unit in Italy. Based on the specific conditions of the patient the best rating scale was used (Numerical Rating Scale or the Critical-Care Pain Observation Tool). Two ICU nurses performed pain assessments before and during some nursing procedures that are considered nociceptive.

RESULTS

The pain incidence rate in 1,602 days of observation was 0.06 patient/day (59/1000 days of observation). The incidence rate of intense pain was 0.012 patient/day (12/1000 days of observation). Pain at rest was detected in 67 (27.6%) patients. Pain during procedures was found 134 (36.1%) times. In the 96 patients who were in pain the ICU stay (15.4 days + 7.8 vs 11.4 days + 5.6) and the days of mechanical ventilation (13.4 + 7.9 vs 9.7 + 4.9) was increased. Surgical patients had an increased pain risk than non-surgical patients (RR = 2.7, CI = 2.0-3.6; p<.001).

CONCLUSIONS

The incidence of pain was recorded in 39.5% of ICU patients. However further studies of larger patient samples are needed.

Knowledge and attitude of pain management among Italian nurses in intensive care unit: a multicentric descriptive study

AIM

The main objective of the study was to document the current knowledge and attitudes towards pain management among Italian nurses working in intensive care unit (ICU).

METHODS

A multicenter cross-sectional study design was carried out. In order to assess the knowledge and attitudes of pain management, the KASRP questionnaire was used. The questionnaire was submitted online through Google Forms platform.

RESULTS

A total of 864 nurses completed and returned the study questionnaire (58% were males). The mean of the total correct answers was 31.21 (SD 2.92) out of 40 (total score if all items answered correctly) with range of 22-38. No significant differences were observed with regard to gender (t = 1.875, P = .061). Spearman's correlation test showed a positive significant relationship between knowledge and attitude of pain management and years of ICU experience (r = -.424, P <.001) and between knowledge and attitude of pain management and the attendance of a pain update course in the last 3 years (r= -0.83, P =.014). We haven't found any correlation neither between age and knowledge nor between age and attitude score (r = -0.32, P = .351).

CONCLUSIONS

This study has shown that Italian ICU nurses have good level of pain management knowledge and attitudes of pain medication. It is recommended to consider pain management in the context of continuing professional development.

Alois Alzheimer and Gaetano Perusini: should man divide what fate united?

Three points of interest lie in considering how Alzheimer, and more significantly Perusini, struggled to throw light on the cause of this devastating disease. There is a stimulating possibility that Perusini believed presenile forms of Alzheimer's disease described the same disease as senile forms. If so this would anticipate current opinion, and reveal Perusini to dissent from Kraepelin. In addition, Perusini may have understood the pathological relationship between neuritic plaques and vascular changes, once more foreseeing the modern view of Alzheimer's disease. Finally, Perusini and Alzheimer disagreed with Jung's view concerning the relationship between neuropathology and clinical psychiatry. This point highlights the major change occurring at that time from classical neurology to the psychoanalytic era. In his last work (1911) Alzheimer quoted his Italian disciple many times, even speaking of 'Perusini's cases' (Perusinischen Fälle). This article is an attempt to change the eponym of Alzheimer's disease into the Alzheimer-Perusini disease. This is a brief history of a master and his disciple, whose scientific lives were, by events, divided.

Does PRNP gene control the clinical and pathological phenotype of human spongiform transmissible encephalopathies?

BACKGROUND

Human spongiform transmissible encephalopathies (TSE) are a group of neurodegenerative diseases caused by a transmissible not yet recognized agent; their distinctive neuropathological features are astrocytosis, spongiform lesions of the neuropil, neuronal loss and occasionally amyloid plaques in the cortical and subcortical gray matter. TSE are biochemically characterized by the deposition in the nervous system of an amyloid-type protein, PrPres derived from the post-translational modification of a normal protein, PrPsen. The expression of this protein is controlled by the PRNP gene mapped on chromosome 20 in man. A number of point mutations of the PRNP gene have been described in the familial forms of these TSE. Some of these mutations have been associated with differences in the phenotypic expression of the disease.

MATERIAL AND METHODS

This study was designed to verify whether it was possible to identify a selective phenotype depending upon a given PRNP modified genotye; for this purpose, a group of familial TSE cases (CJD 210ILE, CJD 201LYS, FFI 178ASN) were selected and their neuropathological profiles have been compared with those of a large series of sporadic CJD cases.

RESULTS

No significant differences were found between the topography and severity of lesions in the cerebral cortex, cerebellum, hippocampus, basal ganglia and thalamus between the two groups. Two differences were found: the clinical duration of the disease which appeared significantly (p = 0.02) shorter in the 210ILE-mutated cases compared to that of non-mutated sporadic cases. The highly selective vulnerability of thalamus in FFI showing a severe pathology especially in its dorso-medial part in comparison with that of the sporadic CJD cases.

CONCLUSION

The results of this study confirm that the different polymorphism at codon 129 of the PRNP gene, which could be involved in the structural "domains" of human PrP, might modulate the pathological phenotype of TSE.

Camillo Golgi: a clinical pathologist

Camillo Golgi opened new avenues in histology and neurobiology as well as in clinical neurology and internal medicine. This is demonstrated by investigations Golgi performed during 1861-1876 on the etiology and pathology of mental diseases, on the neuropathology of Huntington's chorea (Golgi provided the first detailed description at the microscopic level of pathological changes in the basal ganglia and cerebral cortex of one case of chorea), on meningiomas and cerebral gliomas. In the period following these investigations, Golgi focused especially on infectious diseases. He pursued fundamental studies on malaria (which remain among the most important and original of his contributions) on rabies, as well as on smallpox and influenza. Thus, Camillo Golgi should be remembered for his discoveries of the black reaction and the Golgi apparatus, as well as for the modern impulse he was able to give to clinical neurology and internal medicine.

Prion protein glycotype analysis in familial and sporadic Creutzfeldt-Jakob disease patients

Creutzfeldt-Jakob disease (CJD) and other transmissible spongiform encephalopathies (TSEs) are characterised by the accumulation of a pathological conformer of PrP, named PrPsc. Molecular weight and glycosylation of the protease-resistant core of PrPsc (PrP27-30) are heterogeneous in different forms of TSEs. We analysed PrP27-30 glycotypes in a large number of TSE-affected patients: 50 sporadic CJD (sCJD), 1 iatrogenic CJD, 1 Gerstmann-Sträussler-Scheinker syndrome (GSS) with the Pro102Leu mutation of PrP, 3 familial CJD (fCJD) with the Glu200Lys mutation and, for the first time, 7 fCJD with the Val210ll3e mutation. All patients were screened for the polymorphic codon 129 of the PrP gene. PrP27-30 deglycosylation and PrPsc immunohistochemistry were performed in selected cases. We found that two PrP27-30 glycotypes (type 1A and type 2A) are produced in sCJD. Type 1A is more frequently associated with methionine than valine in position 129. Type 1A is also formed in Val210lle fCJD. In Glu200Lys fCJD and GSS patients, we found that PrP27-30 has the same mobility of type 1 but different glycosylation ratios (type 1B). Our findings indicate that the polymorphic residue 129 of PrP has a leading role in determining the proteinase degradation site of PrPsc while mutant residues 102 or 200 influence only the glycosylation pattern.

Is the "nonspecific" thalamus still "nonspecific"?

The classical concept of "nonspecific" thalamus, as distinguished from the principal thalamic nuclei (i.e. the primary sensory, motor and limbic relays) is here briefly revisited in the light of anatomical investigations performed in the last decades, and primarily those based on tract tracing techniques. Altogether these data pointed out that the so-called "nonspecific" thalamus is composed by a heterogeneous collection of nuclear masses, which display not only species differences, but also marked internuclear variations in their cytological and neurochemical features, connections, areal and laminar distribution upon the cortex, and functional properties. Thus, the "nonspecific" thalamus exerts a modulatory role on cortical activity, chiefly regulated at the intrathalamic level by the interplay between the thalamic reticular nucleus and the interneurons and projection neurons of the dorsal thalamus. However, each of the components that have been traditionally considered as "nonspecific" also subserves selective roles in the transfer of different kinds of information from the thalamus to the cerebral cortex and basal ganglia.

Fatal familial insomnia: genetic, neuropathologic, and biochemical study of a patient from a new Italian kindred

Fatal familial insomnia (FFI) is an inherited prion disease linked to a mutation at codon 178 of the PRNP gene that results in aspartic acid to asparagine substitution, in coupling phase with methionine at position 129. The disease is characterized clinically by insomnia with disturbances of the autonomic, endocrine, and motor systems and neuropathologically by selective degeneration of the thalamus. Phenotypic variability is well known and has been linked to homozygosity or heterozygosity at PRNP codon 129. We report the clinical, neuropathologic, and biochemical findings and genomic analysis of a patient with FFI from a new Italian kindred. Although homozygous for methionine at codon 129, this patient showed some clinical and pathologic features most commonly found in heterozygotes.

Diffuse thalamic degeneration in fatal familial insomnia. A morphometric study

A morphometric investigation disclosed most thalamic nuclei severely degenerated in two patients with fatal familial insomnia. Associative and motor nuclei lost 90% neurons, and limbic-paralimbic, intralaminar and reticular nuclei lost 60%. These findings point to the disorganization of most thalamic circuits as a condition necessary for the sleep-wake rhythm being affected.

Toward an agreement on terminology of nuclear and subnuclear divisions of the motor thalamus

The nomenclature most commonly applied to the motor-related nuclei of the human thalamus differs substantially from that applied to the thalamus of other primates, from which most knowledge of input-output connections is derived. Knowledge of these connections in the human is a prerequisite for stereotactic neurosurgical approaches designed to alleviate movement disorders by the placement of lesions in specific nuclei. Transfer to humans of connectional information derived from experimental studies in nonhuman primates requires agreement about the equivalence of nuclei in the different species, and dialogue between experimentalists and neurosurgeons would be facilitated by the use of a common nomenclature. In this review, the authors compare the different nomenclatures and review the cyto- and chemoarchitecture of the nuclei in the anterolateral aspect of the ventral nuclear mass in humans and monkeys, suggest which nuclei are equivalent, and propose a common terminology. On this basis, it is possible to identify the nuclei of the human motor thalamus that transfer information from the substantia nigra, globus pallidus, cerebellum, and proprioceptive components of the medial lemniscus to prefrontal, premotor, motor, and somatosensory areas of the cerebral cortex. It also becomes possible to suggest the principal functional systems involved in stereotactically guided thalamotomies and the functional basis of the symptoms observed following ischemic lesions in different parts of the human thalamus.

Toward an agreement on terminology of nuclear and subnuclear divisions of the motor thalamus

The nomenclature most commonly applied to the motor-related nuclei of the human thalamus differs substantially from that applied to the thalamus of other primates, from which most knowledge of input-output connections is derived. Knowledge of these connections in the human is a prerequisite for stereotactic neurosurgical approaches designed to alleviate movement disorders by the placement of lesions in specific nuclei. Transfer to humans of connectional information derived from experimental studies in nonhuman primates requires agreement about the equivalence of nuclei in the different species, and dialogue between experimentalists and neurosurgeons would be facilitated by the use of a common nomenclature. In this review, the authors compare the different nomenclatures and review the cyto- and chemoarchitecture of the nuclei in the anterolateral aspect of the ventral nuclear mass in humans and monkeys, suggest which nuclei are equivalent, and propose a common terminology. On this basis, it is possible to identify the nuclei of the human motor thalamus that transfer information from the substantia nigra, globus pallidus, cerebellum, and proprioceptive components of the medial lemniscus to prefrontal, premotor, motor, and somatosensory areas of the cerebral cortex. It also becomes possible to suggest the principal functional systems involved in stereotactically guided thalamotomies and the functional basis of the symptoms observed following ischemic lesions in different parts of the human thalamus.

Resistance of the hippocampus in Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) belongs to the group of subacute spongiform encephalopathies of animals and man. Their pathogenesis is certainly related to the formation and deposition in the brain of an amyloid-type specific protein, named PrPres (prion protein-resistant). The neuropathological topography of CJD does generally admit that archicortex is relatively spared, but only a few papers have been devoted to this issue. A neuropathological study of CJD cases divided in sporadic, familial, and iatrogenic forms of the disease has been carried out, taking into consideration the archipallial lesions in relation to different clinical and neuropathological parameters. The pyramidal cell layer of CA1 of all CJD cases did not show any major loss of neurons in comparison to that observed in other cortical fields of the limbic cortex (mainly in the presubicular and entorhinal cortex) and of the neocortex. Spongiogliotic reaction was observed only in the stratum radiatum and molecularis lacunosum in a iatrogenic case of the disease. The findings observed in the pyramidal cell layer of CA1 were neither related to the clinical duration of the disease nor to the severity of the lesions found in other limbic and neocortical areas. The results of this study support the view of no close relationships between the demential syndrome typically related to the clinical onset and progression of CJD, and the structural damage of the hippocampus classically involved in the pathogenetic mechanism of the amnestic syndrome related to the clinical presentation and course of more common forms of dementias, such as Alzheimer's disease.

Polymorphism at codon 129 or codon 219 of PRNP and clinical heterogeneity in a previously unreported family with Gerstmann-Sträussler-Scheinker disease (PrP-P102L mutation)

We present a new, large, Italian family affected by Gerstmann-Sträussler-Scheinker syndrome (GSS) associated with the Pro to Leu point mutation at codon 102 of the prion protein gene (PRNP). The affected members of this family show a remarkable phenotypic variability of the disease: three of them had a clinical picture characterized by dementia and a brief illness duration (less than 1 year), while the other five members presented an ataxic, slowly evolving syndrome (a clinical duration of 3 to 4 years) with no evidence of cognitive impairment. Despite these remarkable clinical differences among affected members, we found no correlation between the clinical presentation and the codon 129 or codon 219 genotypes. These data suggest that factors as yet unidentified may influence the clinical expression of the disease.

A panencephalopathic type of Creutzfeldt-Jakob disease with selective lesions of the thalamic nuclei in 2 Swiss patients

Creutzfeldt-Jakob disease (CJD), a subacute spongiform encephalopathy, is generally included among the group of human and animal diseases which is transmissible by a non-conventional agent, the prion, whose expression is conditioned by the host's genome. The process leading to neuropathological changes is still unknown. We report the neuropathological findings in 2 cases of the "panencephalopathic" variant of CJD, which is relatively common in Japan, but extremely rare in Europe and North America. When compared with the classical form this variant is characterized by a relatively long clinical course with persistent vegetative state and primary involvement of the white matter presenting in the form of demyelination and gemistocytic gliosis. The selective involvement of certain thalamic nuclei is a particular pathological feature in both our cases. There was practically complete neuronal loss with diffuse gliosis of the anteroventral (AV) and dorsomedial (DM) nuclei, while the neuronal loss in the pulvinar remained moderate: the other nuclei were apparently spared. A similar involvement of the thalamus has been reported in fatal familial insomnia, a recently described prion disease in which these lesions are predominant. A comparable distribution has also been observed in other degenerative neurological diseases such as Steele-Richardson-Olszewski disease, Alzheimer disease, and thalamic dementia (selective thalamic atrophy or with multisystemic degeneration). The AV and DM nuclei, commonly referred to as "limbic thalamus" represent phylogenetically the most recent thalamic structures and would appear to play an important role in the superior functions in man as memory, attention and awareness. In our cases thalamic lesions are selective, bilateral, and symmetric, not explained by Wallerian degeneration. These lesions may be due to the primary pathogenetic properties of the infectious agent. The rapid clinical evolution in a persistent vegetative state could be consequential to precocious and severe disfunction of the limbic thalamus.

Trends in the anatomical organization and functional significance of the mammalian thalamus

The last decade has witnessed major changes in the experimental approach to the study of the thalamus and to the analysis of the anatomical and functional interrelations between thalamic nuclei and cortical areas. The present review focuses on the novel anatomical approaches to thalamo-cortical connections and thalamic functions in the historical framework of the classical studies on the thalamus. In the light of the most recent data it is here discussed that: a) the thalamus can subserve different functions according to functional changes in the cortical and subcortical afferent systems; b) the multifarious thalamic cellular entities play a crucial role in the different functional states.

Creutzfeldt-Jakob disease in an Iranian: the first clinico-pathologically described case

This is the first report of a definite case of Creutzfeldt-Jakob disease in an Iranian and it has been confirmed by a neuropathological study and by the immunoelectrophoretic demonstration of PrP, the pathological amyloid protein specific to the spongiform encephalopathies. The clinical course and the topography and severity of brain pathology classify this case as of panencephalopathic type and support the view of different phenotypic expressions of CJD in relation to the existence of multiple strains of the causative agent.

Branched connections to the septum and to the entorhinal cortex from the hippocampus, amygdala, and diencephalon in the rat

Neuronal cell populations giving origin to bifurcating projections to the septum and the entorhinal cortex were studied in the rat by means of double retrograde labeling using the fluorescent tracers Fast Blue and Diamidino Yellow. Double labeled pyramidal neurons were consistently detected in the temporal level of the CA1 area and subiculum of the hippocampal formation, where they represented at least 50% of the cells retrogradely labeled from the entorhinal injections. Double labeled neurons were also detected in the amygdala, where they prevailed in the basal complex. Scattered double labeled neurons were observed in a number of hypothalamic nuclei, with a slight predominance in the preoptic region. Finally, a few double labeled cells were detected in the midline thalamus, and especially in the thalamic paraventricular nucleus. In all these structures, double labeled neurons were located ispilaterally to the injection sites. The present data indicate that the septum and entorhinal cortex are tightly interconnected by axonal bifurcations deriving from a variety of telencephalic and diencephalic sources.

Mapping subcortical extrarelay afferents onto primary somatosensory and visual areas in cats

Projections from the claustrum (Cl) and the thalamic anterior intralaminar nuclei (AIN) to different representations within the primary somatosensory (S1) and visual (V1) areas were studied using the multiple retrograde fluorescent tracing technique. The injected cortical regions were identified electrophysiologically. Retrograde labeling in Cl reveals two different projection patterns. The first pattern is characterized by a clear topographic organization and is composed of two parts. The somatosensory Cl shows a dorsoventral progression of cells projecting to the hindpaw, forepaw, and face representations of S1. The visual Cl has cells projecting to the vertical meridian representation of V1 surrounded dorsally by neurons projecting to the representation of retinal periphery. A second pattern of Cl projections is composed of neurons that are distributed diffusely through the nucleus. In both somatosensory and visual sectors, these intermingle with the topographically projecting cells. Neurons retrogradely labeled from cortical injections are always present in the AIN. In the central medial nucleus, the segregation of modality is evident: The visual-projecting sector is dorsal, and the somatosensory is ventral. Projections from the central lateral nucleus display detectable somatotopic and retinotopic organization: Individual regions are preferentially connected with specific representations of S1 or V1. In the paracentral nucleus, no clear regional preferences are detectable. Also performed were comparisons of the proportions of neurons projecting to different sensory representations. Projections to V1 from both AIN and Cl are biased towards the retinal periphery representation. S1 projection preference is for the forepaw representation in Cl and for the hindpaw in the AIN. The quantitative analysis of multiply labeled cells reveals that, compared to Cl, the AIN contains a higher proportion of neurons branching between different representations of S1 or V1. The concept of topographic vs. diffuse projecting systems is reviewed and discussed, and functional implications of quantitative analysis are considered.

Nucleus reticularis thalami and neocortical paroxysms in the rat

The role of the nucleus reticularis thalami in spike-wave discharges in rats with genetic absence epilepsy has already been demonstrated. This study further investigated the role of the nucleus reticularis thalami in paroxysmal synchronizations in Sprague-Dawley rats; this strain shows no propensity to epileptic activity. Electroencephalographic patterns were followed in chronically implanted, unrestrained rats. After both electrolytic and chemical unilateral lesions, stereotaxically placed in the anterolateral sectors of this nucleus (verified post mortem), abnormal electroencephalographic rhythms (high-voltage polyspikes and spike-wave complexes) were recorded from the frontoparietal cortex, primarily in the contralateral hemisphere. Stereotyped discharges at 3 Hz developed progressively from multiple spikes within the alpha frequency range through the lengthening of the wave component. The excessive synchronized activity recorded from the intact hemisphere was of greater amplitude and occurred slightly earlier than from the lesioned hemisphere. These EEG patterns were associated with behavioural manifestations closely resembling those seen during absence seizures in humans. Bilateral lesions did not induce paroxysmal activity, both hemispheres being characterized by dominant delta/theta activity without signs of EEG-synchronized sleep. The seizures may thus have been due to disinhibition of the contralateral reticularis nucleus, recently shown to project to the reticularis nucleus of the other side in rats. This working hypothesis is supported by callosal cuts. The results indicate that the reticular neurons exert a control over neocortical paroxysmal activity even in animals which do not present genetic absence epilepsy.

Chemical compartmentation and relationships between calcium-binding protein immunoreactivity and layer-specific cortical caudate-projecting cells in the anterior intralaminar nuclei of the cat

Neurons projecting to the parietal cortex or striatum and neurons showing immunoreactivity for the calcium-binding proteins parvalbumin and 28KD-calbindin were examined in the anterior intralaminar nuclei (IL) of the cat. Retrograde tracing from deep or superficial parietal cortical layers or from the caudate nucleus was coupled with immunohistochemistry to determine which of these proteins were expressed in the projection neurons. It was found that IL neurons project to deep as well as to superficial layers of the parietal cortex, that IL-cortical neurons could be differentiated into two populations according to their cortical projection pattern and their soma size, and that IL neurons projecting to the parietal cortex or to the striatum express 28KD calbindin immunoreactivity but not parvalbumin immunoreactivity. The distribution of immunoreactivity to 28KD calbindin and parvalbumin in the neuropil showed a consistent complementary distribution pattern in the IL. The compartments based on differential parvalbumin and 28KD calbindin expression may indicate the presence of functionally segregated units in IL.

A new point mutation of the prion protein gene in Creutzfeldt-Jakob disease

Complete sequencing of the prion protein open reading frame of a 68-year-old woman affected by a familial form of Creutzfeldt-Jakob disease (CJD) revealed a new mutation at codon 210 resulting in the substitution of isoleucine for valine. Moreover, a new 24-bp deletion encompassing codons 54 to 61 or 62 to 69 was found in the other allele. Four of the 17 asymptomatic relatives tested carry the 210 mutation. Two of them were 81 and 82 years old. Four of 22 patients with CJD whose recorded familial history was negative for demented illnesses, but none of 103 healthy control subjects, tested positive for the 210 mutation. These data suggest that the 210 mutation is associated with CJD, but that environmental factors or incomplete penetrance may contribute to the development of the disease. This finding also suggests that in Italy, familial CJD is more common than previously reported.

Early MRI findings in Creutzfeldt-Jakob disease

We describe the MRI changes preceding the onset of myoclonus in two patients whose post-mortem examination confirmed the diagnosis of Creutzfeldt-Jakob disease (CJD). MRI showed changes in the striatum early in the course of CJD (2-6 months after the onset of apathy, interpreted as depression, and 1-2 months before the onset of further clinical symptoms). Only in one patient did electroencephalography record the typical triphasic sharp-waves, 1 month after MRI.

Potentiation of electroencephalographic spindles by ibotenate microinjections into nucleus reticularis thalami of cats

It is well known that the electroencephalogram of the cat in the early stages of slow wave sleep is mainly characterized by rhythmic wave activity at 7-14 Hz, termed spindles, which recur periodically with a slow rhythm of 0.1-0.2 Hz. From early stimulation, decortication and transection studies (see Ref. 14), spindle oscillations were thought to originate in the thalamus. The search for the anatomical substrate of thalamic spindling, however, moved from medial (intralaminar nuclei) to lateral thalamic nuclei, and recently focused on the extreme shell-shaped collection of GABA-ergic cells, the nucleus reticularis thalami. This proposition was based on its structural, hodological, and physiological aspects. There is accumulating evidence that the nucleus reticularis may act as a conditional pacemaker, synchronizing the activity of cortically projecting thalamic neurons. The introduction of glutamate analogues with excitotoxic properties such as ibotenic acid provided the opportunity of studying the immediate effects of chemical excitation of this nucleus on synchronized electroencephalographic activity. We found that, in cats, spindle density was dramatically increased following infusion of ibotenic acid into the rostral pole of the nucleus, supporting the role of this sector in spindle-related rhythmicity.

White matter lesions in Creutzfeldt-Jakob disease. A short review

This short review takes in consideration the role played by the cerebral white matter in Creutzfeldt-Jakob disease (CJD) and analyzes three different hypotheses on the meaning of the involvement of the white matter only as secondary phenomenon or as primary neuropathological damage related to the causative agent(s) of the disease.

[Percutaneous mitral commissurotomy: immediate and short-term results]

31 symptomatic patients with mitral stenosis were selected for percutaneous transvenous mitral commissurotomy using Inoue catheter. The patients were selected using the echocardiographic score for: leaflets mobility, leaflets thickening, subvalvular thickening, degree of calcifications. All patients had a score less than or equal to 8 and represented 17.5% of the patients studied in our echocardiographic laboratory for mitral stenosis. We were able to perform the commissurotomy in 30 of them. Mean left atrial pressure decreased from 26 +/- 5.2 mmHg to 14.6 +/- 6 mmHg (p less than 0.001). The mean mitral diastolic pressure gradient decreased from 8.9 +/- 3.1 mmHg to 3.9 +/- 1.3 mmHg (p less than 0.001). The mitral valve area, using the echocardiographic Pressure Half Time (PHT), increased from 0.94 +/- 0.17 cmq to 1.96 +/- 0.33 cmq (p less than 0.001). Mitral regurgitation, angiographically evaluated in 29 patients, increased in 11 (38%), being of degree + + + in 3 patients. There were 2 heart tamponades and 5 cases (16.6%) of left-to-right shunt with Qp / Qs less than 2. After 3 months, the follow-up showed improvement of one or more functional classes in 96.6% of all patients. The mitral valve area, determined after 6 months in 24 patients by PHT, was stable (1.98 +/- 0.31 vs 1.93 +/- 0.25) (p = 0.5); we did not find mitral stenosis recurrence in any instance. In the first 10 patients, after 1 year, the results are stable (1.85 +/- 0.28 cmq vs 1.93 +/- 0.21 cmq) (p = 0.5) without mitral stenosis recurrence. These data suggest that in selected tight mitral stenosis the percutaneous transvenous commissurotomy may be alternative to the open surgical solution. Using an Inoue catheter, the percutaneous transvenous mitral commissurotomy is easier and the complications are few. The major procedural hazards derive from the transseptal technique.

GABAergic interneurons and neuropil of the intralaminar thalamus: an immunohistochemical study in the rat and the cat, with notes in the monkey

Immunohistochemistry using antibodies to glutamic acid decarboxylase (GAD) was used to investigate the intralaminar nuclei of the thalamus in rat, cat and monkey. Antibodies to gamma aminobutyric acid (GABA) were also used in the cat. Intralaminar immunoreactive cell bodies were not detected in the rat, but were clearly present in cat and monkey. In the latter species, GABA- or GAD-immunopositive perikarya were distributed throughout the anterior intralaminar nuclei, whereas in the posterior intralaminar complex they prevailed in the lateral part of the centre median nucleus and around the fasciculus retroflexus. Measurements of the area of immunostained intralaminar cell bodies in cat and monkey indicated that they are represented by small neurons. Experiments in the cat, based on retrograde tracers injections involving large sectors of the frontal and parietal cortices and the head of the caudate nucleus, revealed that the GABA- or GAD-immunoreactive cells and the retrogradely labeled projection neurons represented two separate intralaminar cell populations, although the latter also included small cells. Considerable differences were observed in the immunoreactive GABAergic neuropil of the anterior and posterior intralaminar nuclei. Clusters of densely packed bouton-like immunoreactive elements were detected in the former structures in the rat, cat and monkey, and were especially evident in the central lateral nucleus; immunopositive varicose fibers and puncta were diffusely distributed in the posterior intralaminar structures. Taken together with data from the literature, the present findings indicate that in cat and monkey local circuit inhibitory cells regulate not only the activity of principal thalamic nuclei which project densely upon restricted cortical fields, but also of the intralaminar structures which are widely connected with the cerebral cortex and the striatum. Regional variations in the distribution of GABAergic fibers and terminals suggest major differences in the organization of inhibitory circuits and synaptic arrangements of the anterior and posterior intralaminar thalamus.

A procedure for the simultaneous visualization of two anterograde and different retrograde fluorescent tracers. Application to the study of the afferent-efferent organization of thalamic anterior intralaminar nuclei

The present report describes a method for the simultaneous visualization, in the same structure, of two different sets of afferent pathways and the neurons of origin of some efferent projections. This method has been applied in the cat for studying, in the thalamic anterior intralaminar nuclei, the topographical relationships of afferent arising from the spinal cord and deep cerebellar nuclei with neurons projecting to different cortical areas. Spino- and cerebello-thalamic terminals were anterogradely labeled by injections of the fluorescent dyes fast blue (FB) and 1,1'-dioctadecyl-3,3,3',3'-tetramethyl-indocarbocyanine perchlorate (DiI) in the spinal cord and cerebellum. Thalamo-cortical neurons were retrogradely labeled by injections of fluorescent tracers in the precruciate and anterior suprasylvian cortices. The findings show that spinal and cerebellar afferent fibers and the cells of origin of intralaminocortical projections are organized in a clear modular manner and indicate that the method used here is suitable for analyzing simultaneously, in light microscopy, multiple input-output interrelationships of a single structure.

Clinical-electrophysiological correlations in a long-term case of subacute sclerosing panencephalitis with partial clinical improvement

An electrophysiological follow-up was performed in a rare case of subacute sclerosing panencephalitis (SSPE) that from the vegetative stage had an extremely favourable course, lasting 4 years, in which clinical conditions passed, according to the Risk and Haddad scale, from stage 3 to stage 1. In this period of time, 5 CT scans and a series of EEGs, visual evoked potentials (VEPs) and brainstem auditory evoked potentials (BAEPs) were performed to investigate the correlation between clinical course and electrophysiological diagnostic data. The results showed a significant improvement in diagnostic results, directly correlated with the remission of clinical symptoms. Electrophysiological signs of improvement in VEPs were obtained before observable improvement was seen on CT scans. These results indicate that an accurate electrophysiological study (through cerebral evoked potentials) has an important role in investigating suspected cases of SSPE, in following the clinical evolution of this disease and providing prognostic data.

Combination ultrafiltration and 6 M urea treatment of human growth hormone effectively minimizes risk from potential Creutzfeldt-Jakob disease virus contamination

Although genetically engineered human growth hormone (hGH) is now commercially available, native pituitary-derived hGH is still used by physicians in many countries for the treatment of hormone deficiency states. We describe a method using ultrafiltration and 6 M urea that reduced infectivity in human pituitary tissue that had been deliberately contaminated with scrapie virus (an animal analogue of human Creutzfeldt-Jakob disease virus) from an initial level of 10(9.7) infectious units to just 5 infectious units. Based on estimates of the frequency of contamination and infectivity levels in batches of human pituitaries, the use of this protocol to prepare GH from cadaveric human glands yields a calculated probability of exposure to a contaminated vial of not greater than 1 in 3.2 million recipients; therefore, native hormone prepared by this method may be considered to be essentially risk-free. The same methodology may be useful in the preparation of other hormones, such as prolactin, for which no synthetic substitutes are currently available, as well as biological products derived from sheep or cattle, that may be infected with scrapie or bovine spongiform encephalopathy.

Considerations on a group of 13 patients with Creutzfeldt-Jakob disease in the region of Parma (Italy)

We report a group of 13 cases of Creutzfeldt-Jakob disease treated in the region of Parma (Italy) between 1975 and 1984. An extensive study did not point to any common source of infection. The clinical stereotypy and distinctive neuropathology in this temporo-spatially confined group of patients might be stressed, but the possibility of infection by a single strain of the CJD agent remains speculative.

Neuronal cell types in the thalamic intralaminar central lateral nucleus of the cat

The existence of Golgi type II neurons was verified in the anterior intralaminar central lateral (CL) nucleus of the cat thalamus, and its projection cell types were identified, by means of Golgi impregnation. CL principal neurons were found to display a large- or medium-sized cell body and a radiate dendritic pattern. Their primary dendrites were limited in number, and had a rather long course; they were poorly ramified. The axons of principal neurons were impregnated only occasionally and for a short distance. Projection neurons of the 'bushy' or tufted type, described in the main thalamic sensory nuclei, were not identified in the CL in the present study. Typical Golgi type II neurons were found throughout CL. They were mainly small-sized, and displayed a rich dendritic arborization characterized by dendritic appendages. The axons of Golgi type II neurons were seen to give rise to extensive local arborizations. The present findings indicate that in the cat CL, principal cells are mainly represented by radiate neurons. Typical local circuit neurons also are evident in CL, suggesting that the activity of anterior intralaminar structures is regulated by intrinsic mechanisms similar to those operating in the main thalamic relay nuclei.

A case of epidermal nevus syndrome with carotid malformation

Epidermal Nevus Syndrome (ENS) is characterized by linear verrucous lesions of the skin and congenital anomalies including bone deformities, eye and central nervous system (CNS) malformations. We describe a case of ENS associated with an abnormality of the carotid artery which is considered a risk for stroke.