Expression profiling of extramedullary acute myeloid leukemia suggests involvement of epithelial-mesenchymal transition pathways

Extramedullary (EM) colonization is a rare complication of acute myeloid leukemia (AML), occurring in about 10% of patients, but the processes underlying tissue invasion are not entirely characterized. Through the application of RNAseq technology, we examined the transcriptome profile of 13 AMLs, 9 of whom presented an EM localization. Our analysis revealed significant deregulation within the extracellular matrix (ECM)-receptor interaction and focal-adhesion pathways, specifically in the EM sites. The transcription factor TWIST1, which is known to impact on cancer invasion by dysregulating epithelial-mesenchymal-transition (EMT) processes, was significantly upregulated in EM-AML. To test the functional impact of TWIST1 overexpression, we treated OCI-AML3s with TWIST1-siRNA or metformin, a drug known to inhibit tumor progression in cancer models. After 48 h, we showed downregulation of TWIST1, and of the EMT-related genes FN1 and SNAI2. This was associated with significant impairment of migration and invasion processes by Boyden chamber assays. Our study shed light on the molecular mechanisms associated with EM tissue invasion in AML, and on the ability of metformin to interfere with key players of this process. TWIST1 may configure as candidate marker of EM-AML progression, and inhibition of EMT-pathways may represent an innovative therapeutic intervention to prevent or treat this complication.

Sewage Sludge Management at District Level: Reduction and Nutrients Recovery via Hydrothermal Carbonization

In this study, two scenarios of a municipal wastewater treatment plant (WWTP) are presented, which include the integration of the hydrothermal carbonization (HTC) process into the sludge line as a post-treatment of the anaerobic digestion (AD) process. The objective of the simulation is to investigate the performances of AD + HTC treatment to reduce sludge production and improve nutrient and energy recovery. For this purpose, the scheme of an under-construction WWTP was considered, named Trento 3 (Trento, Italy) and with a treatment capacity of 300,000 PE. In the first scenario, the HTC process was fed with thickened sludge from the Trento 3 WWTP, while in the second scenario, dewatered sludge from other local WWTPs was also used as feedstock for the HTC process. Both scenarios allowed to obtain a considerable sludge reduction ranging from 70 to 75% with a notably increase in the biogas production up to 47%, due to the recycling of HTC liquor (HTCL) to the anaerobic digester. Considering nutrients recovery, all the phosphorus and nitrogen present in the HTCL could be used for struvite precipitation with an average yearly gain of 1 million euros. Moreover, the introduction of HTC in the Trento 3 WWTP could allow a reduction in the sludge management costs of up to 2 M€/year.

Graphical Abstract

Non-thyroidal illness syndrome and SARS-CoV-2-associated multisystem inflammatory syndrome in children

PURPOSE

COVID-19 disease may result in a severe multisystem inflammatory syndrome in children (MIS-C), which in turn may alter thyroid function (TF). We assessed TF in MIS-C, evaluating its impact on disease severity.

METHODS

We retrospectively considered children admitted with MIS-C to a single pediatric hospital in Milan (November 2019-January 2021). Non-thyroidal illness syndrome (NTIS) was defined as any abnormality in TF tests (FT3, FT4, TSH) in the presence of critical illness and absence of a pre-existing hormonal abnormality. We devised a disease severity score by combining severity scores for each organ involved. Glucose and lipid profiles were also considered. A principal component analysis (PCA) was performed, to characterize the mutual association patterns between TF and disease severity.

RESULTS

Of 26 (19 M/7F) patients, median age 10.7 (IQR 5.8-13.3) years, 23 (88.4%) presented with NTIS. A low FT3 level was noted in 15/23 (65.3%), while the other subjects had varying combinations of hormone abnormalities (8/23, 34.7%). Mutually correlated variables related to organ damage and inflammation were represented in the first dimension (PC1) of the PCA. FT3, FT4 and total cholesterol were positively correlated and characterized the second axis (PC2). The third axis (PC3) was characterized by the association of triglycerides, TyG index and HDL cholesterol. TF appeared to be related to lipemic and peripheral insulin resistance profiles. A possible association between catabolic components and severity score was also noted.

CONCLUSIONS

A low FT3 level is common among MIS-C. TF may be useful to define the impact of MIS-C on children's health and help delineate long term follow-up management and prognosis.

The Role of Medical Counseling in Secondary Prevention of Cancer in the Elderly

In western countries the elderly are those who experience the major impact of cancer, as epidemiologic data clearly show. Thus, secondary prevention of cancer (SPC) in older persons deserves more attention than it has received until now. Target subjects, however, are often reluctant to enter SPC plans. The reasons range from the lack of knowledge about the importance of SPC to the underevaluation of the risk of cancer, or, even more often, to the anxiety and fear that may stem from such a clinical investigation. In this context, the intervention known as couseling finds its natural and essential role. In the paper some general considerations on the significance of medical counseling is given, with particular emphasis on its role in SPC in the elderly. The analysis herein reported points out the specific skills and methods that physicians can adopt to cope with the eventually adverse influences that may affect the participation of the elderly in SPC initiatives. However, such action should avoid any paternalistic approach and respect the patient's will and autonomy.

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

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

Treating Phenylketonuria: A Single Centre Experience

Hyperphenylalaninaemia (HPA) is an inherited disorder that results in raised plasma phenylalanine levels with a range of severities, including phenylketonuria (PKU). Since the first attempts at treatment using a low-phenylalanine diet and after more than 50 years of research, considerable progress has been made so we are now at a stage where mental retardation caused by high plasma phenylalanine can be prevented. We must, however, be aware of the new challenges we face in managing PKU. These include: maintaining optimal growth by providing enough phenylalanine without jeopardizing the child's psychomotor development; providing an optimal nutritional status that ensures other essential nutrients, such as long chain polyunsaturated fatty acids, are not excluded from the diet; ensuring optimal compliance to the dietary intervention; and considering patients' quality of life. New strategies, such as tetrahydrobiopterin (BH4) supplementation, need to be evaluated with regard to safety, efficacy and expected outcomes in specific types of HPA.

Lipid profiles of oil from trout (Oncorhynchus mykiss) heads, spines and viscera: trout by-products as a possible source of omega-3 lipids?

Lipid profiles of fish oil extracted from trout heads, spines and viscera using supercritical carbon dioxide and Randall extraction with hexane were measured. The amount of unsaturated fatty acids (as a percentage of total fatty acids) was within the range of 72.6-75.3% in all the substrates. A significant presence of the most important omega-3 fatty acids was detected. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) content in oil from spines, heads and viscera resulted to be 8.7% and 7.3%, 7.9% and 6.3%, and 6.4% and 6.0%, respectively. A low (≈3%), but worth noting, presence of lipids with omega-1 polyunsaturated fatty chains was observed in all the oils. Finally, significant differences were noticed in the relative amounts of triacylglycerides (TAG), diacylglycerides (DAG) and free fatty acids (FFA). Whereas oil from heads and spines was essentially composed of TAG (≈98%), in viscera oil the molar distribution ratio became TAG:DAG:FFA=87:8:5.

How individuals with phenylketonuria experience their illness: an age-related qualitative study

BACKGROUND

The aim of the study was to explore the illness experience of individuals affected by phenylketonuria (PKU) and its differences in different patient age groups.

METHODS

A qualitative-interpretative methodology was used through in-depth interviews. Textual data were explored using the principles of grounded theory.

RESULTS

Forty-seven patients participated in the study, aged from 10 to >25 years old. The results suggested the age-related PKU experience: (1) a paradox, either to feel normal but isolated from the social context, or to be different while participating in the convivial aspects of the social being; and (2) the need for education about the disease tailored to the individual and growing needs. Specific themes seem to characterize each age range.

CONCLUSIONS

This study constitutes a first attempt at understanding PKU from a non-medical-biological perspective.

Phenotypic variability, neurological outcome and genetics background of 6-pyruvoyl-tetrahydropterin synthase deficiency

This study aimed to investigate the clinical variability and factors implied in the outcome of 6-pyruvoyl-tetrahydropterin synthase deficiency (PTPSd). Biochemical and clinical phenotype, treatment variables, and 6-pyruvoyl-tetrahydropterin synthase (PTS) genotype, were explored retrospectively in 19 Italian patients (12 males and 7 females, aged 4 months to 33 years). According to the level of biogenic amines in cerebrospinal fluid (CSF) at the diagnosis, the patients were classified as mild (6) (normal level) or severe (13) (abnormal low level) form (MF and SF, respectively). Blood Phe ranged from 151 to 1053 micromol/l in MF (mean +/- SD: 698 +/- 403) and 342-2120 micromol/l in SF (mean +/- SD: 1175 +/- 517) (p = 0.063). Patients with MF showed a normal neurological development (a transient dystonia was detected in one), while all SF patients except one presented with severe neurological impairment and only four had a normal neurological development. The outcome of the SF was influenced by the precocity of the treatment. Serial CSF examinations revealed a decline of 5-hydroxyindolacetic acid in MFs and an incomplete restoration of neurotransmitters in SFs: neither obviously affected the prognosis. PTS gene analysis detected 17 different mutations (seven so far unreported) (only one affected allele was identified in three subjects). A good correlation was found between genotype and clinical and biochemical phenotype. The occurrence of brain neurotransmitter deficiency and its early correction (by the therapy) are the main prognostic factors in PTPSd.

Bio-drying of grape marc and other biomass: a comparison

The winery industry produces every year in the world about 270 millions of hectolitres of wine. A consequent amount of grape marc is then generated that has to be somehow treated and processed. For this reason a technique to treat grape marc (bio-drying) was studied and applied at the University of Trento. Grape marc, as is, is not suitable for direct combustion because of its high water content. By bio-drying the lower heating value has been increased up to the limit for a good combustion. This result allows a decentralized management of a grape marc drying differently from the conventional solutions.

Biomass as an energy source: thermodynamic constraints on the performance of the conversion process

In the present work an equilibrium model (gas-solid), based on the minimization of the Gibbs energy, has been used in order to estimate the theoretical yield and the equilibrium composition of the reaction products (syngas and char) of biomass thermochemical conversion processes (pyrolysis and gasification). The data obtained from this model have also been used to calculate the heating value of the fuel gas, in order to evaluate the overall energy efficiency of the thermal conversion stage. The proposed model has been applied both to partial oxidation and steam gasification processes with varying air to biomass (ER) and steam to carbon (SC) ratio values and using different feedstocks; the obtained results have been compared with experimental data and with other model predictions obtaining a satisfactory agreement.

Combined transcranial and endoscopic nasal resection for esthesioneuroblastoma. Technical note

Esthesioneuroblastoma is a rare malignant neoplasm arising in the nasal cavity. Huge esthesioneuroblastomas, extending into the ethmoid roof and the cribriform plate, or invading the anterior cranial fossa, have traditionally been treated by craniofacial resection. Because of the invasiveness and potentially disfiguring results of a transfacial approach, a new technique has been proposed, combining endoscopic nasal and anterior craniotomy resection. We describe the case of a young male presenting with a large esthesioneuroblastoma involving the nasal cavity and the anterior cranial fossa, causing a huge skull base destruction. A combined transcranial and endoscopic nasal resection resulted in a macroscopically total removal of the tumor. The operative technique is reviewed in detail, along with the method used for the reconstruction of the anterior skull base defect.

Phenylketonuria: dietary and therapeutic challenges

PKU subjects need special attention in the definition of optimal supplementation of nutrients, which may be insufficient in relation to the type of diet and may otherwise manifest symptoms of deficit. In particular, it is necessary to pay great attention to the long-chain polyunsaturated fatty acid (LC-PUFA) levels in relation to correct development of the central nervous system. On the basis of numerous beneficial effects currently known, a permanent supplementation with LC-PUFAs, in particular with docosahexaenoic acid, should be considered. Moreover, new formulas, Phe-free peptides, and 'modulated' amino acid preparations might help in preventing nutritional deficiencies and imbalances, with the ultimate aim of improving growth. New strategies--such as supply of tetrahydrobiopterin--need to be optimized in terms of targets, patients and expected outcomes.

Double blind placebo control trial of large neutral amino acids in treatment of PKU: effect on blood phenylalanine

Large neutral amino acids (LNAA) have been used on a limited number of patients with phenylketonuria (PKU) with the purpose of decreasing the influx of phenylalanine (Phe) to the brain. In an open-label study using LNAA, a surprising decline of blood Phe concentration was found in patients with PKU in metabolic treatment centres in Russia, the Ukraine, and the United States. To validate the data obtained from this trial, a short-term double-blind placebo control study was done using LNAA in patients with PKU, with the participation of three additional metabolic centres--Milan, Padua and Rio de Janeiro. The results of the short trial showed significant lowering of blood Phe concentration by an average of 39% from baseline. The data from the double-blind placebo control are encouraging, establishing proof of principle of the role of orally administered LNAA in lowering blood Phe concentrations in patients with PKU. Long-term studies will be needed to validate the acceptability, efficacy and safety of such treatment.

Pharmacokinetics of orally administered tetrahydrobiopterin in patients with phenylalanine hydroxylase deficiency

The oral loading test with tetrahydrobiopterin (BH(4)) is used to discriminate between variants of hyperphenylalaninaemia and to detect BH(4)-responsive patients. The outcome of the loading test depends on the genotype, dosage of BH(4), and BH(4) pharmacokinetics. A total of 71 patients with hyperphenylalaninaemia (mild to classic) were challenged with BH(4) (20 mg/kg) according to different protocols (1 x 20 mg or 2 x 20 mg) and blood BH(4) concentrations were measured in dried blood spots at different time points (T(0), T(2), T(4), T(8), T(12), T(24), T(32) and T(48 h)). Maximal BH(4) concentrations (median 22.69 nmol/g Hb) were measured 4 h after BH(4) administration in 63 out of 71 patients. Eight patients presented with maximal BH(4) concentrations approximately 44% higher at 8 h than at 4 h. After 24 h, BH(4) blood concentrations dropped to 11% of maximal values. This profile was similar using different protocols. The following pharmacokinetic parameters were calculated for BH(4) in blood: t (max) = 4 h, AUC (T(0-32)) = 370 nmol x h/g Hb, and t (1/2) for absorption (1.1 h), distribution (2.5 h), and elimination (46.0 h) phases. Maximal BH(4) blood concentrations were not significantly lower in non-responders and there was no correlation between blood concentrations and responsiveness. Of mild PKU patients, 97% responded to BH(4) administration, while one was found to be a non-responder. Only 10/19 patients (53%) with Phe concentrations of 600-1200 mumol/L responded to BH(4) administration, and of the patients with the severe classical phenotype (blood Phe > 1200 mumol/L) only 4 out of 17 patient responded. An additional 36 patients with mild hyperphenylalaninaemia (HPA) who underwent the combined loading test with Phe+BH(4) were all responders. Slow responders and non-responders were found in all groups of HPA.

Abdominal ultrasonography in inheredited diseases of carbohydrate metabolism

PURPOSE

To determine the usefulness of abdominal sonography in inherited diseases of carbohydrate metabolism.

MATERIALS AND METHODS

Thirty patients (age range, 4 months to 27 years) with glycogen storage diseases, galactosemia, disorders of fructose metabolism were studied with sonography. Echogenicity of the liver, sonographic dimensions of liver, kidneys and spleen were evaluated. Plasma blood parameters (ALT, AST, total cholesterol, triglycerides) were determined.

RESULTS

Liver was enlarged in 21/22 patients (95.4%) with glycogen storage diseases, in both subjects with disorders of fructose metabolism, and in 2/6 patients (33.3%) with galactosemia. Hepatic echogenicity was increased in 20/22 patients (90.9%) with glycogen storage diseases, and in the subject with hereditary fructose intolerance. Patients with galactosemia did not show increased liver echogenicity. Both kidneys were enlarged in 8/17 patients (47.0%) with glycogen storage disease type I. Subjects with increased hepatic echogenicity exhibited higher plasma concentrations of any blood parameter than the others with normal echogenicity (p<0.05).

CONCLUSIONS

Sonography can be useful in identification of inherited diseases of carbohydrate metabolism even if further examinations are necessary for an ultimate diagnosis.

Body mass index rebound and overweight at 8 years of age in hyperphenylalaninaemic children

AIM

To evaluate whether the age at body mass index (BMI) rebound may be associated with overweight at age 8 y in hyperphenylalaninaemic (HPA) children.

METHODS

A longitudinal observational study including 97 HPA children born 1984-1993 and detected by the National Neonatal Screening programme. Children were followed up at the same institution and evaluated for dietary intakes and anthropometrical parameters from diagnosis up to the age of 8 y. Outcome measure was overweight at age 8 y, defined according to the International Obesity Task Force. The age at BMI rebound, BMI before and at rebound were considered as potential determinants. Familial overweight, breastfeeding and macronutrients intake at age 1 y were considered as confounders.

RESULTS

Mean (95% confidence interval [CI]) age at BMI rebound was 5.0 (4.7-5.3) y. At the age of 8 y, 24.7% (95% CI 16.3-33.1%) of children was overweight. Children overweight at the age of 8 y exhibited earlier BMI rebound than non-overweight children (mean difference [95% CI] -2.1 [-2.8 to - 1.4] y) and higher BMI from the age of 1 y (mean difference [95% CI] 1.2 [0.9-2.5] kg/ m2) onward. Overweight was more likely in children with, rather than without, parental overweight (41.0% vs 19.8%). After adjustment for confounders, logistic analysis showed that earlier BMI rebound (odds ratio [OR] 2.4, 95% CI 1.2-4.8) and BMI at age I y (OR 2.3, 95%CI 1.1-4.98) were independently associated with overweight at the age of 8 y.

CONCLUSION

Within the population of this study, overweight at age 8 y was positively associated with early BMI rebound and BMI at age 1 y.

The headache in the Emergency Department

The headache is a very frequent symptom and represents the 0.36%-2.5% of all reasons of claim to Emergency Department. Even if it is rarely related to high risk diseases, it is mandatory to promptly differentiate life-threatening conditions. In order to establish a correct diagnostic and therapeutic pathway and ask for aimed specialistic consultation, the emergency physician must be familiar with the various categories of headache. It is important to distinguish between essential headache and secondary headache. All patients presenting to the emergency department with the complaint of headache should be interviewed carefully regarding their history. The quality of pain associated with the intensity, location, rate, duration, modality of onset, relieving or worsening conditions, response to drugs, symptoms or signs associated must be investigated as well. Careful neurological examination including the vision of fundus oculi and the evaluation of rigor nucalis can provide further important diagnostic information. Laboratory exams do not usually give significant issues in the majority of patients with headache. However, dosage of inflammation index can be useful when an infective or inflammatory disease is suspected. CT scan can rule-out the suspicion of organic intracranial causes. When the physician suspects meningitis or subarachnoid hemorrhage (SAH) not showed by CT scanning, rachicentesis can turn out diagnostic. The modality of onset, clinical characteristics and differential diagnosis of subarachnoid hemorrhage, intracranial hypertension, colloidal cyst of the third ventricle, trigeminal neuralgia, temporal arteritis and pituitary adenomas and apoplexy will be discussed. These diseases are not only of neurological and neurosurgical interest, but involve also the physician in the Emergency Department.

Long term effects of long chain polyunsaturated fats in hyperphenylalaninemic children

Blood fatty acid status and visual function of 20 treated hyperphenylalaninemic (HPA) children, randomly allocated into two groups to receive supplementation of either long chain polyunsaturated fatty acids (LCPUFA), including docosahexaenoic acid (DHA), or placebo for 12 months, have been investigated three years after the end of the treatment. Although in the LCPUFA group blood DHA levels and P100 wave latency improved at the end of supplementation, they had returned to baseline after three years.

Phenylalanine hydroxylase mutations and phenylalanine-tyrosine metabolism in heterozygotes for phenylalanine hydroxylase deficiency

The aim of this study was to determine whether any relationship exists between the severity of mutation of the phenylalanine hydroxylase (PAH) gene and the plasma concentrations of phenylalanine (Phe) and tyrosine (Tyr) under fasting and semifasting conditions among heterozygotes in a matched case-control study. Parents of patients affected by PAH deficiency (n = 25) detected through the Italian Neonatal Screening Program and referred from January 1994 to June 2000, and parents of healthy children were investigated. In total, 68 subjects without any disease, 34 hyperphenylalaninaemia (HPA) heterozygous parents and 34 age- and gender-matched controls, were recruited. Plasma concentrations of Phe and Tyr in fasting and semifasting (1600 mg Phe oral load) conditions were the main outcome measures. DNA analysis for PAH mutations was performed in all 68 subjects. Compared with controls, heterozygotes showed higher fasting and semifasting Phe concentrations (p < 0.0001), lower semifasting Tyr concentrations (p = 0.015), lower Tyr variations (p = 0.003) and a higher Phe/Tyr ratio (p < 0.0001) in switching from fasting to semifasting conditions. Heterozygotes carrying a severe mutation showed semifasting plasma Tyr concentrations lower than controls (p = 0.019) but not significantly different from Tyr levels found in non-severe carriers (p = 0.197). The Tyr variations were minor in severe carriers than controls (p < 0.001) and non-severe carriers too, although with lower significance (p = 0.089). In six carriers of A403V mutation, parents of mild hyperphenylalaninaemics on an unrestricted diet, significant differences in variations from fasting to semifasting conditions were found compared with parents of patients on a diet.

CONCLUSION

Although the great heterogeneity of PAH mutations limits any general conclusion, the results suggest that monitoring plasma Tyr variations may be more sensitive than plasma Phe in assessing the severity of PAH mutations in HPA heterozygotes.

Clinical and genetic variability of glycogen storage disease type IIIa: seven novel AGL gene mutations in the Mediterranean area

Deficiency of amylo-1,6-glucosidase, 4-alpha-glucanotransferase enzyme (AGL or glycogen debrancher enzyme) is responsible for glycogen storage disease type III, a rare autosomal recessive disorder of glycogen metabolism. The AGL gene is located on chromosome 1p21, and contains 35 exons translated in a monomeric protein product. The disease has recognized clinical and biochemical heterogeneity, reflecting the genotype-phenotype heterogeneity among different subjects. The clinical manifestations of GSD III are represented by hepatomegaly, hypoglycemia, hyperlipidemia, short stature and, in a number of subjects, cardiomyopathy and myopathy. In this article, we discuss the genotypic-phenotypic heterogeneity of GSD III by the molecular characterization of mutations responsible for the disease on a collection of 18 independent alleles from the Mediterranean area. We identified by heteroduplex band shift, DNA direct sequencing, and restriction analysis, seven novel mutations (four nonsense point-mutations: R34X, S530X, R1218X, W1398X; two microinsertions: 1072insT and 4724insAA; and one bp deletion: 676DeltaG), together with two new cases carrying a IVS21 + 1 G --> A splicing site mutation previously described in Italian patients. Altogether, 15 alleles were characterized. The correlation between type of mutation and clinical severity was studied in six patients in whom both mutated alleles were detected. Our data confirm the extreme genetic heterogeneity of this disease, thus precluding a strategy of mutation finding based on screening of recurrent common mutations.

Stenting of atherosclerotic stenoses of the extracranial carotid artery

BACKGROUND

Percutaneous transluminal angioplasty (PTA) and stenting seems to be, at present, the treatment of choice for early restenosis after endarterectomy and for atherosclerotic stenoses of supra-aortic trunks near or at the ostium. In contrast, the role of PTA and stenting for treatment of symptomatic and asymptomatic atherosclerotic stenosis of carotid bifurcation is still debated.

METHODS

The present study comprises 27 consecutive cases of atherosclerotic lesions of the carotid bifurcation treated with PTA and stenting. All patients were symptomatic, except for 2 suffering from asymptomatic stenosis with contralateral carotid occlusion. There were 23 stenoses occluding 70% or more of the lumen according to the NASCET criteria and 4 mild stenoses (50-60% of the lumen) with large type C ulcers. Criteria for exclusion from surgery in these cases were aged >79 years, previous neck surgery for laryngeal cancer, carotid bifurcation at C2, association with intracranial aneurysms, occlusion of the contralateral carotid artery, and heart, lung and kidney diseases. All procedures were performed under local anaesthesia associated with mild sedation in a few cases. In all cases, self-expandable stents (Wallstent) were used. Follow-up ranged from 6 to 37 months.

FINDINGS

Transient neurological deficit occurred in 3 cases (11%). One case (3.7%) experienced a minor stroke at three months. Asymptomatic tight restenosis due to intimal hyperplasia occurred in one case (3.7%). In 8 cases (40%) of complex stenosis involving common and internal carotid arteries there was some loss of contact of the stent with the wall of the common carotid artery in the late follow-up. One case (3.7%) experienced severe and prolonged hypotension and bradycardia during the release of the stent.

INTERPRETATION

From literature data and our results it emerges that periprocedural catastrophic embolism is unlikely to occur. The best results are undoubtedly obtained when treating stenosis limited to the internal carotid artery. Nevertheless, the ideal stent to treat vessels of different calibre, as occurs at the carotid bifurcation, is not yet available. The problem of periprocedural cerebral protection has not been resolved. Reported series are heterogeneous and retrospective, and an adequate follow-up of cases is still lacking.

Sonographic findings in type I glycogen storage disease

PURPOSE

The aim of this study was to document the sonographic appearance and dimensions of the liver and spleen in patients affected by type I glycogen storage disease and to correlate those findings with laboratory data to evaluate the potential role of sonography in diagnosing that disease.

METHODS

Fourteen patients (age range, 3-26 years; 10 patients younger than 18 years) with type I glycogen storage disease proved by liver biopsy were studied prospectively with gray-scale sonography, color Doppler sonography, and spectral analysis. The liver, kidneys, spleen, portal system, hepatic veins, and hepatic arteries were evaluated. Laboratory data were correlated with sonographic findings.

RESULTS

In 13 (93%), of 14 patients, the liver was enlarged, and in 11 patients (79%), hepatic echogenicity was increased. In 9 patients (64%), both kidneys were enlarged, and in 6 cases (43%), the spleen was enlarged. In all patients, flow in the portal, splenic, and superior mesenteric veins was hepatopetal, and flow in the hepatic veins was triphasic. In 5 patients (36%), both triglyceride and total cholesterol levels were higher than normal. No focal hepatic lesions were identified. Analysis found no significant association between sonographic findings and laboratory data.

CONCLUSIONS

The most frequent sonographic findings in patients with type I glycogen storage disease were hepatomegaly, increased hepatic echogenicity, and enlarged kidneys. Sonography may help in the diagnosis of type I glycogen storage disease, but a liver biopsy is required for a definitive diagnosis.

Should genetic analysis in newborn screening and a heterozygote test for hyperphenylalaninaemia be recommended? An Italian study

OBJECTIVE

To determine whether the introduction of genetic analysis for phenylalanine hydroxylase (PAH) deficiency into regional screening programmes can be supported by the benefit-cost ratio.

METHOD

Tests for the genetic PAH locus were carried out in 151 patients with hyperphenylalaninaemia originally from all of the Italian regions. PAH mutations were identified by extraction of genomic DNA from leucocytes (whole blood in EDTA), PAH exon amplification was determined by polymerase chain reaction, restriction enzyme analysis was carried out for some recognised mutations, and DNA sequence analysis for the other mutations.

RESULTS

It was found that the eight most common mutations in the population accounted for 49% of the mutant alleles, which is well below the required standard for effective population screening (90%).

CONCLUSIONS

Genetic screening for PAH deficiency in Italy does not increase the sensitivity of the methodology and the benefit-cost ratio, and thus provides no advantage, particularly as the correlation between genotype and the metabolic phenotype needed to optimise dietary intervention is still being studied.

Surgery and stenting As combined treatment of a symptomatic tandem stenosis of the carotid artery

International co-operative studies have demonstrated a benefit from surgery for symptomatic and asymptomatic patients affected by internal carotid artery stenosis of 60-70%. The presence of a tandem lesion, intracranial or extracranial, may annul the benefit of surgery. Such patients may thus represent a challenging problem for management if age, good general conditions and a normal neurological status favour a therapy. A 54-year-old man developed transient ischaemic attacks of the left hemisphere; his general condition was good, and neurological status was normal. Angiography showed a tight stenosis at the left common carotid artery near the ostium and at the homolateral carotid bifurcation. At first, a self-expanding wall stent was placed at the level of the common carotid artery stenosis, and immediately after a standard endarterectomy under general anaesthesia was performed. The postoperative course was normal and was complicated only by the presence of a mild deficit of the hypoglossal nerve due to the presence of a high bifurcation. The early and late outcome of our case suggests that stenosis of the proximal common carotid artery may be successfully treated by stenting. While awaiting additional data about this new technology, endovascular techniques and surgery may be complementary in the management of patients suffering from such tandem lesions.

[Cerebral blood flow in subarachnoid hemorrhage]

Cerebral blood flow (CBF) following subarachnoid haemorrhage varies according to the time of sampling, with regard to the time of bleeding, to clinical conditions of patients and to any possible occurrence of vasospasm. CBF is proportionally reduced upon clinical conditions, involves the totality of patients and represents a diffuse bilateral phenomenon, not dependent on the location of the aneurysm. Following events, such as vasospasm, may deteriorate haemodynamic conditions, especially when unstable. Thus, CBF monitoring is necessary and useful in these patients. The evaluation of this parameter, according to the metabolic demands, appears rather fundamental. Besides, during the first two weeks, all the available therapeutic strategies have to employed in order to achieve the best optimization of the CBF so as to avoid the occurrence or at least minimising the extent of ischemic cerebral lesions.

[Surgical versus endovascular treatment in cerebral aneurysm. The opinion of a neurosurgeon]

The high risk of rebleeding of ruptured aneurysms imposes the need of their early exclusion from arterial circulation. The onset of endovascular technique of embolization gives a new chance, making, time by time, necessary the choice for the best treatment. The advantages and limits of surgical option are well known and consolidated. The results of endovascular technique are similar in the acute phase, but it lacks an adequate follow up and a clear definition of some technical knowledges. Clinical and anatomical data and a serious analysis of specific technical difficulties of both methods must condition the choice of treatment. Present experience allows us to give sure indications only for certain cases, whereas final landmarks are indisposable in many other situations. However, the team discussion between the neurosurgeon, the neuroradiologist and the neuroreanimator must be the crucial point of the decisional way in every single case.

Dissecting vertebral aneurysm. Report of a case

Aneurysms of the vertebral artery (VA) are relatively uncommon, accounting for less than 0.5-3.0% of all aneurysms and 20% of aneurysms originating in the posterior fossa. There are three distinct forms of aneurysms: saccular, fusiform and dissecting. The diagnosis of dissecting aneurysm is based on the findings of angiography, surgery and autopsy. Irregular fusiform appearance, intramural retention of contrast medium in the venous phase and alternating irregular stenotic and dilated segment (string and pearl sign) are the basal angiographic findings. Patients with dissection of VA often develop subarachnoid hemorrhages (SAHs), with the typical neck pain or suffer cerebral ischemia. Because of the high risk of rebleeding of dissecting aneurysms, they should be treated as soon as possible, with occlusion of the VA. Nowadays, both surgical and endovascular procedures allow the treatment of dissecting vertebral aneurysms. Anyway, one should be aware that vertebral occlusion performed proximal to PICA origin may be followed by ischemic complications. In this paper, we discuss the diagnostic and therapeutic difficulties associated with dissecting vertebral aneurysms on the basis of personal observation and a review of the literature.

Incidence of asymptomatic berry aneurysms among patients undergoing carotid endarterectomy

BACKGROUND

Scattered reports of literature suggest the hypothesis that patients suffering from a severe stenosis of extracranial carotid artery may present an increased rate of intracranial berry aneurysms caused by the hemodynamic stress on the side opposite to the stenosis, namely on physiological shunts. However, this hypothesis has never been verified upon a large and homogeneous series focused on the argument.

MATERIALS AND METHODS

We reviewed a consecutive series of 405 patients submitted to carotid endarterectomy for stenosis greater or equal to 70%.

RESULTS

Thirteen aneurysm were found in 11 patients (2.6%). Our patients showed a slight increase of incidence regards to general population (1%), maybe due to the large number of aged patients among our subpopulation. Preoperative TCD evaluation showed the presence of increased flow velocities in the physiological shunts, namely the anterior cerebral artery and the anterior communicating artery, in 65% of the patients, and angiography confirmed the redistribution of intracranial circulation. Nevertheless, according to aneurysm location, no statistically significant correlation (0.3 < p < 0.4) was found between the presence of an aneurysm and the values of velocity in these arteries.

CONCLUSIONS

As regards the etiology of berry aneurysms, these data suggest that increased hemodynamic stress per se is not sufficient to cause the origin of berry aneurysms. Maybe, a role is possible only if either congenital, or acquired and age-related factor, peculiar of cerebral arteries, coexist.

Combined transcranial Doppler and electrophysiologic monitoring for carotid endarterectomy

The results of carotid endarterectomy can be improved by reducing the perioperative embolic and hemodynamic risks. Electrophysiologic monitoring, although reliable, cannot provide full information. In this study, we report on the combined use of transcranial Doppler (TCD) and electrophysiologic monitoring in 153 patients undergoing 166 carotid endarterectomy procedures. TCD monitoring confirmed the low incidence of intolerance to cross-clamp (1.8%), showing a good correlation with electrophysiologic monitoring. In addition, it frequently showed embolic signals immediately after clamp release, but never during carotid dissection or in the final operative phases. Furthermore, TCD allowed the detection of hyperperfusional flow patterns in four cases, making immediate and aggressive control of arterial pressure possible.

Electrophysiological (EEG-SSEP) monitoring during middle cerebral aneurysm surgery

SSEPs were monitored during 38 procedures for aneurysms of the middle cerebral artery. In 13 selected patients intraoperative barbiturate protection with sodium thiopental was performed during temporary M1 occlusion. Combined EEG monitoring, showing burst suppression typical pattern of electrical cortical activity, allows a minimal dosage (3-6.5 mg/kg) of thiopental to achieve brain protection. Any patient with TYPE I SSEP changes had a new postoperative neurological deficit. Five patients during temporary middle cerebral artery clipping showed TYPE II SSEP changes and only one, not achieving burst suppression EEG pattern, had transient postoperative neurological deficit. In two other patients, a progressive worsening of TYPE II SSEP was observed; this was due to excessive brain retraction without brain protection and had a prolonged postoperative neurological deficit. Four patients showed TYPE IV SSEP changes during temporary M1 occlusion, one of whom was a 52-year-old woman, who, in spite of brain protection with thiopental, had serious postoperative neurological sequelae. In this patient N20 amplitude and central conduction time did not have full recovery to the preocclusive values. This study suggests that combined electrophysiological monitoring may reduce complications due to excessive retraction of cerebral tissue, make temporary clipping safer and improve the results of middle cerebral artery aneurysm surgery.

Management of symptomatic carotid stenoses with coincidental intracranial aneurysms

There are at present strong indications for surgery in patients suffering from symptomatic extracranial carotid stenoses of > 70%. Surgery of coincidental aneurysms is a still debated problem, but there is general agreement that it is indicated in selected cases according to the patient's life-expectancy and size and site of the aneurysm. The coexistence of these two lesions raises a decision-making problem. We reviewed 389 endarterectomies and found 12 intracranial berry aneurysms in 10 (2.6%) patients. All the 10 patients were harbouring a symptomatic carotid stenosis of > 70%. Since the correction of a stenosis increases blood flow to an aneurysm, our approach was to first operate on the intracranial lesion and then the stenosis in 7 patients harbouring aneurysms > 5 mm. Two patients affected by small aneurysms < 5 mm of an A2 azygos and left internal carotid artery underwent left endarterectomy only. The last patient was submitted first to percutaneous angioplasty of a left stenosis, then to open surgery of a contralateral middle cerebral aneurysm and finally to intravascular occlusion of a small aneurysm of the left internal carotid bifurcation by menas of a coil; this policy was adopted in order to restore normal haemodynamic conditions before the intracranial procedure. There was no mortality or permanent morbidity following surgery for aneurysm or endarterectomy. Transient morbidity occurred in 2 cases after clipping of aneurysms of the anterior communicating and middle cerebral arteries. Our results suggest that surgery of coincidental aneurysms may give good results even when there is a severe symptomatic stenosis in the neck. Moreover, the presence of a small intracranial aneurysm does not seem to be an additional risk factor for endarterectomy. When the lesions are on different sides, it may be better to treat the stenosis first if it decreases the ipsilateral cerebral blood flow.

Early breastfeeding is linked to higher intelligence quotient scores in dietary treated phenylketonuric children

Strict control of phenylalanine intake is the main dietary intervention for phenylketonuric children. Whether other dietary-related factors improve the clinical outcome for treated phenylketonuric children in neurodevelopmental terms, however, remains unexplored. We retrospectively compared the intelligence quotient (IQ) score of 26 school-age phenylketonuric children who were either breastfed or formula fed for 20-40 days prior to dietary intervention. Children who had been breastfed as infants scored significantly better (IQ advantage of 14.0 points, p = 0.01) than children who had been formula fed. A 12.9 point advantage persisted also after adjusting for social and maternal education status (p = 0.02). In this sample of early treated term infants with phenylketonuria there was no associated between IQ scores and the age at treatment onset and plasma phenylalanine levels during treatment. We conclude that breastfeeding in the prediagnostic stage may help treated infants and children with phenylketonuria to improve neurodevelopmental performance.

Electrophysiological monitoring for selective shunting during carotid endarterectomy

Selective shunt during carotid endarterectomy is more and more widespread, but it requires a monitoring system able to identify severe brain ischemia correctly. In 255 endarterectomies for severe carotid stenosis, we evaluated cerebral activity by means of sequential use of computerized two-channel electroencephalogram (EEG) and somatosensory evoked potentials (SSEPs). In 1.96% of cases, we observed changes referable to severe cerebral ischemia: in one case, in spite of shunting, EEG asymmetry persisted till the end of the operation, and the patient awoke with irreversible aphasia. In two other cases, a progressive disappearance of the cortical wave (N20) occurred in spite of a normal EEG pattern. None of the unshunted patients had postoperative deficit. Computerized EEG is an easily interpretable method of monitoring and reveals rapidly developing cerebral ischemia, but severe SSEP changes can occur in spite of a normal EEG pattern when cerebral ischemia has a slow onset. Although SSEP monitoring is a slower method of recording, it can give a finer distinction of less severe cerebral ischemia.

Anterior fossa dural arteriovenous malformation discovered by means of PW-Doppler examination

One case of dural arteriovenous malformation in the base of the anterior cranial fossa is reported. It was discovered by means of a PW-Doppler examination of angular branch of the ophthalmic artery in a patient under observation for hypertrophy of a superficial temporal artery. The nidus was located in the region of the cribriform plate and fed by the anterior ethmoidal arteries of both sides, draining into the superior sagittal sinus, via pial enlarged veins. The patient successfully underwent surgical treatment and a post-operative PW-Doppler confirmed normalization of the flow pattern in the angular branches of both ophthalmic arteries.

Ruptured cerebral aneurysms operated on with only MRA. Reports of two cases

Two cases of ruptured aneurysms of anterior communicating artery were reported. The aneuryms were showed only by means of MR angiography and operated on without conventional angiography, since patients' allergy to drugs and medium contrast. The MRA showed precisely the sites of the aneurysm and the directions of the sac, but underestimated the size of the sac. In spite of the lack of angiograms induced a great caution during the dissection of the aneurysm and made necessary a larger operative field, anyway clipping of the aneurysm's neck was performed without great difficulties.

The role of pulse-wave Doppler sonography in quantifying internal carotid stenosis

To determine the accuracy of pulse-wave Doppler (PWD) sonography in quantifying cervical internal carotid artery (ICA) stenosis, we compared results of PWD with conventional digital subtraction angiography (DSA). A total of 202 carotid arteries were evaluated by means of these two techniques. The patients were divided into four groups according to the percentage of angiographic carotid stenosis as suggested by NASCET. A mathematic model of quadratic relationship between DSA stenosis and blood flow velocity, recorded by PWD, was worked out; peak systolic velocity and mean velocity values, corresponding to 70% DSA stenosis, were employed as key values to check PWD ability to detect high-grade stenosis. Finally, for each case, the correlation between the two techniques was evaluated. PWD well correlates with DSA, making it possible to detect and correctly quantify high-grade ( > 70%) ICA stenosis. In 4 cases with moderate ICA stenoses, blood flow velocity values were over the key values: in cases of moderate angiographic ICA stenosis, PWD identifies those patients in whom the haemodynamic pattern is comparable to the higher group, providing further matter for discussion in order to define surgical selection criteria.

CDP-choline in the treatment of chronic cerebrovasculopathies

Ninety-two patients affected by chronic cerebrovasculopathy were treated with cytidine diphosphate choline (CDP-choline) 1000 mg/day i.m. or with placebo, in a double-blind study. Two cycles of therapy of 4 weeks each were performed, with an interval of 1 week. There were 46 patients in each group with chronic cerebrovascular diseases, and the two groups were comparable as far as mental deterioration was concerned. The following psychometric tests were administered: Toulouse-Piéron (attention to non-verbal stimuli), Randt Memory test (memory), Sandoz Clinical Assessment of Geriatrics (SCAG, measurement of the behavioral and emotional control). The comparison between the two groups revealed significant improvements in the CDP-choline group compared with the placebo group in some of the attention capabilities (decrease in the number of wrong answers at the Toulouse-Piéron test), of the mnemonic capabilities ('General Information' subtest of Randt Memory test) and behavioral capabilities (SCAG 'affective disturbances' score). No side-effects were detected in the CDP-choline group.

In vivo radiofrequency-based ultrasonic tissue characterization of the atherosclerotic plaque

BACKGROUND AND PURPOSE

The ultrasonic image can offer unique information on the composition of atherosclerotic plaque, ie, the relative content of lipids, fibrous tissue, and calcific deposits. To date, however, the echographic assessment of plaque structure is based on a subjective, qualitative evaluation of the bidimensional images. We evaluated the feasibility and accuracy of assessing, in vivo, the acoustic properties of arterial carotid plaques by means of a suitably modified echographic apparatus allowing direct access to the radiofrequency signal.

METHODS

In 15 patients undergoing carotid thromboendarterectomy, the ultrasonic findings in 70 discrete sites (within the plaque, n = 54; normal sites, n = 11; or intraluminal thrombi, n = 5) were correlated with the histological analysis (hematoxylin-eosin and Mallory trichrome stains) independently performed on the arterial samples. The pathological examination was carried out at a similar level of the insonation; the sites analyzed within the plaque were chosen because of their uniform echoic characteristics. In each ultrasonic region of interest selected from the echographic image, the integrated amplitude of the rectified radiofrequency signal was measured as the integrated backscatter index.

RESULTS

The intimal-medial layer of normal carotid wall (n = 11) exhibited values of -32.5 +/- 9.4 dB. The integrated backscatter index in fatty sites (n = 11, -40.3 +/- 5.4 dB) differed from that of fibrous (n = 12, -23.8 +/- 5.0 dB) and calcified (n = 26, -11.5 +/- 5.2 dB, P < .01 for all intergroup differences) sites. Intraluminal thrombotic sites (n = 5, -42 +/- 5.1 dB, P < .01) differed from fibrous and calcified subsets (P < .01) but overlapped (P = NS) with fatty sites. Histological sampling also showed two sites of intraplaque hemorrhage that exhibited very low backscatter values (-53 and -58 dB) and three fibrofatty sites showing backscatter values (-28, -28, and -32 dB) intermediate between the fibrous and the fatty subsets.

CONCLUSIONS

Quantitative analysis of integrated backscatter of the arterial wall is feasible in humans and provides an operator-independent assessment of plaque echoic structure. In particular, integrated backscatter is effective in distinguishing lipidic, fibrotic, and calcific components in human atherosclerotic plaques.

Primary cauda equina tumors

During the last seven years (1985-91) 28 primary tumours in the cauda among 104 intraspinal tumors were observed. The largest group (71%) comprised ependymomas and neurinomas. The rest included 5 lipomas, 2 astrocytomas and 1 epidermoid. Low-back pain without or with sciatic or crural irradiation was the most common initial symptom. The length of symptomatology is generally measured in months, because pain is erroneously referred to discal pathology for long time. The X-ray standard test and the CT scan have been of modest utility in the diagnosis of these lesions, but however they have been necessary for diagnostic screening. The MNR, a bloodness test, showed an important diagnostic value for the identification of these tumors; it is also useful in follow-up to exclude recurrence. The lipoma's and ependymoma's surgery, although performed by microsurgical techniques, showed great problems. Total removal of the ependymomas assured no recurrence at the follow-up. Sphincter disturbances were frequent after the operation, but they disappeared after some months. In most patients with lipomas the resection was partial, but at follow-up they were symptomless. Neurinomas' surgery presented less technical difficulties and the postoperative course was more favorable. Astrocytomas underwent to radiotherapy but their prognosis is not favorable.