Thunderclap headache caused by spontaneous intracranial hypotension

We report a group of 4 patients with thunderclap headache as the initial manifestation of spontaneous intracranial hypotension.

Spontaneous cerebrospinal fluid leak syndrome: report of 18 cases

We examined a group of 18 consecutive patients with spontaneous cerebrospinal fluid leak syndrome (SCSFLS) and investigated clinical, MRI, radioisotope findings and therapeutic outcome of this syndrome.

Gonadotropin-releasing hormone initiates multiple signaling pathways in human GH-secreting adenomas

Abnormal GH responses to GnRH test, observed in about 15% of patients with acromegaly, have been reported exclusively in patients bearing tumors without gsp mutation. The absence of responsiveness to GnRH in gsp+ tumors was not predicted on the basis of the mechanism of GnRH action that mainly involves the activation of calcium and protein kinase C dependent pathways. The aim of the present study was to investigate in detail the transduction of GnRH signaling in these tumors. GH-secreting adenomas removed from patients in vivo responsive to GnRH test were studied. Tumor DNA was screened for Gsalpha and GnRH receptor gene sequences. Intracellular calcium ([Ca2+]i) and cAMP levels were measured in dispersed cells and adenylyl cyclase (AC) activity in membrane preparations. DNA analysis showed wild sequence of both Gsalpha and GnRH receptor genes. GnRH caused a significant increase in intracellular Ca2+ that was associated with a significant stimulation of cAMP accumulation. In these cells neither TRH nor GHRP-6 were effective in causing significant modifications of cAMP levels, despite their ability to increase [Ca2+]i. Finally, GnRH was able to directly stimulate AC from 11.1 +/- 3.3 pmol/mg prot/min to 26.9 +/- 5.4 (p<0.005). We report that GnRH was effective in increasing both [Ca2+]i and AC in GH-secreting adenomas removed from responsive patients. The ability of GnRH to signal through Gsalpha protein may account for the lack of GH responses to GnRH observed in acromegalic patients with tumors carrying gsp mutation.

Postural headache in a patient with Marfan's syndrome

A 26-year-old man with Marfan's syndrome had postural headache. Brain MRI with gadolinium showed diffuse pachymeningeal enhancement. MRI myelography revealed bilateral multiple large meningeal diverticula at sacral nerve roots level. He was suspected to have spontaneous intracranial hypotension syndrome. Eight days later headache improved with bed rest and hydration. One month after the onset he was asymptomatic and 3 months later brain MRI showed no evidence of diffuse pachymeningeal enhancement. The 1-year follow-up revealed no neurological abnormalities. The intracranial hypotension syndrome likely resulted from a CSF leak from one of the meningeal diverticula. In conclusion patients with spinal meningeal diverticula (frequently seen in Marfan's syndrome) might be at increased risk of developing CSF leaks, possibly secondary to Valsalva maneuver or minor unrecognized trauma.

Pathophysiology, clinical manifestations and supportive care of metastatic brain cancer

Brain metastases (BrM) are tumours that originate in tissues outside the central nervous system and spread secondarily to involve mainly the brain. The management of patients with cerebral metastases is complex, costly, and in some instances controversial. Furthermore, even in patients with widespread systemic cancer, the symptoms of the disease are often controllable while the symptoms of the BrM may be disabling. The treatment of BrM is one of the few areas of neuro-oncology where real progress has been made in the last twenty years. Moreover, the costs of managing this disease are rising, as therapies become more intensive and the number of patients with BrM increases. Modern neuroradiological imaging techniques, which are able to discover BrM earlier in the course of systemic cancer, and the greater efficacy of specific treatments, which lengthens survival, have increased the prevalence. The aggressive treatment of BrM may add some benefits to the patient, but its excessive cost leads to the necessity for accurate cost-effectiveness analysis. The latter begins with a complete understanding of the disease: its diagnosis, natural history and results of various modalities of treatment. While the development of BrM usually indicates a poor prognosis for the patient, advances in supportive care have made it possible to reverse most of the neurological symptoms and to give patients a meaningful extension of useful life.

Current practice in assessment and treatment of bronchial asthma in young males in Italy

The aim of the study was to evaluate, in a sample of young asthmatics in Italy, the current practice in assessment and treatment of asthma after the publication of guidelines. Young soldiers who declared bronchial asthma at the beginning of the compulsory military service were evaluated. One-hundred and thirty-eight subjects with confirmed asthma were selected. Sixty-seven subjects (48.5%) had had at last one spirometry, and only one subject had underwent peak flow monitoring at home; most of the subjects (96.8%) had had prick tests. More of the 50% of the subjects with bronchial obstruction or with severe bronchial hyperresponsiveness, with clinical moderate or severe asthma, had used only bronchodilators or no therapy at all in the preceding year. In this sample of young asthmatics, the lung function tests were still underutilized for the diagnosis and follow-up of bronchial asthma; moreover, the inhaled anti-inflammatory drugs were still underutilized.

Hypoxemia in young asthmatics with mild airway obstruction by methacholine challenge

We studied 12 asymptomatic conscripts affected by bronchial asthma to evaluate the level of hypoxemia and its relationship with bronchial obstruction induced by methacholine (Mch) challenge. Arterial blood samples were obtained before and immediately after bronchial challenge. The range of decrease of forced expiratory volume/forced vital capacity x 100 in 1 second of expiration (FEV1), the absolute value reported as a percentage of the baseline value, after Mch challenge was from 21% to 36%. The mean decrease of arterial oxygen tension was 27 mm Hg (from 11.4 to 39.8 mm Hg), the mean decrease of hemoglobin saturation was 3.53% (from 0.4 to 7.2), and the mean increase of alveolar-arterial gradient for oxygen was 28.2 mm Hg. We found a significant correlation between the prechallenge and postchallenge differences of arterial oxygen tension and FEV1 (DFEV1P), which was expressed as a percentage of the predicted value. In conclusion, the Mch challenge seems to be a safe test, and the decrease of arterial oxygen tension can be sufficiently predicted by DFEV1P.

[Nutritional status, obesity, and metabolic balance in pediatric patients with type I diabetes mellitus]

BACKGROUND AND AIMS

The aim of this study was to evaluate the nutritional status of children with type 1 diabetes and to search for possible influences of changes in body composition on aspects of diabetes.

METHODS

A group of 96 diabetic subjects (41 males and 55 females) were studied, aged between 3 and 19 years old. The following parameters were examined: weight, stature, 5 skin folds, 7 circumferences, bioelectric impedance, arterial pressure, cholesterolemia, triglyceridemia, insulin dose, HbA1c and duration of disease.

RESULTS

Obesity and overweight were present in 34.5% of the sample, but obesity was only observed in females (25.5%). There was also a high percentage of underweight subjects (11.5% of the entire sample). The mean values of weight BMI, 5 skin folds, 4 circumferences, FM (calculated using fold measurement and BIA) and AFA were higher in females, whereas mean values of waist/hip ratio and waist/thigh ratio and FFM (in % of body weight) were higher in males. A close correlation was also found between the 4 weight classes (underweight, normal weight, overweight, obese) and the majority of marker parameters for adiposity (5 folds, 4 circumferences, BIA, FM calculated using BIA, fold measurement and AFA). Of the other parameters examined (mean duration of disease, HbA1c assay, daily insulin dose, total cholesterolemia, triglycerididemia, arterial pressure), only the daily insulin dose showed higher values in females in 3 weight classes (underweight, normal weight and obese). Following a comparison with the control population (2469 subjects), higher mean values were found in the latter compared to diabetic subjects, but only in relation to 3 skin folds (tricipital, subscapular and suprailiac) and one circumference (forearm).

CONCLUSIONS

The study shows a high frequency of overweight and obesity in children with type 1 diabetes, comparable to that in the healthy population. The finding of a higher frequency of obesity in diabetic females might be explained by their advanced puberal status, given that almost all the obese diabetic females were aged between 10 and 19 years old. The study confirms the validity of a number of anthropometric measurements (BMI, folds, circumference) and BIA in the evaluation of nutritional status in terms of body composition.

[Nutritional status, obesity and metabolic control in children with type 1 diabetes mellitus]

BACKGROUND AND AIMS

The aim of this study was to evaluate the nutritional status of children with type 1 diabetes and to search for possible influences of changes in body composition on aspects of diabetes.

METHODS

A group of 96 diabetic subjects (41 males and 55 females) were studied, aged between 3 and 19 years old. The following parameters were examined: weight, stature, 5 skin folds, 7 circumferences, bioelectric impedance, arterial pressure, cholesterolemia, triglyceridemia, insulin dose, HbA1c and duration of disease.

RESULTS

Obesity and overweight were present in 34.5% of the sample, but obesity was only observed in females (25.5%). There was also a high percentage of underweight subjects (11.5% of the entire sample). The mean values of weight BMI, 5 skin folds, 4 circumferences, FM (calculated using fold measurement and BIA) and AFA were higher in females, whereas mean values of waist/hip ratio and waist/thigh ratio and FFM (in % of body weight) were higher in males. A close correlation was also found between the 4 weight classes (underweight, normal weight, overweight, obese) and the majority of marker parameters for adiposity (5 folds, 4 circumferences, BIA, FM calculated using BIA, fold measurement and AFA). Of the other parameters examined (mean duration of disease, HbA1c assay, daily insulin dose, total cholesterolemia, triglycerididemia, arterial pressure), only the daily insulin dose showed higher values in females in 3 weight classes (underweight, normal weight and obese). Following a comparison with the control population (2469 subjects), higher mean values were found in the latter compared to diabetic subjects, but only in relation to 3 skin folds (tricipital, subscapular and suprailiac) and one circumference (forearm).

CONCLUSIONS

The study shows a high frequency of overweight and obesity in children with type 1 diabetes, comparable to that in the healthy population. The finding of a higher frequency of obesity in diabetic females might be explained by their advanced puberal status, given that almost all the obese diabetic females were aged between 10 and 19 years old. The study confirms the validity of a number of anthropometric measurements (BMI, folds, circumference) and BIA in the evaluation of nutritional status in terms of body composition.

Transient oculomotor cranial nerves palsy in spontaneous intracranial hypotension

Transient sixth cranial nerves palsy may occur in rare cases after lumbar puncture, spinal anesthesia and myelography as well as in more rare cases of spontaneous intracranial hypotension. We report three cases of spontaneous intracranial hypotension with sixth cranial nerves palsy. One of these patients presented also third cranial nerve palsy, never reported in spontaneous intracranial hypotension.

Intracranial hypotension syndrome: neuroimaging in five spontaneous cases and etiopathogenetic correlations

Intracranial hypotension (IH) is essential or, more frequently, secondary. This syndrome is characterized by severe postural headache and low opening cerebrospinal fluid (CSF) pressure; although other symptoms may exist. In this study five patients are investigated. Neuroimaging showed: on computerized tomography scan (CT), poor visualization of the cerebral sulci with small ventricles; on magnetic resonance imaging (MRI), subdural fluid collections with enhancement on the convexity, along the tentorium and in the upper cervix after administration of contrast medium and downward displacement of the brain. Radionuclide cisternography was normal in the two patients who underwent this treatment as well as the meningeal biopsy in another patient. In all patients the opening CSF pressure was low or unmeasurable. The clinical syndrome spontaneously recovered contextually to normalization of neuroradiological findings. The possible pathogenesis (dural border cell layer tear) was discussed and the importance of diagnostic confirmation with MRI and measurement of CSF pressure when IH is thought to be present was underlined.

Immunological and endocrinological abnormalities in paraneoplastic disorders with involvement of the autonomic nervous system

We report a series of four patients in whom the onset of systemic cancer was heralded by dysautonomic symptoms and a neurological non-metastatic complication mediated by immunological and endocrine factors. The series includes: a patient with acute leukaemia and autonomic sensory-motor polyradiculoneuropathy, a patient affected by colon carcinoma and autonomic neuropathy and limbic encephalitis, a patient with lung cancer and autonomic neuropathy and hypercalcaemic encephalopathy, a patient with small cell lung cancer associated with autonomic neuropathy in Lambert-Eaton Myasthenic Syndrome (LEMS) and syndrome of inappropriate ADH secretion (SIADH). We underline the prognostic importance and discuss the possible etiopathogenetic role of autonomic dysfunction, which is frequently associated with paraneoplastic neurologic syndromes of autoimmune and/or dysendocrine origin.

[Central pontine myelinolysis as potential complication of cerebellar astrocytoma: report of a case]

Central pontine myelinolysis (CPM), a rare condition first observed by Adams et al. in 1959 in a group of malnourished chronic alcoholic subjects, has subsequently been seen in patients treated with thiazide diuretics, patients hyperhydrated postoperatively, and in other clinical situations. it is characterized by quadriplegia and pseudobulbar palsy which sometimes evolves into a locked-in syndrome. The rapid correction of severe hyponatremia (> 12 mmol/L/24 h) seems to be the causal factor, with consequent osmotic edema in the richly vascularized white matter of the pons as the proposed pathogenetic mechanism. We describe the case of a chronic psychotic man with nutritional disorders and inappropriate water intake who came to our attention for a clinical picture of CPM. Neuroradiological findings and postmortem studies revealed a slow-growing cerebellar astrocytoma in addition to the typical features of CPM. We discuss the hypothesis that damage to the nervous pathways and centers involved in water and electrolyte regulation could be the causal factor of CPM pathogenesis in this case.

Primary intracranial hypotension: pathogenetic and neuroradiological considerations

Primary or spontaneous intracranial hypotension (SIH) is a rare syndrome which causes postural headache associated with spinal fluid hypotension. We report three cases of SIH, characterised on magnetic resonance imaging (MRI) by pachymeningeal enhancement not only at cerebral level, but also in the cervical spinal cord, which subsequently resolved completely and spontaneously. We discuss the possible pathogenetic mechanisms of the dural alterations and underline the radiological aspects.

Effects of a filter at the mouth on pulmonary function tests

The aim of this study was to verify whether the increase of resistance to airflow using a filter at the mouth could determine significant systematic errors of measurement or change the diagnostic performance in a respiratory physiology laboratory. The effect of the new filter Spirobac (DAR Spa, Italy) was assessed on out-patients referred to our laboratory for routine functional evaluation. The following tests were performed: maximal expiratory flow-volume curve, plethysmographic lung volume and airway resistance, bronchodilator test, and methacholine challenge test. Each test was performed randomly, twice with the filter and twice without. Significant differences between measurements with and without filter were found for forced vital capacity, forced expiratory volume in one second, airway resistance, and specific airway conductance (sGaw). These differences were unrelated to the average values of the measurements, except for sGaw. The limits of agreement were within the range of intraindividual short-term repeatability for almost all of the function indices. The overall concordance between tests performed with and without filter was 78% for bronchodilator test and 53% for methacholine test. However, in all the cases but one, the concordance of the methacholine test was inside the short-term repeatability. We conclude that the filter Spirobac has a statistically significant effect on the results of some pulmonary function tests. However, this is not considered to be clinically significant, since the changes due to the filter were within the intraindividual variability of repeated measurements for almost all the function indices and no appreciable classification error was found in diagnostic tests.

Coeliac disease, enamel defects and HLA typing

The presence of dental enamel defects in coeliac disease and their relation to hypocalcaemia or a particular HLA class in 82 Italian children with coeliac disease was studied. Demarcated opacities or hypoplasia were detected in 23 subjects (group 1) while minimal or no dental lesions were found in the remaining 59 patients (group 2); in 189 normal controls, enamel lesions were significantly less frequent than in patients with coeliac disease (14.8% versus 28.0%; p < 0.005). No statistically significant differences were found for age at diagnosis and calcium concentrations between groups 1 and 2. Regression analysis showed a correlation between age at diagnosis and number of teeth with enamel defects. In our patients, the presence of HLA DR3 antigen significantly increased the risk of dental lesions, while genotype DR5,7 seemed to protect against enamel defects. A logistic regression analysis of the variables age, serum calcium concentrations, number of affected teeth, type of enamel defect and DR antigens showed that only DR antigens discriminated coeliac disease patients with from those without enamel defects.

A dosage sensitive locus at chromosome Xp21 is involved in male to female sex reversal

Male to female sex reversal has been observed in individuals with duplications of the short arm of the X chromosome. Here we demonstrate that sex reversal results from the presence of two active copies of an Xp locus rather than from its rearrangement and that alterations at this locus constitute one of the causes of sex reversal in individuals with a normal 46,XY karyotype. We have named this locus DSS (Dosage Sensitive Sex reversal) and localized it to a 160 kilobase region of chromosome Xp21, adjacent to the adrenal hypoplasia congenita locus. The identification of male individuals deleted for DSS suggests that this locus is not required for testis differentiation. We propose that DSS has a role in ovarian development and/or functions as a link between ovary and testis formation.

[Retrospective study on weaning in Rome and its province. Results and critical considerations]

The authors report and comment on the results of an epidemiological retrospective study on weaning. The study was performed in Rome and its province through the administration of a structured interview to the parents of 851 children, aged between 6 months and 3 years. Data show that most children are correctly weaned, in terms of both timing and quality of foods. In some cases, however, incorrect dietary habits were found, such as: too early (usually together with too early administration of gluten-containing foods) or too late weaning, and use of cow's milk instead of follow-up formulae during the second semester of life. Data presented here show that the early weaning significantly correlates with a maternal low degree of education and short period of breast-feeding. On the basis of their data and according to the international literature, the authors present some new weaning suggestions: these could help decrease the present gap between recommended dietary allowances and real consumption in this age group.

Bronchial asthma: still an inadequately assessed and improperly treated disease

In this paper we present data on the assessment and treatment of asthma in a large sample (13,899 subjects) representative of the population of young males living in four districts of the Tuscany region (Italy). In this group, 404 asthmatics (2.9%) were identified and 365 of the eligible patients were included in the study. A total of 323 asthmatics (88.5%) reported respiratory symptoms during the preceding year. A total of 162 asthmatics (44%) had previously had lung function tests to assess asthma, whereas in 89% of the patients the atopic component of asthma had been previously evaluated by prick tests. Fifty-seven percent of the patients in whom bronchial obstruction was observed and 38% of the asthmatics with severe bronchial hyperresponsiveness (BH) were receiving either no medication or treatment with only one drug. The drugs prescribed most frequently during the preceding year were beta agonists (56%) as opposed to sodium cromoglycate (22%) and inhaled steroids (17%); the latter two drugs were included in the therapy of 143 asthmatics (39%) and represented the treatment of choice in 16% of the subjects with bronchial obstruction and in 38% of the subjects with severe BH. We conclude that in our sample of young asthmatics the pulmonary function tests and the inhaled anti-inflammatory drugs were insufficiently utilized.

The relationship between sporting activity and smoking habits in young adults

The authors investigated the relationship between sporting activity and smoking habits in young Italian men. One thousand, one hundred fifty-three men, age 20 years, completed a self-administered questionnaire on their smoking habits and sporting activity patterns. Five hundred sixty subjects (53%) were found to be smokers, with a high prevalence of heavy smokers (33.6%). Four hundred sixty-four (44%) of the examined subjects were sportsmen. In the group of young men not engaged in sports, the rate of smokers was significantly higher. Non-sportsmen started smoking earlier than sportsmen, and the prevalence of heavy smokers was significantly higher in the non-sportsmen group than in the sportsmen group. Finally, the young men not engaged in sports were more likely to be habitual smoke inhalers than sportsmen. These results suggest that sporting activity may indirectly influence smoking habits.

[The evaluation of body composition in children by anthropometry and impedance measurement]

Several anthropometric parameters (weight, height, thickness skinfolds, and body circumferences) together with the bioelectric impedance (BIA) were measured in a group of 407 healthy prepuberal children (205 males, mean age +/- SD: 6.8 +/- 1.6 years; 202 females, mean age +/- SD: 6.6 +/- 1.6 years) who did not practice any competitive sport. The group was divided into six weight classes (underweight to obese 3). The average values of the anthropometric data, BIA, FM (which is derived from the thickness skinfolds and BIA), TBW (derived from BIA), AFA and AMA (both derived from the forearm circumference and triceps skinfold) were all evaluated in relation to sex and weight classes. The average values of all the measured thickness skinfolds, FM and AFA were higher in the females. When considering the body circumferences, only the wrist circumference showed a statistically significant difference between sexes, being higher in males. In contrast both the rates waist/hips circumferences and waist/thigh circumferences were higher in males. As far as the BIA and FM average values is concerned, these were higher in females. The average value of FM derived from measuring the thickness skinfolds (males = 17.65 +/- 4.89%: females = 23.81 +/- 4.72% of body weight) proved higher than that one derived from BIA (males = 17 +/- 9.02%; females = 19.27 +/- 9.18%). The analysis of anthropometric and BIA data in relation to the weight classes showed significant variations of the mean values, except the rates waist/hips circumferences and waist/thigh circumferences. Therefore our data seem to exclude the presence of any difference of the fat distribution between sexes in paediatric age.(ABSTRACT TRUNCATED AT 250 WORDS)

[The usefulness of the skeleton in the diagnosis of malformation]

Most malformation syndromes (70%) show evidence of skeletal anomalies, mainly in the vertebral bodies and in the bony segments of the limbs. This explains the importance of studying the skeleton when faced with any multi-malformation syndrome, using techniques like CT, MRI, echography and densitometry as well as standard radiology. To increase the quantity of information available for diagnostic purposes it would be profitable to create a data bank containing all the possible radiological findings encountered in the numerous multi-malformation syndromes.

[The nonspecific bronchial stimulation test with methacholine and an ultrasonic mist of distilled water: which is to be preferred in the military sphere?]

The authors compare the methacholine (Mch) and the nebulized ultrasonic distilled water (NUDW) bronchial challenge as regard sensitivity and time required to perform them. For military service fitness, were studied 24 asthmatic patients. Each subject performed random a bronchial challenge by Mch (Yan method) and by NUDW (Allegra method) in two different days; for each bronchial challenge has been measured the time required to perform it. The atopic status has been evaluated by skin-prick test. All the subjects have shown a positive response to Mch test (PD 20 FEV1 mean: 352 mcg, range 80-850) whereas 13 subjects (54%) have shown a positive response to NUDW. The time required to evaluate all the subjects by Mch test has been 199.5 minutes whereas the total time required to evaluate all the subjects by NUDW test (127 minutes) and to evaluate by Mch test the non responders to NUDW (100 minutes) has been 227 minutes. The most of subjects were skin reactors. No difference was found as regard onset of disease, basal lung function and atopic status between responders and non responders to NUDW test. We conclude that NUDW test has shown a lack of sensitivity in this sample (50% of asthmatic patients could be misdiagnosed) and that the Mch test is preferable to determine a rapid method for measurement of bronchial responsiveness.