Neurosurgery at an earlier stage of Parkinson disease: A randomized, controlled trial

BACKGROUND

Stimulation of the subthalamic nucleus is an effective treatment for advanced Parkinson disease (PD) and is currently performed after a mean disease duration of 14 years, when severe motor complications have resulted in marked loss of quality of life. We examined whether surgery at an early stage would maintain quality of life as well as improve motor function.

METHODS

Twenty patients with PD of short duration (time elapsed since first symptom +/- SD: 6.8 +/- 1.0 years) with mild to moderate motor signs (Unified Parkinson's Disease Rating Scale III "off" medication: 29 +/- 12) who responded well to levodopa treatment were included in pairs, matched for age, duration and severity of disease, and impairment in socioprofessional functioning. Patients were prospectively randomized to undergo bilateral subthalamic nucleus stimulation (n = 10) or receive optimized medical treatment (n = 10). Parkinsonian motor scores, quality of life, cognition, and psychiatric morbidity were assessed at inclusion and at 6, 12, and 18 months after randomization.

RESULTS

Quality of life was improved by 24% in surgical and 0% in nonsurgical patients (p < 0.05). After 18 months, the severity of parkinsonian motor signs "off" medication, levodopa-induced motor complications, and daily levodopa dose were reduced by 69%, 83%, and 57% in operated patients and increased by 29%, 15%, and 12% in the group with medical treatment only (p < 0.001). Adverse events were mild or transient, and overall psychiatric morbidity and anxiety improved in the surgical group.

CONCLUSIONS

Subthalamic nucleus stimulation should be considered a therapeutic option early in the course of Parkinson disease.

Neurosurgery in Parkinson disease: A distressed mind in a repaired body?

OBJECTIVE

To prospectively evaluate the impact of subthalamic nucleus (STN) stimulation on social adjustment in patients with Parkinson disease (PD).

METHODS

Before and 18 to 24 months after bilateral STN stimulation, the authors assessed 29 patients with PD for motor disability, cognition (Mattis dementia rating scale, frontal score), psychiatric morbidity (Mini-5.0.0, MADRS, BAS), quality of life (PDQ-39), social adjustment (Social Adjustment Scale), and psychological status using unstructured in-depth interviews.

RESULTS

Despite marked improvement in parkinsonian motor disability, the absence of significant changes in cognitive status, and improvement of activities of daily living and quality of life by the end of the study, social adjustment did not improve. Several kinds of problems with social adjustment were observed, affecting the patients' perception of themselves and their body, marital situation, and professional life. Marital conflicts occurred in 17/24 couples. Only 9 out of 16 patients who had a professional activity before the operation went back to work after surgery.

CONCLUSION

After STN stimulation, patients experienced difficulties in their relations with themselves, their spouses, their families, and their socio-professional environment. The authors suggest a multidisciplinary psychosocial preparation and follow-up to help patients and their entourage cope with the sudden changes in their existence following successful neurosurgery.

Smooth muscle cell injury after cryopreservation of human thoracic aortas

The cryopreservation protocol we use for arterial reconstructive surgery has been studied to evaluate smooth muscle cell (SMC) structural integrity and viability before implantation. Samples of human thoracic aortas (HTA) were harvested from five multi-organ donors. Sampling included unfrozen and cryopreserved specimens. Cryopreservation was performed using RPMI with human albumin and 10% Me(2)SO in a controlled-rate freezing apparatus. Thawing was accomplished by submerging bags in a water bath (39 degrees C) followed by washings in cooled saline. In situ cell preservation as investigated by light and transmission electron microscopy showed that SMCs from cryopreserved HTA had nuclear and cytoplasmic changes. A TUNEL assay, performed to detect DNA fragmentation in situ, showed increased SMC nuclear positivity in cryopreserved HTA when compared to unfrozen samples. 7-AAD flow cytometry assay of cells derived from cryopreserved HTA showed that an average of 49+/-16% cells were unlabeled after cryopreservation. Organ cultures aimed to study cell ability to recover cryopreservation damage showed a decreasing number of SMCs from day 4 to day 15 in cryopreserved HTA. In conclusion, the cryopreservation protocol applied in this study induces irreversible damage of a significant fraction of arterial SMCs.

Peripheral arterial occlusive disease: role of MR angiography

PURPOSE

Magnetic resonance angiography (MRA) has recently become instrumental in the diagnosis of arterial disease in various body districts and is gaining an increasingly important role in the study of peripheral vascularisation. The aim of our study was to evaluate the reliability of MRA using digital subtraction angiography (DSA) as the reference standard.

MATERIALS AND METHODS

Between November 2003 and August 2004, 30 patients with known peripheral arterial disease were studied by MRA and DSA. MRA was performed with a Philips Intera 1.5 T, with acquisitions from the coeliac trunk to the feet. For acquisitions of the feet and ankles we used unenhanced time-of-flight (TOF) sequences with a head coil. The angiographic sequence was acquired in three volumes of 40-45 cm after administration of paramagnetic contrast material.

RESULTS

In the patients with peripheral arterial disease, the technique provided a precise evaluation of the stenosis (mild, moderate, severe) or obstruction of the peripheral district as well as the detection of other diseases, such as stenosis of the renal arteries or aneurysms.

CONCLUSIONS

Total-body three-dimensional (3D) MRA allows a fast, safe, and accurate assessment of the arterial system in patients with arteriosclerosis and can be considered an alternative to DSA in the management of patients with steno-obstructive disease of the peripheral arteries.

Neurosurgery in Parkinson's disease: the doctor is happy, the patient less so?

Despite the overall excellent outcome of neurosurgery in patients with Parkinson's disease, there is often a contrast between the improvement in motor disability and the difficulties of patients to reintegrate a normal life. In this study, the personal, familial and professional difficulties experienced by patients two years after bilateral high frequency stimulation of the subthalamic nucleus were carefully analyzed. To avoid such socio-familial maladjustment, we strongly suggest taking into consideration the patients' psychological and social context before the operation and during the post-operative follow-up.

Peripheral Angioplasty as the First-choice Revascularization Procedure in Diabetic Patients with Critical Limb Ischemia: Prospective Study of 993 Consecutive Patients Hospitalized and Followed Between 1999 and 2003

OBJECTIVE

To evaluate the effectiveness of peripheral angioplasty (PTA) as the first-choice revascularisation procedure in diabetic patients with critical limb ischemia (CLI).

DESIGN

Prospective study.

METHODS

PTA was employed as first choice revascularisation in a consecutive series of diabetic patients hospitalized for CLI between January 1999 and December 2003.

RESULTS

PTA was successful performed in 993 patients. Seventeen (1.7%) major amputations were carried out. One death and 33 non-fatal complications were observed. Mean follow-up was 26+/-15 months. Clinical restenosis was observed in 87 patients. The 5 years primary patency was 88%, 95% CI 86-91%. During follow-up 119 (12.0%) patients died at a rate of 6.7% per year.

CONCLUSIONS

PTA as the first choice revascularisation procedure is feasible, safe and effective for limb salvage in a high percentage of diabetic patients. Clinical restenosis was an infrequent event and PTA could successfully be repeated in most cases.

[Epidermoid carcinoma of oral cavity in patients less than twenty]

OBJECTIVE

To analyze a review of literature of patients aged less than 20 years with epidermoid carcinoma of oral cavity.

PATIENTS AND METHODS

Two sources were used to identify cases. A Medline search was performed as well as a review of our Medlog files where two cases of oral epidermoid carcinoma were identified in patients aged less than 20 years.

RESULTS

Sixteen patients treated between 1981 and 2000 were included in this study. The mean age was 15.6 years and the sex ratio was 2.2 male/female. The mean time to diagnosis was 16.4 months. Tumors were staged III or IV in 71.4% of cases. The mean follow-up was 33.2 months. Rate of failure was 50% and one patient experienced local recurrence. At last follow-up, seven patients were alive with one patient living with cancer. All deaths resulted from the original cancer.

DISCUSSION

This study illustrates the rarity of epidermoid carcinoma of the oral cavity in patients aged less than 20 years. Owing to the fact that most tumors were classified III or IV, time to diagnosis is probably the most important prognosis factor. Histological examination of all lesions of the oral cavity is required, irrespective of the age of the patient.

Quality of Life in Patients Treated with First-Line Antiretroviral Therapy Containing Nevirapine And/Or Efavirenz

Objective

To assess whether differences in safety profiles between nevirapine (NVP) and efavirenz (EFV), as observed in the 2NN study, translated into differences in ‘health related quality of life’ (HRQoL).

Design

A sub-study of the 2NN study, with antiretro-viral-naive patients randomly allocated to NVP (once or twice daily), EFV or NVP+EFV, in addition to stavudine and lamivudine.

Methods

Comparing differences in changes of HRQoL over 48 weeks as measured with the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire, using analysis of variance.

Results

The 2NN study enrolled 1216 patients. No validated questionnaires were available for 244 patients, and 55 patients had no HRQoL data at all, leaving 917 patients eligible for this sub-study. A total of 471 (51%) had HRQoL measurements both at baseline and week 48. The majority (69%) of patients without HRQoL measurements did, however, complete the study. The change in the physical health score (PHS) was 3.9 for NVP, 3.4 for EFV and 2.4 for NVP+EFV ( P=0.712). For the mental health score (MHS) these values were 6.1, 7.0 and 3.9, respectively ( P=0.098). A baseline plasma HIV-1 RNA concentration (pVL) ≥100 000 copies/ml and a decline in pVL (per log10) were independently associated with an increase of PHS. An increase of MHS was only associated with pVL decline. Patients experiencing an adverse event during follow-up had a comparable change in PHS but a significantly smaller change in MHS, compared with those without an adverse event.

Conclusions

First-line ART containing NVP and/or EFV leads to an improvement in HRQoL. The gain in HRQoL was similar for NVP and EFV, but slightly lower for the combination of these drugs.

[Plasma HIV-1 RNA viral load up to one year of follow-up in 64 patients treated with HAART]

The aim of this study was to evaluate efficacy of highly active antiretroviral therapy (HAART) in 64 HIV-1 positive treatment-naive and previously treated patients, with different viral load at baseline. The HAART regimen consisted of one protease inhibitor and two reverse-transcriptase inhibitors. Plasma RNA viral load was measured by RT-PCR (Roche Amplicor Monitor kit) at enrolment and at months 3, 6, 9, and 12 of follow-up. The viral load fell below the threshold of 200 copies/ml in 46.9% of patients at month 6 and this result lasted up to month 12 of follow-up in 42.2% of patients. In these patients the CD4+ cell count increased from a baseline with a median of 194 cells/mmc at month 12. Treatment failure occurred in 35.9% of patients and the proportion was higher among previously treated patients. 7 patients stopped therapy because of poor compliance and 5 because of adverse drug effects. Also in our cases the HAART regimen showed more efficacy in treatment-naive patients, whereas baseline viral load >1x105 was the cause of less efficacy of therapy.

[Rhodococcus equi pneumonia in AIDS: a case report]

We describe the first case, in Campania, of Rhodococcus equi pneumonia in an HIV positive subject. The clinical symptoms resolved after antibiotic therapy. The pulmonary lesion at 10 months of radiological follow up results just partially reduced in its diameters.

Genetic testing and genetic counselling in hypertrophic cardiomyopathy: the French experience

AIMS

A major breakthrough in the molecular genetics of hypertrophic cardiomyopathy (HCM) has made genetic testing now available in clinical practice, raising new questions about its implications, potential benefits, and the organisation of the procedure. The aim of this work was (1) to discuss the different questions related to genetic testing in HCM, and propose guidelines for the different situations, (2) to report our preliminary experience with a specific procedure.

METHODS AND RESULTS

The main questions asked by patients and relatives concern presymptomatic diagnosis and prenatal counselling/diagnosis, while clinicians sometimes discuss diagnostic and prognostic testing. To take into account the complex medical and psychological implications of this new approach, we developed a specific, multidisciplinary, and multiple step procedure, including a cardiologist, a geneticist, and a psychologist. Seventy subjects were examined, including (1) 29 adults for presymptomatic diagnosis (of whom 10 left the procedure after the first visit and 19 continued, among whom six had a mutation and two experienced negative psychological impact, observed during follow up), (2) nine couples of parents for presymptomatic diagnosis in their children (the procedure was stopped after the first visit in eight and continued in one), (3) 22 couples for prenatal counselling (no prenatal genetic testing was asked for after the first visit), and (4) 10 subjects for diagnostic testing. We decided to perform no prognostic testing.

CONCLUSION

Our preliminary experience confirms the complexity of the situation and suggests the necessity for a specific procedure to ensure good practice in genetic testing of HCM.

Behavioural disorders, Parkinson's disease and subthalamic stimulation

OBJECTIVE

to analyse 24 parkinsonian patients successfully treated by bilateral STN stimulation for the presence of behavioural disorders.

METHOD

patients were evaluated retrospectively for adjustment disorders (social adjustment scale, SAS), psychiatric disorders (comparison of the results of psychiatric interview and the mini international neuropsychiatric inventory) and personality changes (IOWA scale of personality changes).

RESULTS

parkinsonian motor disability was improved by 69.5% and the levodopa equivalent daily dosage was reduced by 60.5%. Social adjustment (SAS) was considered good or excellent in nine patients, moderately (n=14), or severely (n=1) impaired in 15 patients. Psychiatric disorders consisted of amplification or decompensation of previously existing disorders that had sometimes passed unnoticed, such as depressive episodes (n=4), generalised anxiety (n=18), and behavioural disorders with drug dependence (n=2). Appearance of mild to moderate emotional hyperreactivity was reported in 15 patients. Personality traits (IOWA scale) were improved in eight patients, unchanged in seven, and aggravated in eight

CONCLUSION

Improvement in parkinsonian motor disability induced by STN stimulation is not necessarily accompanied by improvement in psychic function and quality of life. Attention is drawn to the possible appearance of personality disorders and decompensation of previous psychiatric disorders in parkinsonian patients who are suitable candidates for neurosurgery. We suggest that a careful psychological and psychiatric interview be performed before surgery, and emphasise the need for psychological follow up to ensure the best possible outcome.

Premature lesions of the carotid vessels in HIV-1-infected patients treated with protease inhibitors

OBJECTIVES

To evaluate the presence of premature atherosclerotic lesions of epiaortic vessels in HIV-1-infected protease inhibitor-(PI) treated patients compared with PI-naive patients and healthy individuals.

DESIGN

One-hundred and two HIV-1-positive patients, including 55 treated with PI for at least 12 months and 47 either naive or treated with PI-sparing regimens, were subjected to epiaortic vessel ultrasonography. These data were compared with those obtained from 104 healthy individuals.

METHODS

Intima characteristics, pulsation and resistance indexes, and minimal, peak and mean speed were evaluated using a colour power doppler. Atherosclerotic plaques were described. Independent risk factors and values for glycaemia, cholesterolaemia and triglyceridaemia were considered. Statistical analysis included the chi-square test, Mantel-Haenszel test, odds ratio and logistic regression analysis.

RESULTS

Of the PI-treated patients, 29 out of 55 (52.7%) presented acquired lesions of the vascular wall at ultrasonography, whereas similar lesions were found in seven out of 47 (14.9%) PI-naive patients. Of the 104 healthy individuals, seven cases (6.7%) of intimal medial thickness were noted. A slightly significant correlation was found between carotid lesions and age, male sex and hypercholesterolaemia, whereas cigarette smoking, hypertriglyceridaemia and Centers for Disease Control and Prevention stage significantly increased the risk of vascular lesions (P= 0.022, P= 0.017 and P= 0.079 respectively). However, the highest significance regarded use of PI (P= 0.011). These results were confirmed by logistic regression analysis.

CONCLUSIONS

These data demonstrate a higher than expected prevalence of premature carotid lesions in the PI-treated compared with PI-naive patients. If confirmed, a periodic ultrasonographic study of the vascular wall should be included in the follow-up of HIV infected patients.

[Postoperative treatment of alcohol withdrawal syndrome in a patient operated for oral cancer]

A case of alcohol withdrawal occurred in a patient affected by cancer of the oral cavity is reported. The patient underwent resection of the floor of the oral cavity, partial glossectomy mandibulectomy and neck dissection; reconstruction was done using microsurgical forearm radial flap. The patient didn't refer his alcohol dependence before operation and withdrawal symptoms with agitation, tachycardia, tachypnea, tremors and vomiting appeared during his postoperative recovery in intensive care where the patient was unable to take any alcohol. A therapeutic plan to use in patients operated for oral cancer with alcohol withdrawal (92% association of oral cancer with alcohol dependence) is reported.

Negative pressure wound dressing of the radial forearm donor site

Donor site complications of the radial forearm are a significant cause of post-operative morbidity. 15 patients had radial forearm free tissue donor sites treated with split skin grafts and a negative pressure dressing. All grafts showed 100% take at 5 days. The advantages of this technique include rapid healing at an unfavourable graft recipient site, increased graft take and decreased donor site complications. This method is ideally suited for the management of large defects. The dressing can be quickly and easily applied and there have been no significant complications.

[Loco-regional fibrinolysis in the treatment of acute, non-traumatic ischemia of an artery. Use of PTFE, homologous vein, and Dacron in the treatment of acute thrombosis]

The acute thrombosis of a bypass graft can always be a common and challenging problem for the vascular surgeon, since surgical revascularization procedures can often result in failure, limb loss and infection. Since over the past 15 years literature reports emphasize the efficacy of intraarterial thrombolytic therapy (IATT) in achieving clot lysis and initial patency of thrombosed arteries and grafts, the purpose of this study is to verify if IATT with urokinase represents a valid alternative procedure to surgery. From our experience of 18 cases of lower limb ischemia, 9 of which graft thrombosis and 9 native artery occlusions, 3 cases of acute thrombosis of lower extremity bypass grafts, successfully treated with IATT are considered. After arteriography proof of lower extremity artery or bypass graft occlusion, thrombolytic therapy with urokinase was delivered at a rate of 100,000 UI/hour for 24/48 hours. At the conclusion of the thrombolytic treatment, percutaneous transluminal angioplasty (PTA) was performed on any residual stenosis of the bypass graft. In all three cases complete clot lysis within 48 hours was obtained, with patency of the bypass graft at two years follow-up. Urokinase in our experience, has always given good results. In many cases restoration of normal blood flow was obtained in bypass grafts thrombosed a three days. Urokinase has also been helpful in defining the causes of the occlusion (stenosis proximal or distal to the bypass) or of the anastomosis itself. Regional urokinase thrombolytic therapy, even if expensive, represents a primary tool for the vascular surgeon, since excellent results may be obtained, especially in cases where surgery is of high risk.