Combined staged therapy of complex arteriovenous malformations: initial experience

OBJECTIVES

Definitive treatment of complex supratentorial arteriovenous malformations (AVMs) has been classically assigned to ruptured or progressively symptomatic cases. The aim of this study is to report our initial experience in the treatment of complex AVMs by means of staged embolization with Onyx followed by microsurgery.

MATERIAL AND METHODS

Thirteen consecutive patients with supratentorial Spetzler-Martin grades III, IV and V AVMs were treated between January 2009 and June 2010. Mean age at the beginning of the therapy was 34. All patients were symptomatic. Mean AVM size was 48 mm, and mean volume prior to embolization was 47 ml.

RESULTS

Mean number of endovascular procedures was 3, and mean volumetric obliteration prior to surgery was 79.2%. Mean time between two embolizations was 24 days. One patient showed a non-disabling complication after endovascular procedures. Mean time between the last embolization and surgery was 42 days. Two patients showed disabling complications after surgery, and one patient showed a non-disabling complication. Follow-up angiography showed the complete removal of permeable AVM in all patients. According to the modified Rankin Scale, all patients were non-dependent concerning daily life activity at 6-month follow-up. One-year follow-up angiography has been performed in 11 patients so far showing an absence of permeable AVM in spite of the remainder intravascular Onyx.

CONCLUSIONS

Staged preoperative embolization with Onyx followed by microsurgery has made possible 100% cure of complex AVMs with 0% mortality, 15.4% disabling complications and 15.4% non-disabling complications. Complete Onyx resection is not essential to achieve the cure of the patient.

Magnetic structures and physical properties of Tm3Cu4Ge4 and Tm3Cu4Sn4

Tm(3)Cu(4)Ge(4) crystallizes in the orthorhombic Gd(3)Cu(4)Ge(4)-type crystal structure (space group Immm) whereas Tm(3)Cu(4)Sn(4) crystallizes in a distorted variant of this structure (monoclinic space group C2/m). The compounds were studied by means of neutron diffraction, specific heat, electrical resistivity and magnetic measurements. Analysis of experimental data revealed the presence of an antiferromagnetic order below 2.8 K in both compounds. In Tm(3)Cu(4)Ge(4) the magnetic unit cell is doubled in respect to the crystal unit cell and the magnetic structure can be described by a propagation vector k = [0, 1/2, 0]. A larger magnetic unit cell was found in Tm(3)Cu(4)Sn(4), given by a propagation vector k = [1/2, 1/2, 0] (for simplicity the orthorhombic description is used for both the germanide and the stannide). Close to 2 K, in each compound an incommensurate antiferromagnetic order develops. This low-temperature magnetic phase is characterized by a propagation vector k = [1/4, 0, k(z)], where k(z) is close to 0.49 and 0.47 in Tm(3)Cu(4)Ge(4) and Tm(3)Cu(4)Sn(4), respectively. The antiferromagnetic phase transitions are clearly seen in the bulk magnetic and specific heat data of both compounds.

Patient radiation dose management in the follow-up of potential skin injuries in neuroradiology

BACKGROUND AND PURPOSE

Radiation exposure from neurointerventional procedures can be substantial, with risk of radiation injuries. We present the results of a follow-up program applied to potential skin injuries in interventional neuroradiology based on North American and European guidelines.

MATERIALS AND METHODS

The following guidelines approved in 2009 by SIR and CIRSE have been used over the last 2 years to identify patients with potential skin injuries requiring clinical follow-up: peak skin dose >3 Gy, air kerma at the patient entrance reference point >5 Gy, kerma area product >500 Gy · cm(2), or fluoroscopy time >60 minutes.

RESULTS

A total of 708 procedures (325 in 2009 and 383 in 2010) were included in the study. After analyzing each dose report, 19 patients (5.9%) were included in a follow-up program for potential skin injuries in 2009, while in 2010, after introducing several optimizing actions and refining the selection criteria, only 4 patients (1.0%) needed follow-up. Over the last 2 years, only 3 patients required referral to a dermatology service.

CONCLUSIONS

The application of the guidelines to patient radiation dose management helped standardize the selection criteria for including patients in the clinical follow-up program of potential skin radiation injuries. The peak skin dose resulted in the most relevant parameter. The refinement of selection criteria and the introduction of a low-dose protocol in the x-ray system, combined with a training program focused on radiation protection, reduced the number of patients requiring clinical follow-up.

A functional network of the tumor suppressors APC, hDlg, and PTEN, that relies on recognition of specific PDZ-domains

APC and PTEN are tumor suppressor proteins that bind through their C-termini to the PDZ domain containing-hDlg scaffolding protein. We have found that co-expression of PTEN and hDlg enhanced the negative regulation of the PI3K/Akt pathway by PTEN, indicating the physiologic importance of these interactions. APC and PTEN share other PDZ domain containing-interacting partners, including the MAGI scaffolding proteins and the MAST family of protein kinases. Mutational analysis revealed that the C-terminal PDZ-binding motifs from APC and PTEN were differentially recognized by distinct PDZ domains. APC bound to the three PDZ domains from hDlg, whereas PTEN mainly bound to PDZ-2/hDlg. This indicates the existence of overlapping, but distinct PDZ-domain recognition patterns by APC and PTEN. Furthermore, a ternary complex formed by APC, PTEN, and hDlg was detected, suggesting that hDlg may serve as a platform to bring in proximity APC and PTEN tumor suppressor activities. In line with this, tumor-related mutations targeting the PDZ-2/hDlg domain diminished its interaction with APC and PTEN. Our results expand the PDZ-domain counterparts for the tumor suppressor APC, show that APC and PTEN share PDZ-domain partners but have individual molecular determinants for specific recognition of PDZ domains, and suggest the participation of the tumor suppressors APC, PTEN, and hDlg in PDZ-domain interaction networks which may be relevant in oncogenesis.

Effectiveness and Safety of Amlodipine in Newly Diagnosed Hypertensive Patients and in Previously Diagnosed Hypertensive Patients not Controlled with their Usual Treatment (NOTA Study)

OBJECTIVE

To evaluate the effectiveness and safety of amlodipine in two cohorts of hypertensive patients, one newly diagnosed and the other previously diagnosed but not controlled with drug therapy, and to assess the risk factors for the entire sample at the outset of the study.

PATIENTS AND DESIGN

We designed a postmarketing, multicentre, open-label, prospective, observational surveillance study with a 6-month follow-up, which included hypertensive patients (systolic blood pressure [SBP] >/=140mm Hg and/or diastolic blood pressure [DBP] >/=90mm Hg) who attended specialised units and had either newly diagnosed or previously diagnosed pharmacologically uncontrolled arterial hypertension.

RESULTS

Of the total of 1797 patients eligible for evaluation, 760 (42.3%) were newly and 1037 (57.7%) were previously diagnosed. Of these, 22.9% were classified as being in the high-risk and 43.2% in the very high-risk groups at the outset of the study (WHO-ISH [International Society of Hypertension]). On conclusion of the 6-month follow-up, 54.3% of newly diagnosed and 44.4% of previously treated patients had attained the BP therapy targets defined as SBP <140mm Hg and DBP <90mm Hg, representing a statistically significant difference (p < 0.0001). A total of 8% of patients experienced some adverse event during the course of the study, with this percentage being somewhat higher in the previously treated than in the newly diagnosed group (10.8% vs 5.1%, p < 0.0001). Only 0.3% experienced some severe adverse event, although in no case was this linked to the drug under evaluation.

CONCLUSIONS

We conclude that amlodipine has shown itself to be an effective and safe drug for the control of hypertension, whether isolated or associated with other cardiovascular risk factors, both in patients without a previous diagnosis of arterial hypertension and in those previously diagnosed although not controlled under a prior treatment regimen.

[Wikipedia and wikinutrition: key tools for the global promotion of nutrition]

Wikipedia is an encyclopedia collaboratively edited by volunteers from around the world built on the Web since 2003. Today is the sixth most visited site on the Internet, making it the biggest hit of participatory democracy in the field of information dissemination. The English edition, with more than 3 million items, has become an indispensable part of the Internet and the largest and most popular reference work. In this context, it could be argued that Wikipedia is a valuable tool for the general knowledge of the nutritional sciences terminology. At the same time, it does not only facilitate access to knowledge but also can generate it. It also permits to socialize these spaces for collaboration and development, contributing therefore to disclose science to the society. Consequently, in this article we present and discuss the main features of Wikipedia, emphasizing above all its role in food science and nutrition.

Nutrient-mediated modulation of incretin gene expression: a systematic review

Incretins are a cluster of hormones which are secreted and released into the bloodstream after food intake by gut enteroendocrine cells, reaching to pancreas where produce a potentiating effect on insulin release. The aim of this study was to perform a systematic review of incretins gene expression mediated by nutrients using specific search equations in the PubMed database. The two most relevant incretins are GLP-1 and GIP, which come from proglucagon and proGIP precursor respectively. GLP-1 is mainly synthesized and released by ileum and colon L cells, in contrast to GIP which does it by K cells in duodenum and proximal jejunum. It has been shown that canonical Wnt signalling pathway is closely related to the production of these hormones, since transcription factor TCF7L2 affects proglucagon and proGIP gene expression in L and K enteroendocrine cells. On the other hand, it has been shown that the hexosamine biosynthetic pathway can produce N-linked glycosylation of -catenin, an essential component of canonical Wnt signalling. This process hinders β-catenin phosphorylation and, thereby prevents proteasome degradation. Increasing glucose concentration enhances the hexosamine pathway and thus β-catenin glycosylation. This causes a β-catenin cytoplasmic accumulation allowing entry into nucleus, where it exerts its action by binding to a clump of molecules and transcription factors, allowing to express the target genes, including the incretin hormones. There is also evidence that glucose, through the hexosamine pathway, can induces autocrine activation of Wnt signalling pathway by stimulating secretion of Wnt proteins.

The role and requirements of digestible dietary carbohydrates in infants and toddlers

Digestible carbohydrates are one of the main sources of dietary energy in infancy and childhood and are essential for growth and development. The aim of this narrative review is to outline the intakes of digestible carbohydrates and their role in health and disease, including the development of food preferences, as well the consequences of excess carbohydrate. Key experts in these fields provided up-to-date reviews of the literature. A search of available information on dietary intakes of children below the age of 4 years was conducted from 1985 up to 2010. Articles and reports including information about sugars and/or starch intakes were selected. A number of factors limit the ability to obtain an overall picture of carbohydrate intakes and food sources in this age group. These include small numbers of intake studies, differing approaches to analysing carbohydrate, a variety of terms used to describe sugars intakes and a dearth of information about starch intakes. Data suggest that sweet taste is preferred in infancy and later food choices. There are few established adverse consequences of high intakes of digestible carbohydrate for young children. The greatest evidence is for dental caries, although this is influenced by high intake frequency and poor oral hygiene. Evidence for detrimental effects on nutrient dilution, obesity, diabetes or cognition is limited. In infants, minimum carbohydrate (mainly lactose) intake should be 40% of total energy, gradually increasing to 55% energy by the age of 2 years.

Abstract 3118: Star: Solitaire Fr Thrombectomy For Acute Revascularisation, International Clinical Evaluation Of The Solitaire™ Fr Used In The Treatment Of Patients With Acute Ischemic Stroke

Objective: The aim of the study is to evaluate mechanical thrombectomy with the Solitaire FR when used according to hospitals’ stroke protocols (direct intra-arterial, bridging IV/IA and endovascular after failed or contraindicated IV lysis).

Design: Single arm, observational, multi-center, prospective study with consecutive inclusion.

Sample size: The target number of patients is 200 in 20 centers with a maximum of 30 patients per center.

Centers: 2 centers in Switzerland, 9 centers in Germany, 1 in Austria, 4 centers in Spain, 1 in Canada, 1 in Australia, 1 in Portugal, 1 in France.

Study population: Patients presenting with acute ischemic stroke in anterior circulation, aged 18-85 years. Baseline NIH stroke scale between 8 and 30. Pre-stroke mRS ≤2. Treatment initiated within 8 hours of symptom onset. Meet specific imaging criteria based on ASPECT score.

Interventions: Patients will be treated with the Solitaire FR Revascularization Device used as 1st intention device in routine practice.

Endpoints: Primary endpoint will be recanalization of the occluded vessel, core lab reviewed, using TICI score with TICI 2b and 3 defined as successful recanalization. Correspondent TIMI scores will be determined for comparison with other studies.

Safety endpoint: Adverse events related to the device or the procedure. All adverse events will be reviewed by an independent clinical event committee.

Secondary endpoints: Time to revascularization, NIHSS at 90 days, mRS at 90 days, incidence of symptomatic intracranial hemorrhage, immediate flow reperfusion.

Trial status: Enrollment is ongoing. There are currently 7 enrolling centers with a total of 37 patients.

Registers: ClinicalTrials.gov NCT01327989

A mouse model to study the alterations in haemostatic and inflammatory parameters induced by Lonomia achelous caterpillar haemolymph

A mouse model was established to reproduce the haemorrhagic syndrome which occurs in humans after accidental contact with the hairs of the caterpillar Lonomia achelous (LA) and measures the haemostatic and inflammatory alterations that occur as a result of this contact. Mice were injected intradermally with different doses (0.4, 0.8 and 1.6 mg/animal) of L. achelous haemolymph (LAH). Haematological (haemoglobin, haematocrit, platelet count, differential leukocyte count), haemostatic (fibrinogen, plasminogen, factor XIII [FXIII], fibrinolytic activity) and inflammatory parameters (tumour necrosis factor alpha [TNF-α], nitric oxide [NO]) were measured at different times up to 48 h. C57BL/6 mice responded to LAH injection, in terms of these parameters, in a manner similar to that seen in humans, whereas the BALB/c mice were unresponsive. In C57BL/6 mice injected with LAH, time course measurements showed: a) a reduction in the haemoglobin, haematocrit, fibrinogen, FXIII and plasminogen levels, b) no effect on the platelet count and c) immediate leukocytosis and an increase in the fibrinolytic activity in plasma. An inflammatory response (TNF-α) was observed within 1 h post-injection, followed by a more persistent increase in serum NO. These findings suggest that C57BL/6 mice represent a useful model of the haemorrhagic syndrome observed in humans who have suffered contact with the caterpillar, permitting a deeper understanding of the role of the inflammatory response in the haematological and haemostatic manifestations of this syndrome.

Walking assessment with instrumented insoles in patients with lower limb spasticity after botulinum toxin infiltration

INTRODUCTION

Botulinum toxin A (BTA) improves the kinematic parameters of gait in patients with spasticity of lower limbs, but there are no studies in which kinetic parameters are measured with instrumented insoles. We therefore used instrumented insoles to perform a functional assessment of therapeutic results in patients with lower limb spasticity after brain injury or spinal cord infiltration indicating BTA.

MATERIAL AND METHODS

Ten patients (11 lower limbs) seen in a Neurorehabilitation Unit. The tests carried out included clinical examination, gait assessment (Functional Ambulation Categories (FAC); Hospital de Sagunto Gait Scale), and biomechanical assessment (Biofoot / IBV version 5.0), before and three weeks after infiltration with BTA.

STATISTICS

t-test for related samples of clinical variables, functional variables and biomechanical variables before and after infiltration. Level of significance P< .05. Qualitative method to assess whether changes in the biomechanical variables tended toward normal values.

RESULTS

BTA improves muscle tone, joint arch and frequency of spasms (P<.01). The patient sample showed a high level of satisfaction with the improvement in symptoms. There were no changes in walking ability after injection. There were no statistically significant changes in biomechanical parameters, but there was improved gait cadence. The relatively small statistical significance close to P=.1 of the peak pressure in the heel after injection indicates the need for further studies with instrumented insoles in people with spasticity due to central nervous system injury.

CONCLUSIONS

With the decrease in muscle tone after infiltration with BTA the clinical symptoms associated with muscle tone improved without any functional changes in gait scales. The changes in the biomechanical parameters show that larger studies using instrumented insoles should be performed in the population with spasticity after a central nervous system injury treated with BTA infiltration.

Cytoplasmic p27Kip1 counteracts the pro-apoptotic function of the open conformation of PTEN by retention and destabilization of PTEN outside of the nucleus

The tumor suppressor activity of p27Kip1 takes place in the cell nucleus by inhibitory binding to cyclin/CDK complexes. p27Kip1 can also be localized in the cytoplasm, where it has been proposed to have oncogenic properties. Here, we describe a novel role for cytoplasmic p27Kip1 which could account for its activity as an oncoprotein by negative regulation of the PTEN tumor suppressor. p27Kip1 physically interacted with the open conformation of PTEN, which is competent to enter the nucleus. In mammalian cells, cytoplasmic p27Kip1 retained to nuclear-targeted PTEN in the cytoplasm. This retention was exerted by the C-terminal p27Kip1 region, and was independent of cyclin/CDK-binding. The nuclear accumulation of PTEN triggered by pro-apoptotic TNFα treatment was abolished by cytoplasmic p27Kip1. Furthermore, conformationally-open PTEN displayed diminished protein stability and pro-apoptotic activity in the presence of cytoplasmic p27Kip1. Our results support a conformationally-dependent model of cytoplasmic retention and negative regulation of the activity of nuclear PTEN by oncogenic cytoplasmic p27Kip1, and suggest the existence of reciprocal mechanisms to regulate the levels of both p27Kip1 and PTEN.

Presence of the metabolic syndrome in obese children at prepubertal age

BACKGROUND/AIMS

There is a strong debate on the diagnosis and early phenotypic expression of the metabolic syndrome in children. The aim of the present study was to examine the frequency of the metabolic syndrome using various definitions in obese prepubertal and pubertal children.

METHODS

478 (213 females and 265 males) obese children were recruited in three provinces of Spain. Blood pressure (BP), waist circumference, and weight and height were measured, and body mass index was calculated. Glucose, insulin, high-density lipoprotein cholesterol and triacylglycerols were determined. We classified the children according to seven different proposed definitions of the metabolic syndrome.

RESULTS

Regardless of the definition used, the prevalence of the metabolic syndrome (8.3-34.2%) was relatively high in obese children in the prepubertal period as well as in pubertal children (9.7-41.2%). We performed a principal-factor analysis to explain correlations among features of the metabolic syndrome and found that glucose metabolism (factor 1), dyslipidemia (factor 2) and obesity/BP (factor 3) explained 72% of the total variance.

CONCLUSION

Irrespective of the classification used, the metabolic syndrome is not only present in pubertal but also in prepubertal children. International definitions of the metabolic syndrome should also consider criteria specific for children in the prepubertal period, i.e. children aged <10 years.