Neurofeedback and epilepsy: Renaissance of an old self-regulation method?

Neurofeedback is a brain-computer interface tool enabling the user to self-regulate their neuronal activity, and ultimately, induce long-term brain plasticity, making it an interesting instrument to cure brain disorders. Although this method has been used successfully in the past as an adjunctive therapy in drug-resistant epilepsy, this approach remains under-explored and deserves more rigorous scientific inquiry. In this review, we present early neurofeedback protocols employed in epilepsy and provide a critical overview of the main clinical studies. We also describe the potential neurophysiological mechanisms through which neurofeedback may produce its therapeutic effects. Finally, we discuss how to innovate and standardize future neurofeedback clinical trials in epilepsy based on evidence from recent research studies.

Sleep and epilepsy: A clinical and pathophysiological overview

The interaction between sleep and epilepsy is complex. A better understanding of the mechanisms linking sleep and epilepsy appears increasingly important as it may improve diagnosis and therapeutic strategies in patients with epilepsy. In this narrative review, we aim to (i) provide an overview of the physiological and pathophysiological processes linking sleep and epilepsy; (ii) present common sleep disorders in patients with epilepsy; (iii) discuss how sleep and sleep disorders should be considered in new therapeutic approaches to epilepsy such as neurostimulation; and (iv) present the overall nocturnal manifestations and differential diagnosis between epileptic seizures and parasomnia.

Clinical, functional and prognostic correlates of excess left ventricular force in hypertrophic cardiomyopathy

Background

Excess force generation during myocardial contraction represents a cardinal feature of hypertrophic cardiomyopathy (HCM).

Purpose

To evaluate the anatomical, functional and prognostic correlates of left ventricular (LV) force in HCM.

Methods

We prospectively recruited a consecutive sample of 408 HCM patients with LV ejection fraction (EF) >50%, referred for baseline transthoracic echocardiography in 2 primary HCM centers in Hungary and Italy between 1999 and 2021. LV force was calculated as LV outflow tract gradient+systolic blood pressure/LV end-systolic volume. Patients were followed for a median of 107 months (IQ range, 58–158 months), the study endpoint was all-cause mortality.

Results

Mean LV force was 6.0±4.6 mm Hg/ml. Receiver-operating characteristic analysis identified 7.5 mm Hg/ml the best cut-off value to predict mortality. LV force >7.5 mm Hg/ml was present in 86 patients (21%), more frequently in women (58 vs 27%, p<0.0001), more often in patients with diabetes (16 vs 6%, p=0.003), beta-blocker (81 vs 58%, p<0.0001), calcium channel-blocker (19 vs 9%, p=0.012) and diuretic therapy (19 vs 8%, p=0.004), compared to patients with LV force ≤7.5 mm Hg/ml. Patients with excess LV force had more advanced NYHA class (1.8±0.7 vs 1.4±0.7, p=0.0001), greater left atrial diameter [(LAd), 46.7±6.6 vs 43.0±7.2 mm, <0.0001], LV maximal wall thickness (23.2±5.5 vs 21.6±5.5 mm p=0.01), LV EF (74.6±6.4 vs 67.0±6.8%, <0.0001), mitral regurgitation grade (1.2±0.7 vs 0.7±0.7, p<0.0001) and E/e' (10.3±5.0 vs 7.8±5.0, p=0.005). During follow-up 43 deaths occurred. All-cause death was more frequent in patients with excess LV force (21 vs 8%, p<0.0001). At multivariable Cox regression analysis, excess LV force was an independent predictor of mortality (HR 2.9, 95% CI 1.14–7.26, p=0.025) independent of age (HR 1.03, 95% CI 1.00–1.05, p=0.022) and LAd (HR 1.07, 95% CI 1.02–1.14, p=0.005).

Conclusion

LV force with a threshold of 7.5 mm Hg/ml, independently predicts adverse outcome in patients with HCM and preserved systolic function. Excess LV force generation is associated with female sex, diabetes, NYHA class, medications, LAd, LV wall thickness, EF, mitral regurgitation grade and E/e'.

Funding Acknowledgement

Type of funding sources: None.

Validation of the Italian version of the Pediatric CMT Quality of Life Outcome Measure

BACKGROUND AND AIMS

The pediatric Charcot-Marie-Tooth (CMT) specific Quality of Life (QOL) outcome measure (pCMT-QOL) is a recently developed and validated patient reported measure of health QOL for children with CMT. The aim of this study was to provide and validate an Italian version of the pCMT-QOL.

METHODS

The original English version was translated and adapted into Italian using standard procedures. pCMT-QOL was administered to patients genetically diagnosed with CMT, aged 8 to 18 years. A retest was given 2 weeks later to assess reliability in all patients.

RESULTS

A total of 22 patients (median age 14 years, DS 2.5; M:F 1:1) affected with CMT (19 CMT1A, 2 CMT2A, 1 CMT2K) were assessed as part of their clinical visit. The Italian-pCMT-QOL demonstrate a high test-retest reliability. None of the patients experienced difficulty in completing the questionnaire, no further corrections were needed after administration in patients.

INTERPRETATION

The Italian-pCMT-QOL is a reliable, culturally adapted, and comparable version of the original English pCMT-QOL.

Ultrastructural features of the double capsulated connective tissue around silicone prostheses

The implantation of breast prostheses for both aesthetic and reconstructive purposes has been growing exponentially in the last 20 years. Safety and prosthesis lifespan are majorly debated issues in relation to the correlated long-term complications. Mainly the periprosthetic capsule that develops around the implant is often the cause of complications and particularly for macrotextured silicone breast implants. Some reports have tried to elucidate the mechanism by which macrotextured silicone implants undergo damage and cause double capsule formation. In this study, we investigated the morphological characteristics of double capsule of macrotextured implants surgically removed from patients. With the use of microscopy techniques, this work analyzed the newly formed tissue observed in the interaction between synthetic and biological surfaces.

Prevalence of device-detected atrial fibrillation and stroke in patients with hypertrophic cardiomyopathy

Introduction

Atrial fibrillation (AF) is highly prevalent in patients with hypertrophic cardiomyopathy (HCM) and is associated with adverse outcome, impaired quality of life, loss of productivity, and the risk for embolic stroke. However, still today, the real burden of AF is unresolved due to the unknown frequency of silent asymptomatic episodes.

Purpose

To assess the prevalence of device-detected AF and stroke in patients with HCM implanted with cardiac implantable electronic devices (CIEDs) at our institution, a long-standing high flow referral center for cardiomyopathies.

Methods

Clinical and instrumental data of HCM patients implanted with CIEDs (either pacemakers [PM] or implantable cardioverter defibrillator [ICD]) from 1998 to 2019 were retrospectively reviewed. Inclusion criteria were site-designated diagnosis of HCM, age at diagnosis >18 years, >1 follow up visit, follow up >1 year. HCM phenocopies (e.g. Fabry disease) were carefully excluded.

Patients were divided into three categories according to presence of AF (“AF prior to CIED implantation” vs “AF after CIED implantation” vs “no arrhythmia detected”). Outcome was measured against prevalence of thromboembolic events (stroke or transient ischemic attack [TIA]) at follow up. All-cause and cardiovascular (CV) mortality were also assessed.

Results

A total of 255 patients received a CIED (57% men, mean age at implantation 54±17 years). Men were younger at implantation (52±17 vs 56±18 years, p=0.022). At baseline, AF was present in 90 (35.3%) patients.

During 5.0±4.1 years, de novo AF was detected in 30 (11.8%) individuals, resulting in an annual incidence rate of 6.1%/year. Overall, 135 (52.9%) of patients remained is sinus rhythm.

Stroke/TIAs were reported in 30 (11.8%) patients: 16 (53.3%) occurred in patients with prior history of AF, 3 (10%) in patients with de novo AF (with men being at higher risk, OR 3.73, 95% CI 1.88–6.09, p=0.041), and 11 (36.7%) in patients with no history of arrhythmias.

Long term, 45 (17.6%) patients died (CV mortality N=38, 14.9%). At multivariable analysis, history of stroke was directly related to all-cause mortality irrespective of AF in men (OR 4.15, 95% CI 1.35–12.77, p=0.018) but not in women (OR 0.891, 95% CI 0.17–4.64, p=0.801).

Conclusions

In a large cohort of consecutive high risk HCM patients referred to CIED implantation, the incidence of de-novo AF was high. Thromboembolic events were associated to worse outcome only in men, likely due to competing heart failure related causes in women. Strategies promoting early identification of AF and anticoagulation may play an important role in management and prevention of disease-related complications.

Prevalence of AF and Stroke

Funding Acknowledgement

Type of funding source: None

Coronary microvascular function is impaired in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

 

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL; OMIM 125310) is a rare inherited disease, caused by NOTCH3 gene mutations. Main clinical manifestations of CADASIL include recurrent subcortical ischemic events, migraine, cognitive impairment and psychiatric disturbances. CADASIL is a systemic microangiopathy and cardiac involvement has been observed in a series of Dutch patients, presenting higher frequency of myocardial infarction compared to non-mutated relatives and general population. In particular, electron microscopic examination of myocardial tissue of a study participant demonstrated CADASIL characteristics.

We sought to investigate the relationship between CADASIL and microvascular dysfunction (MVD).

Seventeen patients with genetically-confirmed CADASIL, aged <60 years, with ≤1 cardiovascular risk factor (current smoke, diabetes, hypertension, dyslipidemia), recent (<3 months) neurological evaluation with neuropsychological tests and 3 Tesla brain magnetic resonance imaging (MRI) underwent 12-lead ECG, echocardiography, and measurement of maximal myocardial blood flow following Regadenoson infusion (Reg-MBF) by 13NH3positron emission tomography (PET), to investigate the presence of coronary microvascular dysfunction (CMD). Coronary flow reserve (CFR) was defined as Reg-MBF/resting MBF. PET results were compared to those of 15 healthy controls matched for age and sex recruited among a historical cohort of healthy patients. The study was approved by the institutional review board and all the subjects gave informed consent.

Mean age was 40±9 years (range 28–57 years); 6 patients (35%) were male. One was a current smoker and 3 ex-smokers; 1 patient was on aspirin, 1 on acetazolamide and 2 on escitalopram, none was taking statins. 12 patients (71%) presented with migraine, 9 (53%) had psychiatric disturbances and 1 (6%) had a previous stroke. Brain MRI showed mild-moderate and severe leukoencephalopathy in 11 (65%) and 5 (29%) patients respectively, lacunes were present in 14 patients and microbleeds in 1; one patient had normal findings. Both Reg-MBF and CFR were blunted in CADASIL patients compared with controls (Reg-MBF 2.46±0.54 versus 3.09±0.44 ml/gr/min respectively, p<0.001; CFR 2.74±0.36 vs. 3.28±0.66, respectively, p<0.01). In 3 male patients (17%), CFR reduction was severe (<2). Segmental Reg-MBF analysis of left ventricular flow showed diffuse hypoperfusion, excluding preferential regional involvement. No correlations were found between Reg-MBF values and neuropsychological performance or cerebral lesion burden, suggesting that neurological and cardiac involvement might be independent in CADASIL.

These data represent the first documentation of coronary microvascular involvement in a group of young and mildly symptomatic CADASIL patients, confirming the systemic nature of the disease. This proof of concept study expands our understanding of genetically-driven CMD.

Funding Acknowledgement

Type of funding source: None

Eosinophilic granulomatosis with polyangiitis, a new recurrent feature in an extremely rare disease

Introduction

Eosinophilic granulomatosis with polyangiitis (EGPA) is an extremely rare necrotizing vasculitis affecting small- and medium-sized vessels. EGPA may affect the heart leading to myocardial inflammation and necrosis. Although, only a few cardiological based studies have been conducted.

Purpose

This study aimed to investigate the prevalence and clinical impact of cardiac-specific involvement (CSI+) and to give an update on EGPA cardiological manifestations.

Methods

This is a single-centre study. Cardiological evaluation included ECG, blood test, echocardiography, global longitudinal strain (GLS), cardiac magnetic resonance (CMR).

Results

We prospectively enrolled 52 consecutive EGPA patients, between October 2018 and October 2019, mean age 59±3 years, 30 (57%) female. We identified 13 (25%) CSI+ patients: 6 myocarditis, 2 pericarditis, 1 coronaritis, 1 Prinzmetal angina, 2 LV apical thrombosis, 1 unexplained wall motions abnormalities (WMA) in the absence of coronary artery disease.

Twelve-leads ECG revealed abnormalities in 11 (85%) CSI+ vs 9 (23%) CSI−, p=0.0001; ECG abnormalities identified CSI+ with 85% sensitivity, 77% specificity, 94% negative predictive value.

Median troponin level in CSI+ 9 ng/L (IQR 6–11) vs CSI− 11 ng/L (IQR 6–25), p=0.2548; NT-pro-BNP value in CSI+ 210 pg/L (IQR 175–484) vs CSI− 159 ng/L (IQR 66–299), p=0.0576.

Echocardiographic left ventricular end diastolic volume in CSI+ 62±4 ml/m2 vs CSI− 52±1 ml/m2, p=0.0116; LV ejection fraction in CSI+ 57%±2 vs CSI− 66%±1, p=0.0002. In CSI+ patients GLS was −15±1 vs CSI− GLS −21±0.4, p<0.0001. Echocardiography identified WMA in 8 (61%) CSI+ vs 1 (3%) CSI−. In 7 (54%) CSI+ patients, apical segments showed WMA and among them 5 demonstrated the presence of apical aneurysm.

Twelve patients underwent CMR, it showed non ischaemic late gadolinium enhancement in 7 patients; in 5 patients we identified akinetic or dyskinetic segments without associated LGE. Two patients showed LV apical thrombus.

Conclusions

EGPA showed a high prevalence of CSI. We repeatedly found a tropism for apical involvement in WMA that often manifested themselves as apical aneurysm. These may be a new clinical feature, previously not described, in such a rare condition.

Cardiac involvement EGPA

Funding Acknowledgement

Type of funding source: None

MoRoNet a network to strengthen the quality of measles and rubella surveillance in Italy

Background

Measles is a vaccine-preventable infectious disease and it remains one of the leading causes of infant mortality globally. The World Health Organization (WHO) has adopted the goal of eliminating measles and rubella. Detection and control of communicable diseases would not be possible without accurate laboratory results regarding when and where a particular disease circulates.

Methods

WHO/Europe therefore works with all Member States to steadily improve the quality of the laboratory data in order to determine the Region's progress towards measles and rubella elimination. For this purpose coordinates the European Measles and Rubella Laboratory Network (MR LabNet). National labs in this network undergoes regular external quality assessment through an annual accreditation programme.

Results

In Italy, a Sub-national Reference Laboratories Network for measles and rubella (MoRoNET) has been developed since March 2017 and currently includes 15 laboratories. MoRoNet was developed following the indications of the MR LabNet. It is accreditate, coordinated and supervised by the National Reference Laboratory.

Conclusions

Strengthening the role of national laboratories in overseeing the performance of subnational laboratories has become a critical need in order to properly monitor the Region's measles and rubella elimination efforts. MoRoNet permits to Italy to develop a country-specific work plan for establishing national networks and oversight mechanism, including preliminary monitoring and evaluation indicators compliant with MR LabNet standards. This is very significant not only to optimize the participation in national and regional processes to verify disease elimination, but also to strengthen the quality of vaccine-preventable disease surveillance.

MoRoNet Group: A Amendola; F Baldanti; MR Capobianchi; M Chironna; MG Cusi; P D'Agaro; P Lanzafame; T Lazzarotto; K Marinelli; A Orsi; E Pagani; G Palù; F Pittaluga, A Sacchi; F Tramuto.

Key messages

MoRoNet has permitted to Italy to develop a country-specific work plan for establishing national networks and oversight mechanism, compliant with WHO MR LabNet standards. MoRoNet network has permitted to optimize the participation in processes to verify disease elimination, but also to strengthen the quality of vaccine-preventable disease surveillance.

Surgical Pleth Index guided analgesia blunts the intraoperative sympathetic response to laparoscopic cholecystectomy

BACKGROUND

Surgical noxious stimuli generate a stress response with an increased sympathetic activity, potentially affecting the perioperative outcome. Surgical Pleth Index (SPI), derived from the pulse plethysmogram, has been proposed as a tool to assess nociception-antinociception balance. The relationship between SPI and autonomic nervous system (ANS) during general anesthesia is poorly understood and it is doubtful if SPI-guided analgesia may offer advantages over the standard clinical practice. The study was designed to evaluate if SPI-guided analgesia leads to a lower sympathetic modulation compared with standard clinical practice.

METHODS

Electrocardiographic wave, non-invasive blood pressure and SPI were recorded in ASA I-II patients undergoing elective laparoscopic cholecystectomy, randomized to receive SPI-guided analgesia or standard analgesia. Hemodynamic parameters, SPI, mean and variance of heart rate, low (LF) and high frequency (HF) spectral components of heart rate variability were measured at four time points: (T0) baseline, (T1) after induction of general anesthesia, (T2) after pneumoperitoneum insufflation and (T3) after pneumoperitoneum withdrawal.

RESULTS

SPI, hemodynamic and ANS parameters changed significantly in both groups during the study period (P<0.0001). At T2 SPI and markers of sympathetic modulation were significantly lower in SPI group (mean [SD] SPI 38.1 [15.3] vs. 48.1 [16.2] normalized units, P<0.05; LF 38 [8.6] vs. 56.2 [20.6] normalized units, P<0.01; LF/HF 1.01 [1.1] vs. 2.68 [2.07], P<0.01). There was no difference in remifentanil consumption, recovery time from anesthesia, or postoperative pain and complications.

CONCLUSION

SPI-guided analgesia led to a more stable sympathetic modulation but didn't seem to offer clinically relevant advantages over the standard clinical practice for laparoscopic cholecystectomy.

Full-scale phosphorus recovery from digested waste water sludge in Belgium - part I: technical achievements and challenges

To date, phosphorus recovery as struvite in wastewater treatment plants has been mainly implemented on water phases resulting from dewatering processes of the sludge line. However, it is possible to recover struvite directly from sludge phases. Besides minimising the return loads of phosphorus from the sludge line to the water line, placing such a process within the sludge line is claimed to offer advantages such as a higher recovery potential, enhanced dewaterability of the treated sludge, and reduced speed of scaling in pipes and dewatering devices. In the wastewater treatment plant at Leuven (Belgium), a full-scale struvite recovery process from digested sludge has been tested for 1 year. Several monitoring campaigns and experiments provided indications of the efficiency of the process for recovery. The load of phosphorus from the sludge line returning to the water line as centrate accounted for 15% of the P-load of the plant in the reference situation. Data indicated that the process divides this phosphorus load by two. An improved dewaterability of 1.5% of dry solids content was achieved, provided a proper tuning of the installation. Quality analyses showed that the formed struvite was quite pure.

Influence of gravitational sympathetic stimulation on the Surgical Plethysmographic Index

Surgical Plethysmographic Index (SPI), calculated from pulse photo-plethysmographic amplitude oscillations, has been proposed as a tool to measure nociception anti-nociception balance during general anesthesia, but it is affected by several confounding factor that alter the autonomic nervous system (ANS) modulation. We hypothesized that SPI may be mainly affected by sympathetic stimulation independently from nociception. We studied the effects of two sympathetic stimuli on SPI, delivered through passive head-up tilt at 45 and 90 degrees angles, in nine awake healthy adults. The sympathetic modulation was assessed by means of heart rate variability (HRV) analysis. Mean (SD) SPI significantly increased from baseline to 45 degrees [from 38.6 (13.7) to 60.8 (7.6), p<0.001)] and to 90 degrees angle tilt [82.3 (5.4), p<0.001]. The electrocardiographic mean R-to-R interval significantly shortened during both passive tilts, whereas systolic arterial pressure did not change during the study protocol. HRV changed significantly during the study protocol towards a predominance of sympathetic modulation during passive tilt. Gravitational sympathetic stimulation at two increasing angles, in absence of any painful stimuli, affects SPI in awake healthy volunteers. SPI seems to reflect the sympathetic outflow directed to peripheral vessels.

A new scale for the assessment of performance and capacity of hand function in children with hemiplegic cerebral palsy: reliability and validity studies

BACKGROUND

In hemiplegic children, the recognition of the activity limitation pattern and the possibility of grading its severity are relevant for clinicians while planning interventions, monitoring results, predicting outcomes.

OBJECTIVE

Aim of the study is to examine the reliability and validity of Besta Scale, an instrument used to measure in hemiplegic children from 18 months to 12 years of age both grasp on request (capacity) and spontaneous use of upper limb (performance) in bimanual play activities and in ADL.

DESIGN

Psychometric analysis of reliability and of validity of the Besta scale was performed.

SETTING

Outpatient study sample

METHODS

Reliability study: A sample of 39 patients was enrolled. The administration of Besta scale was video-recorded in a standardized manner. All videos were scored by 20 independent raters on subsequent viewing. 3 raters randomly selected from the 20-raters group rescored the same video two years later for intra-rater reliability. Intra and inter-rater reliability were calculated using Intraclass Correlation Coefficient (ICC) and Kendall's coefficient (K), respectively. Internal consistency reliability was assessed using Alpha's Chronbach coefficient. Validity study: a sample of 105 children was assessed 5 times (at t0 and 2, 3, 6 and 12 months later) by 20 independent raters. Each patient underwent at the same time to QUEST and Besta scale administration and assessment. Criterion validity was calculated using rho-Pearson coefficient.

RESULTS

Reliability study: The inter-rater reliability calculated with Kendall's coefficient resulted moderate K=0.47. The intra-rater (or test-retest) reliability for 3 raters was excellent (ICC=0.927). The Cronbach's alpha for internal consistency was 0.972. Validity study: Besta scale showed a good criterion validity compared to QUEST increasing by age and severity of impairment. Rho Pearson's correlation coefficient r was 0.81 (P<0.0001). Limitations. Besta scales in infants finds hard to distinguish between mild to moderately impaired hand function.

CONCLUSIONS

Besta scale scoring system is a valid and reliable tool, utilizable in a clinical setting to monitor evolution of unimanual and bimanual manipulation and to distinguish hand's capacity from performance.

Oxytocin nasal spray in fibromyalgic patients

Fibromyalgia is a pain disorder associated with frequent comorbid mood, anxiety, and sleep disorders. Despite the frequent use of a complex, poly-drug pharmacotherapy, treatment for fibromyalgia is of limited efficacy. Oxytocin has been reported to reduce the severity of pain, anxiety, and depression, and improve the quality of sleep, suggesting that it may be useful to treat fibromyalgia. To evaluate this hypothesis, 14 women affected by fibromyalgia and comorbid disorders, assuming a complex pharmacotherapy, were enrolled in a double-blind, crossover, randomized trial to receive oxytocin and placebo nasal spray daily for 3 weeks for each treatment. Order of treatment (placebo-oxytocin or oxytocin-placebo) was randomly assigned. Patients were visited once a week. At each visit, the following instruments were administered: an adverse drug reaction record card, Visual Analog Scale of Pain Intensity, Spielberger State Anxiety Inventory, Zung Self-rating Depression Scale, and SF-12. Women self-registered painkiller assumption, pain severity, and quality of sleep in a diary. Unlikely, oxytocin nasal spray (80 IU a day) did not induce positive therapeutic effects but resulted to be safe, devoid of toxicity, and easy to handle.

Computer assisted planning of autologous fat grafting in breast

Autologous fat grafting is an emerging and promising surgical technique in regenerative medicine, and its application is quickly spreading in plastic and reconstructive surgery of the breast. However, despite the advantages of the technique, surgical complications may occur, such as implanted tissue necrosis and resorption and onset of microcalcifications. In view of the hypothesis that the uniformity of the lipoaspirate transplantation is related to graft survival and a lower probability of complications, we developed an interactive lipomodeling planning software application based on a genetic algorithm that allows automatic optimization of the uniformity of fat tissue distribution. The input dataset consists of a 3D model of the patient's thorax, created from MRI scans, on which relevant structures are segmented. The developed software was tested starting from either an automatically generated plan or an initial guess of the optimal surgical plan, and in both cases the application yielded a consistent improvement in the planned fat tissue distribution by optimizing the position of the insertion points and the direction of the insertion pathways. On the basis of the simulations performed, the use of genetic algorithms for optimization of the geometry of autologous fat transfer in the breast proved to be effective. These results will foster further activities focused on the comparison of predicted optimized geometries and those obtained in real surgical cases as a means of obtaining a deeper knowledge of the potential influence of a uniform fat tissue distribution on the quality of the surgical outcome. The presented application is also put forward as representing a noteworthy step towards the clinical application of computer assisted planning tools in breast surgery.

K-nearest-neighbor conditional entropy approach for the assessment of the short-term complexity of cardiovascular control

Complexity analysis of short-term cardiovascular control is traditionally performed using entropy-based approaches including corrective terms or strategies to cope with the loss of reliability of conditional distributions with pattern length. This study proposes a new approach aiming at the estimation of conditional entropy (CE) from short data segments (about 250 samples) based on the k-nearest-neighbor technique. The main advantages are: (i) the control of the loss of reliability of the conditional distributions with the pattern length without introducing a priori information; (ii) the assessment of complexity indexes without fixing the pattern length to an arbitrary low value. The approach, referred to as k-nearest-neighbor conditional entropy (KNNCE), was contrasted with corrected approximate entropy (CApEn), sample entropy (SampEn) and corrected CE (CCE), being the most frequently exploited approaches for entropy-based complexity analysis of short cardiovascular series. Complexity indexes were evaluated during the selective pharmacological blockade of the vagal and/or sympathetic branches of the autonomic nervous system. We found that KNNCE was more powerful than CCE in detecting the decrease of complexity of heart period variability imposed by double autonomic blockade. In addition, KNNCE provides indexes indistinguishable from those derived from CApEn and SampEn. Since this result was obtained without using strategies to correct the CE estimate and without fixing the embedding dimension to an arbitrary low value, KNNCE is potentially more valuable than CCE, CApEn and SampEn when the number of past samples most useful to reduce the uncertainty of future behaviors is high and/or variable among conditions and/or groups.

Short-term complexity indexes of heart period and systolic arterial pressure variabilities provide complementary information

It is unclear whether the complexity of the variability of the systolic arterial pressure (SAP) provides complementary information to that of the heart period (HP). The complexity of HP and SAP variabilities was assessed from short beat-to-beat recordings (i.e., 256 cardiac beats). The evaluation was made during a pharmacological protocol that induced vagal blockade with atropine or a sympathetic blockade (beta-adrenergic blockade with propranolol or central sympathetic blockade with clonidine) alone or in combination, during a graded head-up tilt, and in patients with Parkinson's disease (PD) without orthostatic hypotension undergoing orthostatic challenge. Complexity was quantified according to the mean square prediction error (MSPE) derived from univariate autoregressive (AR) and multivariate AR (MAR) models. We found that: 1) MSPEMAR did not provide additional information to that of MSPEAR; 2) SAP variability was less complex than that of HP; 3) because HP complexity was reduced by either vagal blockade or vagal withdrawal induced by head-up tilt and was unaffected by beta-adrenergic blockade, HP was under vagal control; 4) because SAP complexity was increased by central sympathetic blockade and was unmodified by either vagal blockade or vagal withdrawal induced by head-up tilt, SAP was under sympathetic control; 5) SAP complexity was increased in patients with PD; and 6) during orthostatic challenge, the complexity of both HP and SAP variabilities in patients with PD remained high, thus indicating both vagal and sympathetic impairments. Complexity indexes derived from short HP and SAP beat-to-beat series provide complementary information and are helpful in detecting early autonomic dysfunction in patients with PD well before circulatory symptoms become noticeable.

Circulation of West Nile virus lineage 1 and 2 during an outbreak in Italy

In 2011, from 26 September to 16 October, a small outbreak of West Nile virus (WNV) disease occurred on the island of Sardinia (Italy). According to the national case definition, six cases with acute neurological disease were confirmed in hospitalized patients, and four of them died; one of these was only 34 years old. In two case, WNV RNA was detected in urine, suggesting renal involvement. Sequence analysis showed lineage 1 and 2 circulation.

Is target opioid therapy within sight?

Control of pain has a central role in patients treatment either in advanced cancer or other terminal illnesses and in acute postsurgical or chronic non-malignant diseases. Hospitals should promote programs of research on genetic mechanism, and also biochemical and physiological aspects of pain through highly specialized labs. Opioids are the first choice drugs for moderate to severe chronic pain, especially at the end of life, and among them oral morphine is worldwide recognized by the World Health Organization and by the European Association for Palliative Care as the conventional therapy. Although this general agreement, administration of this class of drugs may be a major medical challenge due to the high effects' variability related to pharmacokinetic and pharmacodynamic parameters, such as absorption, distribution and metabolism, as well as intrinsic efficacy at the receptors involved. For such a reason, optimization of the management regime is not always reached in all the patients. Up to now no one can easily predict which patient will experience side effects or an inadequate pain control. The growing body of evidence concerning a sound genetic background of this human intervariability has prompted research on the field of a personalized therapy, focusing on single nucleotide polymorphisms (SNPs), being the most common and diffuse form of genetic variation. This review has the main goal to report the most promising human genetic polymorphisms involved in opioid treatment, and address the relationship between these polymorphisms and the clinical outcome.

Gait pattern classification in children with Charcot-Marie-Tooth disease type 1A

Gait pattern classification may assist in clinical decision making and cluster analysis (CA) has been often adopted to this aim. The goal of this study was to identify, through CA, typical walking patterns in a group of 21 young subjects with CMT1A, a hereditary progressive neuropathy, and to study possible correlation with the disease's clinical status. The protocol included kinematic/kinetic analysis of natural walking and more demanding locomotor tasks, i.e. toe- and heel-walking. Hierarchical cluster analysis was carried out on parameters related to primary signs (foot-drop and push-off deficit) and, separately, to compensatory mechanisms at proximal (pelvis, hip and knee) or distal (ankle) level. CA on primary signs during natural walking identified three clusters: (1) pseudo-normal patients (PN), not significantly different from controls; (2) patients showing only foot-drop (FD); (3) patients with foot-drop and push-off deficit (FD&POD). Patients belonging to the PN subgroup showed distal abnormalities during heel-walking. The FD&POD subgroup was associated to a significantly worse clinical score (CMTES, p<0.05). The main compensatory strategies, which occurred independently from primary clusterization, included augmented hip/knee flexion in swing (steppage) and early ankle plantarflexion at mid stance (vaulting). We concluded that, although a number of young CMT1A patients do not show typical primary deviations during natural walking, they do show significant abnormalities in more demanding locomotor tasks that should be therefore considered. It is also hypothesized that progression of this degenerative condition may be associated to the migration of patients to more severe clusters, with possible appearance of compensatory strategies.

Reliability of instrumented movement analysis as outcome measure in Charcot-Marie-Tooth disease: results from a multitask locomotor protocol

Some neurodegenerative diseases at early stage may not drastically affect basic gait ability, whereas more demanding locomotor tasks are more prone to disease-induced abnormalities. In this study, we evaluated the interday test-retest reliability, 4-6 weeks apart, of instrumented movement analysis on a group of 20 subjects with Charcot-Marie-Tooth (CMT) disease considering a set of kinematic and kinetic curves and related parameters obtained during natural walking (NW) and faster walking, heel and toe-walking, step ascending and descending. Results showed that the reliability was good for NW, with the exception of trunk curves, pelvic tilt and EMG profiles (moderate reliability), and trunk ROM in sagittal/transverse plane (poor reliability). Comparing our results with literature, CMT patients did not present a greater variability during NW than healthy subjects or patients with diseases of CNS. Additional locomotor tasks showed a slight reduction of reliability, although the moderate-to-good level shown in NW was almost never reduced to poor. Most of SEM values (absolute measurement errors) were smaller than 5°, a clinically acceptable threshold. In particular THS, an ankle joint related parameter computed across heel and toe-walking tasks, showed an optimal reliability (ICC=0.95, SEM=2.7°) and correlation with CMT clinical scores. Toe and heel-walking and step ascending tasks maximised the number of parameters with a moderate-to-good correlation with patients' clinical status. We concluded that, in addition to natural walking, more challenging locomotor tasks are good candidates to provide reliable and sensitive outcome measures for CMT patients.

Prevalence of antibodies to phleboviruses and flaviviruses in Peja, Kosovo

In order to investigate the current and past activity of phlebovirus and flavivirus in Kosovo, a seroprevalence study among 200 blood donors was performed. Positive results were obtained for the phleboviruses TOSV and SFNV, and for a flavivirus of the Japanese Encephalitis group. No positive results for TBEV were observed.

Genetic structure and population dynamics of the biting midges Culicoides obsoletus and Culicoides scoticus: implications for the transmission and maintenance of bluetongue

Culicoides species belonging to the Obsoletus complex (Diptera: Ceratopogonidae) have been indicated as primary bluetongue (BT) vectors in many European countries and their possible involvement in the maintenance and overwintering of BT viruses has been suggested, even in regions where Culicoides imicola Keiffer is the main vector. The Obsoletus complex includes two predominant taxa, Culicoides obsoletus (Meigen) and Culicoides scoticus Downes & Kettle. However, the role played by each species in the epidemiology of BT is still unknown. Taxonomic identification is mainly based on the morphology of male genitalia and the lack of other reliable diagnostic features makes the screening of trap-collected vector populations, mainly females, particularly difficult. Although molecular markers have facilitated species identification, little information is yet available on the biology, abundance and population dynamics of the two taxa. The aim of this work was to investigate the genetic profile and temporal distribution of C. obsoletus and C. scoticus by using isozyme electrophoresis applied to adult midges, collected weekly at two selected farms in southern Sardinia. A total of nine enzyme loci were analysed and five of them provided diagnostic allozyme markers (Hk, Mdh, Pgi, Idh-1 and Idh-2). Nei's genetic distance between the two taxa was in the range of other well-separated taxa (D = 1.792), supporting their status as true species. Culicoides scoticus represented almost 61% of the 562 specimens analysed; its genetic structure was characterized by a very low level of intra-population variation (mean heterozygosity H(e) = 0.019) and higher genetic divergence between populations (F(ST) = 0.0016) than in C. obsoletus. The latter species had significantly more heterozygotes (H(e) = 0.123), a higher percentage of polymorphic loci, and no inter-population differentiation (F(ST) ≅ 0). We suggest that different biological and ecological constraints, such as breeding habitat requirements, may contribute to shaping the genetic profiles of C. scoticus and C. obsoletus. However, enough gene flow was maintained between populations of each species as no spatial and temporal structuring was sustained by Fisher's exact probability test (P > 0.5). The seasonal distributions of C. scoticus and C. obsoletus only partially overlapped: both species were mainly found early in the year, when the main vector, C. imicola, was present in low numbers, and peaked in abundance in April and May. Culicoides scoticus was predominant until May, decreased rapidly in the following months and increased again in winter, whereas C. obsoletus decreased more slowly and was still present in early summer. Consequently, C. scoticus may be a good candidate for playing a role in the transmission and maintenance of BT virus in Sardinia, as well as in other Mediterranean countries, during the months of late winter and early spring when the seroconversion of sentinel animals is still occurring in the absence of the main vector.

[Adipocytokines: potential biomarkers for childhood obesity and anorexia nervosa]

Adipose tissue is now considered an important endocrine organ that secretes a large number of physiologically active peptides affecting metabolic homeostasis of human body: they are collectively referred to as adipocytokines. Leptin is a key hormone in the regulation of food intake, energy expenditure, neuroendocrine and immune function. Leptin is related with obesity and its metabolic disorders; starvation-induced depletion of fat stores is accompanied by alterations of circulating adipocytokines that may have potential repercussions in the pathophysiology of anorexia nervosa. Adiponectin enhances insulin sensitivity, controls body weight, prevents atherosclerosis and negatively regulates immune functions. Plasma adiponectin relates inversely to adiposity and reflects the sequelae of accumulation of excess adiposity. Resistin is a protein hormone produced both by adipocytes and immunocompetent cells that affect fuel homeostasis and insulin action. Plasma resistin levels are decreased in anorectic patients, while plasma adiponectin levels are increased. Plasma ghrelin levels present opposite changes in obesity and anorexia nervosa, suggesting that ghrelin is a good marker of nutritional status. Visfatin shows to correlate with visceral fat mass in patients with obesity. Its possible role in patients with anorexia nervosa is unknown. In conclusion, obesity is defined as a state of low-grade inflammation, which is associated with increased leptin, resistin and ghrelin levels and decreased adiponectin levels; anorexia nervosa is characterized by opposite changes. Finally, plasma adipocytokines levels can represent a sensitive parameter of nutritional status that reflects changes in the level of body fat in children and adolescents with obesity and anorexia nervosa.

Soluble serum HLA-G in children with allergic rhinitis and asthma

Allergic rhinitis (AR) and asthma are characterized by Th2 polarized immune response. Soluble HLA (sHLA) molecules play an immunomodulatory activity. It has been reported that both molecules are increased in sera of patients with pollen-induced allergic rhinitis studied outside the pollen season. To date, however, no study has investigated them in AR children. The aim of this preliminary study is to evaluate serum sHLA-G levels in children with AR or asthma patients and in a group of healthy controls. Forty-seven symptomatic allergic patients were enrolled. A group of 50 healthy subjects was considered as control. Serum sHLA-G levels were determined by the immunoenzymatic method. Children with AR had significantly higher levels of sHLA-G molecules than normal controls or children with allergic asthma. However, there is no difference between children with AR and asthmatics. In conclusion, the present study provides the preliminary evidence that serum sHLA-G molecules are significantly increased in children with AR.

Correlation of rhinovirus load in the respiratory tract and clinical symptoms in hospitalized immunocompetent and immunocompromised patients

While human rhinoviruses (HRVs) are well accepted as a major cause of common cold syndromes (rhinitis), their role in the etiology of lower respiratory tract infections is still controversial, and their detection in asymptomatic patients is relatively common. The HRV pathogenic role in four groups of hospitalized patients (pediatric immunocompetent and immunocompromised patients, and adult immunocompetent and immunocompromised patients) was investigated by quantifying HRV load in nasopharyngeal aspirates or bronchoalveolar lavage samples by real-time reverse transcription PCR (RT-PCR). Real-time RT-PCR was performed in duplicate on all respiratory samples resulting positive by qualitative RT-PCR. In addition, molecular typing allowed detection of all known HRV species (A, B, and C). In immunocompetent pediatric patients HRVs were mostly associated with lower respiratory tract infections (in the absence of other viral agents) and wheezing, when viral load was > or =10(6) RNA copies/ml. In young immunocompromised patients (stem cell transplantation recipients), an inverse correlation between HRV persistence over time and time at which the infection occurred after transplantation was observed, whereas in adult immunocompromised patients (lung transplant recipients) HRVs could be detected at a medium-low level (<10(5) RNA copies/ml) in bronchoalveolar lavage samples taken routinely from asymptomatic patients. In conclusion, when detected at high viral load, HRVs may cause severe upper and lower respiratory tract infections, whereas when detected at a medium-low viral load, an event more frequent in immunocompromised subjects, they may represent only bystander viruses.

Clinical severity and molecular typing of human rhinovirus C strains during a fall outbreak affecting hospitalized patients

BACKGROUND

The circulation rate and the clinical severity of infections caused by members of the new human rhinovirus C (HRV-C) species remain to be defined.

OBJECTIVES

To investigate the epidemiologic and clinical impact of HRV-C strains in a fall outbreak interesting hospitalized patients.

STUDY DESIGN

HRV species (A-C) were determined by phylogenetic analysis following amplification of two genome regions (5'NCR and VP4/VP2) by RT-PCR. HRV species were correlated with age, respiratory tract involvement, clinical symptoms, and HRV load in respiratory secretions.

RESULTS

During the first week of the period October-November 2008, single HRV infections were associated with 95% of all respiratory syndromes affecting hospitalized patients. Then, HRV infections (single+coinfections) interested about 90% of positive samples until the end of October, when they declined in frequency until reaching about 30% at the end of November. Overall, 104 HRV strains were detected and, of these, 90 could be classified by phylogenetic analysis, as follows: 45 HRV-A, 12 HRV-B, 28 HRV-C, and 5 human enterovirus D strains. HRV-C identity was confirmed by detection of cis-acting replication elements (cre) in 23/23 strains. As for severity of respiratory syndromes, unlike HRV-A and HRV-B strains, HRV-C strains were responsible for a significantly higher rate (p<0.05) of lower respiratory tract infections in the pediatric as compared to adult patient population.

CONCLUSIONS

HRV-C strains have been shown to circulate at a rate intermediate between HRV-A and HRV-B strains, showing a greater degree of clinical severity in the pediatric population.

Consequences of long-lasting persistent allergic rhinitis in adolescents

While it is well known that asthma is characterized by airway remodelling, only few studies have investigated this issue in patients affected by allergic rhinitis (AR). The aim of the present study is to investigate functional and structural consequences of long-lasting persistent AR (PER) in a cohort of adolescents. Eighty patients, forty with short-lasting and forty with long-lasting PER were prospectively and consecutively evaluated both clinically and by performing skin prick test, nasal cytology, and rhinomanometry. Eosinophils were significantly higher in patients presenting with long-lasting PER rather than in those with short-lasting PER (P < 0.0001). The degree of inflammation was significantly associated with impaired nasal airflow (rs = -0.81). This study provides evidence that adolescents with long-lasting PER may show a progressive worsening of nasal function depending on the inflammation.

Bronchodilation test in allergic adolescents

This study highlights the close link between upper and lower airways and the relevance of bronchodilation test in patients presenting with moderate-severe persistent allergic rhinitis and mild persistent asthma.

Arboviruses in Italy

A brief review of the arboviruses isolated In Italy is presented and discussed. Some of the Arboviruses considered in this paper are endemic in the country and are transmitted by arthropods that play actually a role of vectors, (sand flyes, hard ticks and mosquitoes); other arboviruses, sporadically isolated, are potential agents of emerging human or zoonotic diseases.

A pixel detector-based single photon-counting system as fast spectrometer for diagnostic X-ray beams

Recent advances in semiconductor pixel detectors and read-out electronics allowed to build the first prototypes of single photon-counting imaging systems that represent the last frontier of digital radiography. Among the advantages with respect to commercially available digital imaging systems, there are direct conversion of photon energy into electrical charge and the effective rejection of electronic noise by means of a thresholding process. These features allow the photon-counting systems to achieve high imaging performances in terms of spatial and contrast resolution. Moreover, the now available deep integration techniques allow the reduction of the pixel size and the improvement of the functionality of the single cell and the read-out speed so as to cope with the high fluxes found in diagnostic radiology. In particular, the single photon-counting system presented in this paper is based on a 300-microm thick silicon pixel detector bump-bonded to the Medipix2 read-out chip to form an assembly of 256 x 256 square pixels at a pitch of 55 microm. Each cell comprises a low-noise preamplifier, two pulse height discriminators and a 14-bit counter. The maximum counting rate per pixel is 1 MHz. The chip can operate in two modalities: it records the events with energy above a threshold (single mode) or between two energy thresholds (window mode). Exploiting this latter feature, a possible application of such a system as a fast spectrometer is presented to study the energy spectrum of diagnostic beams produced by X-ray tubes.

Dental radiology dosimetric data as routinely collected in an Italian hospital

The work presented here was developed in the framework of the SENTINEL Project and is devoted to the analysis of dental radiology dosimetric data. The procedure of data processing allows the analysis of some important aspects related to the protection of the patient and the staff because of the position of the operators near the patient and their exposure to the radiation scattered by the patient. Dental radiology data was collected in an Italian hospital. Following the Italian quality assurance (QA) protocols and suggestions by the leaders of the SENTINEL Project, X-ray equipment performances have been analysed in terms of: kVp accuracy, exposure time accuracy and precision, tube output, dose reproducibility and linearity, beam collimation, artefacts and light tightness. Referring to these parameters the physical quality index (QI) was analysed. In a single numerical value between 0 and 1, QI summarises the results of quality tests for radiological devices. The actual impact of such a figure (as suggested by international QA protocols or as adopted by local QA routine) on the policy of machine maintenance and replacement is discussed.

Reappearance of Aedes albopictus in Sardinia

Aedes (Stegomyia) albopictus is a vector of major human diseases. From 1979 established populations were found in the Mediterranean Region. The first record of Ae. albopictus in Italy goes back to 1990 and at present it is permanently established in several provinces of central and northern Italy. Ae. albopictus was detected for the first time in Sardinia in 1995, and a new record was reported in 1997. After these two isolated episodes, the "tiger-mosquito" was considered apparently eradicated. At the end of September 2006, two natural breeding populations including adults of Ae. albopictus were recorded in two different localities of South-Sardinia: in the botanical garden of downtown Cagliari and in a private garden of a small village, Teulada, on the south-western coast of Sardinia. The origin of this new introduction of Ae. albopictus in Sardinia is still unclear. In both cases the species has been found in artificial containers in densely populated areas.

Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells

BACKGROUND

There is evidence that stem cells contribute to the restoration of tissue vascularization and organ function. The objective of this study was to assess the presence of adipose-derived adult stem cells left in their natural scaffold in the purified lipoaspirate and to assess the clinical effectiveness of lipoaspirate transplantation in the treatment of radiation side effects.

METHODS

This study was designed beginning with surgical procedures in 2002 and envisaging a continuous patient follow-up to 31 months. Twenty consecutive patients undergoing therapy for side effects of radiation treatment with severe symptoms or irreversible function damage (LENT-SOMA scale grade 3 and 4) were enrolled. Purified autologous lipoaspirates (60 to 120 cc) taken from a healthy donor site were administered by repeated low-invasive computer-assisted injection. Therapy outcomes were assessed by symptoms classification according to the LENT-SOMA scale, cytofluorimetric characterization, and ultrastructural evaluation of targeted tissue.

RESULTS

In the isolated stromal vascular fraction of 2 cc of human lipoaspirate, cells with mesenchymal stem cell physical properties and immunophenotype were in average 1.07 +/- 0.5 percent (n = 4), with a clonogenic fraction of 0.139 percent. At least 1.02 x 10(3) colony-forming units-fibroblast were present in each lipoaspirate. Ultrastructure of target tissue systematically exhibited progressive regeneration, including neovessel formation and improved hydration. Clinical outcomes led to a systematic improvement or remission of symptoms in all evaluated patients, including otherwise untreatable patients exhibiting initial irreversible functional damage.

CONCLUSIONS

This surgical procedure is a low-invasive therapeutic approach for resolving the late side effects of radiotherapy. According to the proposed hypothesis of the ischemic nature of radiolesions, treatment with lipoaspirate transplantation is potentially extended to other forms of microangiopathies.