Perinatal exposure to tributyltin affects feeding behavior and expression of hypothalamic neuropeptide Y in the paraventricular nucleus of adult mice

Organotins such as tributyltin chloride (TBT), are highly diffused environmental pollutants, which act as metabolism disrupting chemicals, i.e. may interfere with fat tissue differentiation, as well as with neuroendocrine circuits, thus impairing the control of energetic balance. We have previously demonstrated that adult exposure to TBT altered the expression of neuropeptides in the hypothalamus. In this study, we orally administered daily a solution containing oil, or TBT (0.25, 2.5, or 25 μg/kg body weight/day) to pregnant females from gestational day 8 until birth, and to their pups from day 0 until post-natal day 21. Our results showed that TBT exposure of female mice during gestation and of pups during lactation permanently altered the feeding efficiency of pups of both sexes and subcutaneous fat distribution in adult males. In addition, the neuropeptide Y system was affected at the level of the paraventricular nucleus, with a decrease in immunoreactivity in both sexes (significant in females for all TBT doses and in males only for intermediate TBT doses), while no effect was observed in other hypothalamic areas (arcuate, ventromedial and dorsomedial nuclei). Metabolic syndrome, as well as obesity and diabetes, which are significant health issues, are considered multifactorial diseases and may be caused by exposure to metabolic disruptors, both in adults and during perinatal life. In addition, our work indicates that TBT doses defined as the tolerably daily intake had a profound and sex-specific long-term effect.

Maternal separation alters the reward system of activity-based anorexia rats

Maternal separation (MS) is a known chronic stressor in the postnatal period and when associated with another paradigm like the activity-based anorexia (ABA) rat model, causes different effects in the two sexes. In ABA females, the separation leads to increased hyperactivity and anxiety reduction, whereas, in males, the separation induces decreased locomotor activity without similar reduction of anxiety-like behaviors as observed in females. To understand the mechanisms altered by MS in synergy with the induction of the anorexic-like phenotype, we considered the reward system, which involves neurons synthesizing dopamine (DA) in the ventral tegmental area (VTA), substantia nigra pars compacta, and serotoninergic neurons in the dorsal raphe nucleus. Moreover, we analyzed the orexin circuit in the lateral hypothalamic area (LHA), which affects DA synthesis in the VTA and is also known to regulate food consumption and locomotor activity. Rats of both sexes were exposed to the two paradigms (MS and ABA), leading to four experimental groups for each sex: non-separated control (CON), non-separated ABA groups (ABA), MS control (MSCON), and MS plus ABA groups (MSABA). Immunohistochemistry analysis was performed to determine quantitative differences in the number of cells expressing DA, orexin, and serotonin (5-HT) among the experimental groups. The results showed that, in the DA system, the effect of MS was more evident in females than in males, with a substantial increase in DA cells in the VTA of MSABA. However, the analysis of the orexin system revealed a similar cellular increment in the LHA in the non-separated ABA groups of both sexes. Regarding 5-HT, there was an opposite effect in males and females of the MSABA groups, with only females showing a greater density of 5-HT cells. The changes in the reward system could partially explain the behavioral data: the hyperactivity, weight loss, and decreased anxiety levels of the MSABA females could be linked to an increase in DA and 5-HT cells, whereas in males, MS could mitigate the behavioral effects of the ABA protocol affecting the anxiety levels and locomotor activity through a lack of increased activation of the reward system.

Maternal Separation in ABA Rats Promotes Cell Proliferation in the Dentate Gyrus of the Hippocampus

Anorexia nervosa (AN) is a serious eating disorder characterized by self-starvation and excessive weight loss. Several studies support the idea that life stressors during the postnatal period could play a pivotal role in the pathogenesis of AN, underlying the multifactorial etiology of this disease. The activity-based anorexia (ABA) animal model mimics core features of the mental disorder, including severe food restriction, weight loss, and hyperactivity. Previous results obtained in our lab showed that maternal separation (MS) induces behavioral changes in anorexic-like ABA rats in a sexually dimorphic way: in females, the MS promoted hyperactivity and a less anxious-like phenotype in ABA animals; in males, instead, the MS attenuated the anxiolytic effect of the ABA protocol. These results led us to investigate the effect of the MS on brain areas involved in the control of the anxiety-like behavior. We focused our attention on the adult hippocampal neurogenesis, a process involved in the response to environmental stimuli and stressful condition. We analyzed the volume of the whole hippocampus and the proliferation rate in the dentate gyrus (DG) by quantifying Ki67-cells density and characterizing neuronal phenotype (DCX) and glial cells (GFAP) with double-fluorescence technique. The results obtained showed that only in maternally separated anorexic rats there is an increase of proliferation in DG, underlying the presence of a synergic effect of MS and ABA that boost the proliferation of new neurons and glia progenitors in a more evident way in females in comparison to males.

Postnatal genistein administration selectively abolishes sexual dimorphism in specific hypothalamic dopaminergic system in mice

As demonstrated in previous studies, early postnatal genistein (GEN) administration to mice pups of both sexes, at doses similar to that of infant soy-based formulas, may affect the development of some steroid-sensitive neuronal circuits (i.e. nitrergic and vasopressinergic systems), causing irreversible alterations in adults. Here, we investigated the hypothalamic and mesencephalic dopaminergic system (identified with tyrosine hydroxylase immunohistochemistry). GEN administration (50 mg/kg) to mice of both sexes during the first week of postnatal life specifically affected tyrosine hydroxylase immunohistochemistry in the hypothalamic subpopulation of neurons, abolishing their sexual dimorphism. On the contrary, we did not observe any effects in the mesencephalic groups. Due to the large involvement of dopamine in circuits controlling rodent sexual behavior and food intake, these results clearly indicate that the early postnatal administration of GEN may irreversibly alter the control of reproduction, of energetic metabolism, and other behaviors. These results suggest the need for a careful evaluation of the use of soy products in both human and animal newborns.

Negative pressure wound therapy (NPWT) after cytoreductive surgery (CRS) and intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies: preliminary report

AIM

Surgical site (SSI) infection is a common complication that occurs in the post-operative period because it still has a decisive impact on the morbidity and mortality of patients and the costs associated with therapy and prolongation of hospitalization. In recent years, therefore, several authors have published their experience in the use of negative pressure prevention systems (NPWT) for the management of surgical wounds. Few authors in the literature have discussed the use of NPWT in patients undergoing cytoreductive surgery (CRS) for peritoneal surface malignancies associated with hyperthermic intraperitoneal chemotherapy (HIPEC).

PATIENTS AND METHODS

Nineteen patients undergoing open surgery, of which 15 underwent CRS+HIPEC operations; in 2 cases the dressing was applied to patients undergoing colon surgery, 1 case after emergency laparotomy for intestinal occlusion in a patient with a BMI of 29 and 1 case after gastric surgery for a tumour. At the and of the surgery, NPWT was placed on the surgical site; the therapy includes a closed and sealed system which maintains a negative pressure between at -125 mmHg on the surgical wound and which remains in place for five days.

RESULTS

The rationale for using an NPWT is to determine a barrier between the wound and external contamination, reducing wound tension and reducing the formation of seroma and hematoma. Moreover, during the HIPEC, several litres of water are used to wash the patient's abdominal cavity and then the patient is sutured again without the peritoneum, losing the function of protection from external microorganism and also of reabsorbing the intra-abdominal serum. A recent Cochrane collaboration about the application of NPWT demonstrates that it may reduce the rate of SSI compared with SSD, even if there is no sure evidence about the reduction of complications like seromas or dehiscence.

CONCLUSION

After the analysis of the preliminary data, we confirm the possibility to start with a randomised clinical trial, as suggested by the literature.

Environmentally Relevant Perinatal Exposures to Bisphenol A Disrupt Postnatal Kiss1/NKB Neuronal Maturation and Puberty Onset in Female Mice

BACKGROUND

The timing of puberty is highly sensitive to environmental factors, including endocrine disruptors. Among them, bisphenol A (BPA) has been previously analyzed as potential modifier of puberty. Yet, disparate results have been reported, with BPA advancing, delaying, or being neutral in its effects on puberty onset. Likewise, mechanistic analyses addressing the central and peripheral actions/targets of BPA at puberty remain incomplete and conflictive.

OBJECTIVE

We aimed to provide a comprehensive characterization of the impact of early BPA exposures, especially at low, real-life doses, on the postnatal development of hypothalamic Kiss1/NKB neurons, and its functional consequences on female pubertal maturation.

METHODS

Pregnant CD1 female mice were orally administered BPA at 5, 10, or 40μg/kg body weight (BW)/d from gestational day 11 to postnatal day 8 (PND8). Vaginal opening, as an external marker of puberty onset, was monitored daily from PND19 to PND30 in the female offspring. Blood and brain samples were collected at PND12, 15, 18, 21, and 30 for measuring circulating levels of gonadotropins and analyzing the hypothalamic expression of Kiss1/kisspeptin and NKB.

RESULTS

Perinatal exposure to BPA, in a range of doses largely below the no observed adverse effect level (NOAEL; 5mg/kg BW/d, according to the FDA), was associated with pubertal differences in the female progeny compared with those exposed to vehicle alone, with an earlier age of vaginal opening but consistently lower levels of circulating luteinizing hormone. Mice treated with BPA exhibited a persistent, but divergent, impairment of Kiss1 neuronal maturation, with more kisspeptin cells in the rostral (RP3V) hypothalamus but consistently fewer kisspeptin neurons in the arcuate nucleus (ARC). Detailed quantitative analysis of the ARC population, essential for pubertal development, revealed that mice treated with BPA had persistently lower Kiss1 expression during (pre)pubertal maturation, which was associated with lower Tac2 (encoding NKB) levels, even at low doses (5μg/kg BW/d), in the range of the tolerable daily intake (TDI), recently updated by the European Food Safety Authority.

CONCLUSIONS

Our data attest to the consistent, but divergent, effects of gestational exposures to low concentrations of BPA, via the oral route, on phenotypic and neuroendocrine markers of puberty in female mice, with an unambiguous impact on the developmental maturation not only of Kiss1, but also of the NKB system, both essential regulators of puberty onset. https://doi.org/10.1289/EHP5570.

Sexually dimorphic behavioral effects of maternal separation in anorexic rats

Exposure to negative events during the neonatal period is one of the leading factors contributing to the development of psychiatric disorders, including anorexia nervosa. In this study, we investigated the effects of maternal separation (MS) on the development of anorexia in rodents using the mild-stress form of the activity-based anorexia (ABA) model (2 hr of free access to a running wheel and a 1-hr feeding test) in both male and female rats. We assessed anxiety-like and locomotor behavior and hyperactivity with the open field and elevated plus maze tests. Our results showed that ABA rats of both sexes displayed hyperactive behavior associated with reduced anxiety-like behavior when compared to controls. However, a sexually dimorphic effect of MS emerged in anorexic rats: while the females exposed to MS + ABA were hyperactive with diminished anxiety-related behaviors compared to females of the ABA group, MS in males attenuated or did not alter the effects of the ABA protocol. In conclusion, our data reveal that the synergistic effects of MS and ABA on physical activity and anxiety-like behavior act in opposite directions in the two sexes.

Chronic treatment with tributyltin induces sexually dimorphic alterations in the hypothalamic POMC system of adult mice

Tributyltin (TBT), an antifouling agent found in boat paints, is a common contaminant of marine and freshwater ecosystems. It is rapidly absorbed by organic materials and accumulated in many aquatic animals. Human exposure may depend on ingestion of contaminated food or by indirect exposure from household items containing organotin compounds. TBT is defined as an endocrine disruptor compound (EDC) because it binds to androgen receptors. Moreover, it is also included on the list of metabolic disruptors. The brain is a known target of TBT and this compound interferes with the orexigenic system, inducing a strong decrease in NPY expression in the hypothalamus. In the present experiment, we investigated the effect of a chronic treatment with TBT on the mouse anorexigenic system in both sexes, to look at the pro-opiomelanocortin (POMC) expression in the paraventricular (PVN), dorsomedial (DMN), ventromedial (VMN), and arcuate (ARC) hypothalamic nuclei. The results show a sexually dimorphic effect of TBT on both systems. TBT induced a significant decrease of POMC-positive structures only in female mice in DMN, ARC, and in PVN for both sexes. Apparently, these results show that TBT may interfere with the anorexigenic system in hypothalamic areas involved in the control of food intake, by inhibiting POMC in a sexually dimorphic way. In conclusion, in addition to having a direct effect on fat tissue, the effects of TBT as metabolic disruptor, may be due to gender-specific actions on both orexigenic and anorexigenic hypothalamic systems.

Kisspeptin system in ovariectomized mice: Estradiol and progesterone regulation

The kisspeptin system is clustered in two main groups of cell bodies (the periventricular region, RP3V and the arcuate nucleus, ARC) that send fibers mainly to the GnRH neurons and in a few other locations, including the paraventricular nucleus, PVN. In physiological conditions, gonadal hormones modulate the kisspeptin system with expression changes according to different phases of the estrous cycle: the highest being in estrus phase in RP3V and PVN (positive feedback), and in ARC during the diestrus phase (negative feedback). In this work we wanted to study these hormonal fluctuations during the estrous cycle, investigating the role played by progesterone (P) or estradiol (E₂), alone or together, on the kisspeptin system. Gonadectomized CD1 female mice were treated with P, E₂ or both (E₂ + P), following a timing of administration that emulates the different phases of estrous cycle, for two cycles of 4 days. As expected, the two cell groups were differentially affected by E₂; the RP3V group was positively influenced by E₂ (alone or with the P), whereas in the ARC the administration of E₂ did not affect the system. However P (alone) induced a rise in the kisspeptin immunoreactivity. All the treatments significantly affected the kisspeptin innervation of the PVN, with regional differences, suggesting that these fibers arrive from both RP3V and ARC nuclei.

International consensus (ICON) on audiological assessment of hearing loss in children

The prevalence of hearing loss in newborns and infants is estimated between 1 to 3.47 cases per 1000 live births. Early diagnosis and rehabilitation of congenital hearing loss are mandatory in order to achieve a satisfactory linguistic and cognitive development. Without appropriate opportunities to learn language, these children will fall behind their normal hearing peers in communication, cognition, reading and socio-emotional development. After promising results, neonatal screening for hearing loss and audiological evaluation are becoming more extensively carried out. In planning universal neonatal hearing screening programs, transient evoked otoacoustic emissions and auditory brainstem responses are the gold standard for the screening and diagnosis program. However, there is no consensus regarding the use of audiometry and other electrophysiological tests (such as auditory steady-state responses) in current practices. Several screening and audiological assessment procedures have been described and advocated all around the world. But, a systematic scheme of performing diagnosis in the pediatric audiology population is lacking. A consensus conference was held at the International Federation of Oto-rhino-laryngological Societies Congress, in June 2017, to discuss the different current practices and to identify the best neonatal hearing screening and audiological assessment management. This article is intended to provide professionals with recommendations about the "best practice" based on consensus opinion of the session's speakers, and a review of the literature on the efficacy of various assessment options for children with hearing loss.

Metabolism Disrupting Chemicals and Alteration of Neuroendocrine Circuits Controlling Food Intake and Energy Metabolism

The metabolism-disrupting chemicals (MDCs) are molecules (largely belonging to the category of endocrine disrupting chemicals, EDCs) that can cause important diseases as the metabolic syndrome, obesity, Type 2 Diabetes Mellitus or fatty liver. MDCs act on fat tissue and liver, may regulate gut functions (influencing absorption), but they may also alter the hypothalamic peptidergic circuits that control food intake and energy metabolism. These circuits are normally regulated by several factors, including estrogens, therefore those EDCs that are able to bind estrogen receptors may promote metabolic changes through their action on the same hypothalamic circuits. Here, we discuss data showing how the exposure to some MDCs can alter the expression of neuropeptides within the hypothalamic circuits involved in food intake and energy metabolism. In particular, in this review we have described the effects at hypothalamic level of three known EDCs: Genistein, an isoflavone (phytoestrogen) abundant in soy-based food (a possible new not-synthetic MDC), Bisphenol A (compound involved in the manufacturing of many consumer plastic products), and Tributyltin chloride (one of the most dangerous and toxic endocrine disruptor, used in antifouling paint for boats).

Sex Steroids and Adult Neurogenesis in the Ventricular-Subventricular Zone

The forebrain ventricular-subventricular zone (V-SVZ) continuously generates new neurons throughout life. Neural stem cells (type B1 cells) along the lateral ventricle become activated, self-renew, and give rise to proliferating precursors which progress along the neurogenic lineage from intermediate progenitors (type C cells) to neuroblasts (type A cells). Neuroblasts proliferate and migrate into the olfactory bulb and differentiate into different interneuronal types. Multiple factors regulate each step of this process. Newly generated olfactory bulb interneurons are an important relay station in the olfactory circuits, controlling social recognition, reproductive behavior, and parental care. Those behaviors are strongly sexually dimorphic and changes throughout life from puberty through aging and in the reproductive age during estrous cycle and gestation. Despite the key role of sex hormones in regulating those behaviors, their contribution in modulating adult neurogenesis in V-SVZ is underestimated. Here, we compare the literature highlighting the sexual dimorphism and the differences across the physiological phases of the animal for the different cell types and steps through the neurogenic lineage.

Relationship between Mediterranean diet and asymptomatic peripheral arterial disease in a population of pre-menopausal women

BACKGROUND AND AIMS

The Mediterranean Diet (MedD) is considered a very healthy diet useful in the prevention of cardiovascular disease. The present study aims to evaluate adherence to MedD in unselected premenopausal women and its relation with ankle-brachial index (ABI), an index of preclinical atherosclerosis.

METHODS AND RESULTS

A group of 425 patients (age range 45-54 years) was investigated. They were enrolled only if they were asymptomatic for cardiovascular disease. Nutritional parameters were assessed by a self-administered food frequency validated questionnaire (116 items) completed by an interviewer administered 24 h diet recall. They all underwent ABI measurement. The mean MedD Score was 32.2 ± 6.1 (Q1-Q3 range 26-37) comparing with data from Italian population (46 ± 8.3) was significantly lower. Intake of food categories sources of antioxidants was higher in patients with a greater adherence to Med D and was mainly related to fruit and vegetables. Patients were categorized in quartile according to MedD Score and we evaluate the distribution of ABI index within quartile. 31.4% of women in Q1 (lower adherence to MedD) had an ABI lower than 0.9 compared to 18.3% of women in Q4 (higher adherence to MedD): p < 0.01. Obesity was more frequent in Q1 compared to Q4 and in women with lower ABI.

CONCLUSIONS

Women with a low MedD Score were more obese and showed instrumental sign of preclinical peripheral atherosclerosis. MedD rich in antioxidants from fruit, vegetables and nuts influenced the development of atherosclerosis and was associated with a lower incidence of asymptomatic atherosclerosis.

Kisspeptin innervation of the hypothalamic paraventricular nucleus: sexual dimorphism and effect of estrous cycle in female mice

The hypothalamic paraventricular nucleus (PVN) is the major autonomic output area of the hypothalamus and a critical regulatory center for energy homeostasis. The organism's energetic balance is very important for both the regular onset of puberty and regulation of fertility. Several studies have suggested a relationship among neural circuits controlling food intake, energy homeostasis and the kisspeptin peptide. The kisspeptin system is clustered in two main groups of cell bodies [the anterior ventral periventricular region (AVPV) and the arcuate nucleus (ARC)] projecting mainly to gonadotropin-releasing hormone (GnRH) neurons and to a few other locations, including the PVN. In the present study, we investigated the distribution of the kisspeptin fibers within the PVN of adult CD1 mice. We observed a significant sexual dimorphism for AVPV and ARC, as well as for the PVN innervation. Kisspeptin fibers showed a different density within the PVN, being denser in the medial part than in the lateral one; moreover, in female, the density changed, according to different phases of the estrous cycle (the highest density being in estrus phase). The presence of a profound effect of estrous cycle on the kisspeptin immunoreactivity in AVPV (with a higher signal in estrus) and ARC, and the strong co-localization between kisspeptin and NkB only in ARC and not in PVN suggested that the majority of the kisspeptin fibers found in the PVN might arise directly from AVPV.

Early postnatal genistein administration permanently affects nitrergic and vasopressinergic systems in a sex-specific way

Genistein (GEN) is a natural xenoestrogen (isoflavonoid) that may interfere with the development of estrogen-sensitive neural circuits. Due to the large and increasing use of soy-based formulas for babies (characterized by a high content of GEN), there are some concerns that this could result in an impairment of some estrogen-sensitive neural circuits and behaviors. In a previous study, we demonstrated that its oral administration to female mice during late pregnancy and early lactation induced a significant decrease of nitric oxide synthase-positive cells in the amygdala of their male offspring. In the present study, we have used a different experimental protocol mimicking, in mice, the direct precocious exposure to GEN. Mice pups of both sexes were fed either with oil, estradiol or GEN from birth to postnatal day 8. Nitric oxide synthase and vasopressin neural systems were analyzed in adult mice. Interestingly, we observed that GEN effect was time specific (when compared to our previous study), sex specific, and not always comparable to the effects of estradiol. This last observation suggests that GEN may act through different intracellular pathways. Present results indicate that the effect of natural xenoestrogens on the development of the brain may be highly variable: a plethora of neuronal circuits may be affected depending on sex, time of exposure, intracellular pathway involved, and target cells. This raises concern on the possible long-term effects of the use of soy-based formulas for babies, which may be currently underestimated.

Adult exposure to tributyltin affects hypothalamic neuropeptide Y, Y1 receptor distribution, and circulating leptin in mice

Tributyltin (TBT), a pesticide used in antifouling paints, is toxic for aquatic invertebrates. In vertebrates, TBT may act in obesogen- inducing adipogenetic gene transcription for adipocyte differentiation. In a previous study, we demonstrated that acute administration of TBT induces c-fos expression in the arcuate nucleus. Therefore, in this study, we tested the hypothesis that adult exposure to TBT may alter a part of the nervous pathways controlling animal food intake. In particular, we investigated the expression of neuropeptide Y (NPY) immunoreactivity. This neuropeptide forms neural circuits dedicated to food assumption and its action is mediated by Y1 receptors that are widely expressed in the hypothalamic nuclei responsible for the regulation of food intake and energy homeostasis. To this purpose, TBT was orally administered at a dose of 0.025 mg/kg/day/body weight to adult animals [male and female C57BL/6 (Y1-LacZ transgenic mice] for 4 weeks. No differences were found in body weight and fat deposition, but we observed a significant increase in feed efficiency in TBT-treated male mice and a significant decrease in circulating leptin in both sexes. Computerized quantitative analysis of NPY immunoreactivity and Y1-related β-galactosidase activity demonstrated a statistically significant reduction in NPY and Y1 transgene expression in the hypothalamic circuit controlling food intake of treated male mice in comparison with controls. In conclusion, the present results indicate that adult exposure to TBT is profoundly interfering with the nervous circuits involved in the stimulation of food intake.

Testosterone and estradiol differentially affect cell proliferation in the subventricular zone of young adult gonadectomized male and female rats

Steroid hormones are important players to regulate adult neurogenesis in the dentate gyrus of the hippocampus, but their involvement in the regulation of the same phenomenon in the subventricular zone (SVZ) of the lateral ventricles is not completely understood. Here, in male rats, we tested the existence of activational effects of testosterone (T) on cell proliferation in the adult SVZ. To this aim, three groups of male rats: castrated, castrated and treated with T, and controls were treated with 5-bromo-2'-deoxyuridine (BrdU) and killed after 24h. The density of BrdU-labeled cells was significantly lower in castrated animals in comparison to the other two groups, thus supporting a direct correlation between SVZ proliferation and levels of circulating T. To clarify whether this effect is purely androgen-dependent, or mediated by the T metabolites, estradiol (E2) and dihydrotestosterone (DHT), we evaluated SVZ proliferation in castrated males treated with E2, DHT and E2+DHT, in comparison to T- and vehicle-treated animals, and sham-operated controls. The stereological analysis demonstrated that E2 and T, but not DHT, increase proliferation in the SVZ of adult male rats. Quantitative evaluation of cells expressing the endogenous marker of cell proliferation phosphorylated form of Histone H3 (PHH3), or the marker of highly dividing SVZ progenitors Mash1, indicated the effect of T/E2 is mostly restricted to SVZ proliferating progenitors. The same experimental protocol was repeated on ovariectomized female rats treated with E2 or T. In this case, no statistically significant difference was found among groups. Overall, our results clearly show that the gonadal hormones T and E2 represent important mediators of cell proliferation in the adult SVZ. Moreover, we show that such an effect is restricted to males, supporting adult neurogenesis in rats is a process differentially modulated in the two sexes.

Quality of life in bimodal hearing users (unilateral cochlear implants and contralateral hearing aids)

The main objective was to evaluate the bimodal self-rated benefits on auditory performance under real conditions and the quality of life in two groups of cochlear-implanted adults, with or without a contralateral hearing aid. The secondary objective was to investigate correlations between the use of a hearing aid and residual hearing on the non-implanted ear. This retrospective study was realized between 2000 and 2010 in two referral centers. A population of 183 postlingually deaf adults, implanted with a cochlear experience superior to 6 months, was selected. The Speech, Spatial, and other Qualities of Hearing Scale were administered to evaluate the auditory performances, and the Nijmegen Cochlear Implant Questionnaire to evaluate the quality of life. The population was divided into two groups: a group with unilateral cochlear implants (Cochlear Implant-alone, n = 54), and a bimodal group with a cochlear implant and a contralateral hearing aid (n = 62). Both groups were similar in terms of auditory deprivation duration, duration of cochlear implant use, and pure-tone average on the implanted ear. There was a significant difference in terms of pure-tone average on low and low-to-mid frequencies on the non-implanted ear. The scores on both questionnaires showed an improvement in the basic sound perception and quality of social activities for the bimodal group. The results suggest that the bimodal stimulation (cochlear implant and contralateral hearing aid) improved auditory perception in quiet and the quality of life domain of social activities.

Adherence to Mediterranean diet and intake of antioxidants influence spontaneous conversion of atrial fibrillation

BACKGROUND AND AIM

The Mediterranean diet (MedD) has long been associated with lower incidence of cardiovascular disease. Little information is available on association between MedD, vitamins intake and arrhythmias. We sought to investigate the relationship between adherence to MedD, antioxidants intake and spontaneous conversion of atrial fibrillation (AF).

METHODS AND RESULTS

A group of 800 subjects was included in a case-control study; 400 of them had a first detected episode of AF. Nutritional parameters were assessed by a self-administered food frequency validated questionnaire and completed by an interviewer-administered 7 days diet recall. Adherence to MedD was evaluated using the Mediterranean Score and intake of antioxidants from food was calculated. Adherence to the Med Diet was lower in patients that developed AF compared to control (mean Med Score: 22.3 ± 3.1 vs 27.9 ± 5.6; p < 0.001). The median value was 23.5 (Q1-Q3 range 23-30) in patients with AF and 27.4 (Q1-Q3 range 26-33). The estimated intake of total antioxidants was lower in patients with AF (13.5 ± 8.3 vs 18.2 ± 9.4 mmol/d; p < 0.001). Patients in the highest quartile of Mediterranean Score had higher probability of spontaneous conversion of atrial fibrillation (OR1.9; 95%CI 1.58-2.81). High levels of antioxidants intake were also associated with an increasing probability of spontaneous conversion of arrhythmia (O.R. 1.8; 95%CI 1.56-2.99; P < 0.01).

CONCLUSIONS

Patients with atrial fibrillation had lower adherence to MedD and lower antioxidant intake compared to control population. Moreover patients with arrhythmia showing a higher Med Score had more probability of a spontaneous conversion of atrial fibrillation.

[Axillary lymph node dissection in patients with micrometastasis in sentinel lymph node: new predilections]

AIM

Indication for axillary lymph node dissection (ALND) in patients with breast cancer is recommended in presence of metastasis (>2 mm size) in sentinel lymphnode (LS) or for unidentified LS. Our study's intent proposes new predilections for ALND in presence of micrometastasis (size between 0.2 and 2 mm) in LS since they may not give metastatic involvement in other axillary lymphnodes.

METHODS

In our retrospective study we analyzed 1 119 patients's informations in a period of 7 years (2002/2009): 72 patients resulted positive for micrometastasis in LS. We analyzed cancer histology, size, grading.

RESULTS

Six patients of 72 positive micrometastasis LS were not subjected to ALND. We considered 66 patients: 13 patients were positive for metastasis in other axillary lymphnode; in 9 cases T1c and in 4 cases T2 (TNM classification); in 2 cases lobular infiltrated, in 11 cases ductal infiltrated (histology); in 7 cases were II stage, in 6 cases III stage (grading).

CONCLUSION

Nineteen point seven percent of 66 patients with micrometastasis in LS is positive in other axillary lymphnode: this result confirms guide-lines's accuracy, it is not possible to avoid ALND in these patients. It appears that breast cancers responsible for metastasis in other axillary lymphnode have principally a size >1 cm, lobular infiltrated and ductal infiltrated histology and II-III grading.

Influence of coffee and caffeine consumption on atrial fibrillation in hypertensive patients

BACKGROUND AND AIMS

Coffee and caffeine are widely consumed in Western countries. Little information is available on the influence of coffee and caffeine consumption on atrial fibrillation (AF) in hypertensive patients. We sought to investigate the relationship between coffee consumption and atrial fibrillation with regard to spontaneous conversion of arrhythmia.

METHODS AND RESULTS

A group of 600 patients presenting with a first known episode of AF was investigated, and we identified 247 hypertensive patients. The prevalence of nutritional parameters was assessed with a food frequency questionnaire. Coffee and caffeine intake were specifically estimated. Left ventricular hypertrophy was evaluated by electrocardiogram (ECG) and echocardiogram. Coffee consumption was higher in normotensive patients. High coffee consumers were more frequent in normotensive patients compared with hypertensive patients. On the other hand, the intake of caffeine was similar in hypertensive and normotensive patients, owing to a higher intake in hypertensive patients from sources other than coffee. Within normotensive patients, we report that non-habitual and low coffee consumers showed the highest probability of spontaneous conversion (OR 1.93 95%CI 0.88-3.23; p=0.001), whereas, within hypertensive patients, moderate but not high coffee consumers had the lowest probability of spontaneous conversion (OR 1.13 95%CI 0.67-1.99; p=0.05).

CONCLUSION

Coffee and caffeine consumption influence spontaneous conversion of atrial fibrillation. Normotensive non-habitual coffee consumers are more likely to convert arrhythmia within 48h from the onset of symptoms. Hypertensive patients showed a U-shaped relationship between coffee consumption and spontaneous conversion of AF, moderate coffee consumers were less likely to show spontaneous conversion of arrhythmia. Patients with left ventricular hypertrophy showed a reduced rate of spontaneous conversion of arrhythmia.

Hypothalamic amenorrhea: from diagnosis to therapeutical approach

Among secondary amenorrheas, hypothalamic amenorrhea (HA) is the one with no evidence of endocrine/systemic causal factors. HA is mainly related to various stressors affecting neuroendocrine control of the reproductive axis. In clinical practice, HA is mainly associated with metabolic, physical, or psychological stress. Stress is the adaptive response of our body through all its homeostatic systems, to external and/or internal stimuli that activate specific and nonspecific physiological pathways. HA occurs generally after severe stressed conditions/situations such as dieting, heavy training, or intense emotional events, all situations that can induce amenorrhea with or without body weight loss and HA is a secondary amenorrhea with a diagnosis of exclusion. In fact, the diagnosis is essentially based on a good anamnestic investigation. It has to be investigated using the clinical history of the patient: occurrence of menarche, menstrual cyclicity, time and modality of amenorrhea, and it has to be excluded any endocrine disease or any metabolic (i.e., diabetes) and systemic disorders. It is necessary to identify any stressed situation induced by loss, family or working problems, weight loss or eating disorders, or physical training or agonist activity. Peculiar, though not specific, endocrine investigations might be proposed but no absolute parameter can be proposed since HA is greatly dependent from individual response to stressors and/or the adaptive response to stress. This chapter aims to give insights into diagnosis and putative therapeutic strategies.

[Four cases of mesenteric cystic neoformations]

Four cases of mesenteric cystic neoformations personally observed in the last years are reported. This pathology should not be underestimated, since not only does it present several problems regarding diagnosis and treatment, but a nosologic classification is also difficult to make. Since such cysts present with aspecific symptoms, a definite diagnosis cannot always be reached by a preliminary X-ray investigation, which may lead to various interpretations, but often requires a subsequent histologic examination of operative specimen.

[Adenocarcinoma of pancreas with situs viscerum inversus totalis]

A case of adenocarcinoma of the head of the pancreas in a patient with situs viscerum inversus totalis, an association described for the third time in literature, is reported. The possible coexistence of malformations of transposed organs and the specular anatomosurgical situation requires particular attention in the diagnosis and preoperative evaluation as well as a careful reorientation of the surgical perspective and a correct surgical conduct.

[Giant ovarian cyst. A case weighing 23 kg (50.6 lb). Literature review]

The ovarian cysts are one of the most common affections for females. Besides non-neoplastic functional cysts (follicular or luteal) with relatively small sizes, the neoplastic types, generally benign and that can be ascribed to serous tumors, of 10-15 cm or even bigger should be included. Nowdays, these neoformations are diagnosed relatively early, before they become of big dimensions, even if often they present few symptoms. Then it seems to be interesting to report a case recently observed of an ovarian cyst of 35x45x50 cm and weighing 23 kg in 29-year-old woman.

[Surgical treatment of hemorrhoidal disease using the circular stapler. Analysis of 60 operated cases]

BACKGROUND

The authors describe their experience of the treatment of hemorrhoidal disease using a circular stapler in order to evaluate the effectiveness of this technique.

METHODS

They describe the surgical technique used in a comparative study carried out at Modena Policlinic. A transversal mucohemorrhoidal transection is performed using a circular stapler above the anorectal joint, enabling radical surgery to be completed in a single stage with a rapid and mini-invasive technique. This technique associates the resection of hemorrhoidal nodules and prolapsed mucosa with fixing the residual mucosa to the anal canal and correcting the hypertension and hematic stasis in the venous spaces by breaking the terminal branches of the superior hemorrhoidal artery. Both male and female patients were enrolled in the study, aged over 18 years old, presenting second, third and fourth degree hemorrhoidal prolapse with indications for surgery. The analysis of the long-term follow-up for possible late complications in the 60 selected cases will be reported in a later work.

RESULTS

The technique is easy, rapid and causes moderate pain. The postoperative complications are negligible.

CONCLUSIONS

A hospital stay limited to a few hours, rapid physical recovery and the absence of out-patient treatment required by this surgical technique, which is comparable to an internal closed hemorrhoidectomy, all offer undoubted advantages, also of a psychological and social nature which amply justify the higher economic and management cost linked to the use of a surgical stapler.

[Surgical treatment of hemorrhoidal disease using circular mechanical stapler. Analysis of costs]

BACKGROUND

An analysis of surgical treatment costs of haemorrhoid disease with the use of a new circular stapler, is made comparing this operation with Milligan Morgan's technique. The money and management saving due to the reduction of operation time and postoperative stay compensates present costs due to stapler.

METHODS

35 uniform patients (number, age, sex, grade of haemorrhoid disease and surgical equipe) are considered and divided into two groups of study to evaluate perspectively the surgical costs.

RESULTS

The cost of treatment with stapler per patient is like Milligan Morgan's treatment (1.714.681 lire versus 1.681.893), with an important management saving of postoperative days (16 hours versus 42 hours).

CONCLUSIONS

Moreover there are psychologic and social advantages, not quantifiable but considerable, due to the early physical recovery and to the absence of out-patient dressing cycles peculiar of this surgical technique, with a rapid social and working reinstatement of patients (4-5 days versus 4-5 weeks of conventional intervention).

[Cancer of the anus. Analysis of our surgical experience]

BACKGROUND

The different histological varieties of anal cancer due to the presence of different histogenesis tissue can be anatomically distinguished from anal canal tumours by their growth in a periorificial or marginal site. The first appearance of symptoms are common to usual non-tumoral pathologies, but can be ascertained at an early stage using biopsy. Anal cancer can be treated with surgery, conservative or radical treatment, radiotherapy alone and radiochemotherapy with possible surgery.

METHODS

Based on the results obtained by radical surgical exeresis due to the frequent spread of tumours to the pelvis and the possibility of metastases in the cava and portal vein, current therapeutic possibilities were analysed in 101 patients with anal cancer undergoing abdominal-perineal surgery. The priority of radiochemotherapy was underlined, reserving the faculty of surgical treatment for cases of large tumours with insufficient penetration.

RESULTS

The choice of therapy should be modulated according to its histology, tumour site, increase and grading. Only surgery can ensure long-term results similar to those obtained using surgical treatment of rectal cancer.

CONCLUSIONS

For the best results the authors recommend a therapeutic approach which involves some methods used for an early diagnosis.

[Elective surgery in recurrent colon cancer with peritoneal seeding: when to and when not to proceed]

Peritoneal carcinomatosis occurs in about 10% of patients with colon cancer. Patients with progressive disease develop complications, with a median survival of 9 months. Our goal is to present a new quantitative scoring system by which to evaluate patients with peritoneal carcinomatosis. The Peritoneal Cancer Index and Completeness of Cytoreduction Score represent quantitative and prognostic indicators that permit the creation of a clinical pathway. Based on the scores, patients can undergo systemic chemotherapy, exploratory laparotomy or cytoreductive surgery. If there is a complete cytoreduction, perioperative intraperitoneal chemotherapy is given and these patients are considered potential long-term survivors.

Mesenteric cystic neoformations: report of two cases

The authors present two case reports of mesenteric cystic neoformations which they themselves observed and, with the help of the literature regarding this pathology, discuss the problems of both diagnosis and treatment.

Vertical subcutaneous pedicle flaps for posterior perineal reconstruction. Report of three cases

PURPOSE

Loss of a certain amount of cutaneous tissue of the perineal region may be remedied by first intention with creation of cutaneous flaps, thus preventing second intention healing.

METHODS

We present three emblematic cases in which the posterior perineal region was reconstructed by means of vertical subcutaneous pedicle flaps, subsequent to cutaneous tissue loss after surgery for extensive condilomas or neoplastic pathologies.

RESULTS

Tissue loss was repaired by means of a V-Y type vertical subcutaneous pedicle flap, constructed laterally of the extirpation zone and advanced in a median direction. In all cases, no ischemia or infection of flaps occurred; sphincteral continence and long-term aesthetic results have proved to be satisfactory.

CONCLUSIONS

Vertical pedicle subcutaneous flaps are well vascularized, extremely mobile, and easy to perform and have no serious postoperative complications.