Modeling outcome trajectories in patients with acquired brain injury using a non-linear dynamic evolution approach

This study describes a dynamic non-linear mathematical approach for modeling the course of disease in acquired brain injury (ABI) patients. Data from a multicentric study were used to evaluate the reliability of the Michaelis-Menten (MM) model applied to well-known clinical variables that assess the outcome of ABI patients. The sample consisted of 156 ABI patients admitted to eight neurorehabilitation subacute units and evaluated at baseline (T0), 4 months after the event (T1) and at discharge (T2). The MM model was used to characterize the trend of the first Principal Component Analysis (PCA) dimension (represented by the variables: feeding modality, RLAS, ERBI-A, Tracheostomy, CRS-r and ERBI-B) in order to predict the most plausible outcome, in terms of positive or negative Glasgow outcome score (GOS) at discharge. Exploring the evolution of the PCA dimension 1 over time, after day 86 the MM model better differentiated between the time course for individuals with a positive and negative GOS (accuracy: 85%; sensitivity: 90.6%; specificity: 62.5%). The non-linear dynamic mathematical model can be used to provide more comprehensive trajectories of the clinical evolution of ABI patients during the rehabilitation period. Our model can be used to address patients for interventions designed for a specific outcome trajectory.

Predicting Outcome of Acquired Brain Injury by the Evolution of Paroxysmal Sympathetic Hyperactivity Signs

In this multi-center study, we provide a systematic evaluation of the clinical variability associated with paroxysmal sympathetic hyperactivity (PSH) in patients with acquired brain injury (ABI) to determine how these signs can impact outcomes. A total of 156 ABI patients with a disorder of consciousness (DoC) were admitted to neurorehabilitation subacute units (intensive rehabilitation unit; IRU) and evaluated at baseline (T0), after 4 months from event (T1), and at discharge (T2). The outcome measure was the Glasgow Outcome Scale-Extended, whereas age, sex, etiology, Coma Recovery Scale-Revised (CRS-r), Rancho Los Amigos Scale (RLAS), Early Rehabilitation Barthel Index (ERBI), PSH-Assessment Measure (PSH-AM) scores and other clinical features were considered as predictive factors. A machine learning (ML) approach was used to identify the best predictive model of clinical outcomes. The etiology was predominantly vascular (50.8%), followed by traumatic (36.2%). At admission, prevalence of PSH was 31.3%, which decreased to 16.6% and 4.4% at T1 and T2, respectively. At T2, 2.8% were dead and 61.1% had a full recovery of consciousness, whereas 36.1% remained in VS or MCS. A support vector machine (SVM)-based ML approach provides the best model with 82% accuracy in predicting outcomes. Analysis of variable importance shows that the most important clinical factors influencing the outcome are the PSH-AM scores measured at T0 and T1, together with neurological diagnosis, CRS-r, and RLAS scores measured at T0. This joint multi-center effort provides a comprehensive picture of the clinical impact of PSH signs in ABI patients, demonstrating its predictive value in comparison with other well-known clinical measurements.

Unreliability of classic provocative tests for the diagnosis of growth hormone deficiency

In this study we investigated 9 prepubertal children with blunted GH response to classic pharmacological stimuli in contrast with normal auxological evaluation. The children were followed to evaluate their growth velocity for a longer period before starting replacement GH therapy. To evaluate the pituitary reserve a supraphysiologic stimulus such as GHRH plus arginine was used. Serum GH levels were measured by a time-resolved immunofluorimetric assay before and after 1 microg/kg body weight iv injection of GHRH, while serum PRL, IGF-I, and insulin were evaluated only in basal conditions using an automatic immunometric assay. Out of 9 studied subjects, 7 underwent GHRH plus arginine administration and showed a normal GH response; the parents of the remaining 2 children refused the test. Normal serum levels of PRL, IGF-I, insulin, and a normal insulin sensitivity were observed in all children. After 1 yr, the growth rate in each patient was further improved and reached almost normal values. Our results further confirm that the decision to start replacement GH therapy should be based on both auxological parameters and laboratory findings. The GHRH plus arginine test appears to be useful to identify false GH deficiency in children showing a blunted GH response to classic stimuli in contrast with normal growth rate.

Osteonecrosis of the jaw and bisphosphonate therapy: Experience from a single Italian institution

19661

Background: Osteonecrosis of the jaw (ONJ) is reported as serious side-effect after bisphosphonate (B) therapy. Although the number of patients (pts) presenting with ONJ seems to be increasing, the exact prevalence and etiology of osteonecrosis are not well established because of heterogeneous of clinical reports. Methods: From May 2005 and October 2006, 12 cases of ONJ were diagnoses at our Institution. Results: Characteristics of patients: the median age at presentation of ONJ was 64.2 years (range 43–79); 9 pts were female and 3 pts were male. All pts were treated with Zoledronic acid, none of pts were pretreated with other B. Location of necrosis was mandible and maxilla. Presenting symptoms were: parondotosis disease, bone exposure and ulceration. Osteonecrosis was preceded by dental extraction in 5 pts (45%). The diagnosis of ONJ was: clinical (exposed bone) and radiological in all pts; the biopsy was performed in 3 pts, none of wich showed the presence of neoplastic disease. The treatments of ONJ were: antibiotic in 3 pts, partial maxillectomiy in 2 pts, curettage in 8 pts. Only 1 pts was documented residual sites of necrosis after surgical malignancies. All pts are alive at the time of this report, with except of one. Characteristics of malignancies: breast cancer 7 pts, prostate cancer 2 pts, multiple myeloma 1 pts, carcinoma of unknown primary 1 pts. Concomitant or previous therapies for malignancies were: chemotherapy and/or radiotherapy in all pts. None of pts received radiotherapy to the involved region. B therapy has been continued in about half pts, irrespective previously ONJ, without worsening clinical condition. Conclusions: In our experience the number of pts with previous history of dental extraction and subsequent ONJ during B therapy is consistent as described in many reports. This condition may represent an important risk factor for developing osteonecrosis correlated with prolonged infusion of B. In order to reduce incidence and serious side effects of B therapy, we adopted alternative schedule treatment with bi or tri - monthly infusion.

No significant financial relationships to disclose.

Modified intraoral maxillo-malar osteotomy: long-term results in 16 consecutive cases

The authors report their experience with sixteen consecutive cases of maxillo-malar osteotomy via an intraoral approach. Some technical expedients and modifications to the original technique are described here. This procedure was associated in all cases with bilateral sagittal splitting of the mandible and in two cases with vertical reduction of the chin. Results from this series confirm the reliability of this technique and the stability of functional and aesthetic results.

Endosseous implants for prosthetic rehabilitation in bone grafted alveolar clefts

The authors report their experience in the surgical and prosthetic rehabilitation of three patients affected by sequelae of cleft lip and palate, with residual alveolar cleft and absence of maxillary anterior teeth. The patients were treated by means of late secondary bone grafting of the alveolar cleft, followed by the insertion of endosseous titanium plasma-sprayed implants (IMZ). After a further healing period (6-12 months) fixed dental prostheses were constructed. Preliminary results from this series have shown how dental prostheses supported by endosseous implants in grafted alveolar clefts are a very reliable possibility in dental rehabilitation of this malformation.

[The superior thoracic outlet compression syndrome: a report of a case in childhood with complete cervical rib]

Authors report a paediatric patient with thoracic outlet syndrome (TOC) and complete cervical rib. The symptoms at the time of presentation result from pressure on either the subclavian vessels or the lower trunk of the brachial plexus. TOC is infrequent in young people and usually the symptomatology does'nt need a surgical approach. Some Authors affirm that there are necessary impulsive moments like growth, increased muscular mass and rib ossification, decreased elasticity of ligaments, vessels, muscles and nerves, for outcoming the clinical manifestations. Paediatric competention has risen until adolescent age and may be more frequent the observation of this syndrome that present problems of both diagnosis and management.

[Mucopolysaccharidosis IS: Scheie's syndrome. A report of 2 brothers]

We describe two brothers affected by MPS type IS (Scheie syndrome). Mucopolysaccharidosis type I consists of three clinical entities of varying severity, all due to alfalevo-iduronidase enzyme deficiency. The MPS IS in characterized by joint stiffness, aortic valve disease and corneal clouding. The intellect is normal. All these findings are present on our brothers; furthermore retinal degeneration also occurred. It could give in the future attendant deterioration of vision.

[Hypoglycemia secondary to transitory hyperinsulinism in infancy: a case report]

We refer about an infant with transitory hyperinsulinism who first developed symptoms at the age of nine month treated with diazoxide. The therapy was successfully discontinued at the age of twenty-one month. The follow-up until the age of 38 month revealed a normal growing up and a normal neurological development. The main cause of hypoglycaemia are discussed referring the different cases of hyperinsulinism of the recent literature.

[Facial paralysis secondary to arachnoid cysts. Description of a case in a girl with precocious puberty]

Arachnoid cysts are unusual in childhood. We describe a case of arachnoid cyst in a girl with precocious puberty. The cyst caused facial paralysis from compression. A link between arachnoid cyst and precocious puberty was excluded by cerebral TAC. We briefly discuss the aetiology and topography of arachnoid cysts.

[Arthritis caused by type B Haemophilus influenzae. Description of 2 cases]

Haemophilus Influenzae type B is perhaps the most important pathogen in childhood. H.I. is the most common cause of bacterial septic arthritis in children under 2 years of age in the U.S.A. We describe two cases of H.I. septic arthritis and we discuss the the treatment. The antibiotic therapy is invasive H.I. type B disease is in a period of transition. New drugs are available that offer the same therapeutic efficacy as Ampicillin and Chloramphenicol but with decreased toxicity.