Volumetric MRI analysis of hippocampal subregions in Cushing's disease: A model for glucocorticoid neural modulation

Several preclinical studies have demonstrated neuronal effects of glucocorticoids on the hippocampus (HC), a limbic structure with anterior–posterior anatomical and functional segmentation. We propose a volumetric magnetic resonance imaging analysis of hippocampus head (HH), body (HB) and tail (HT) using Cushing's disease (CD) as model, to investigate whether there is a differential sensitivity to glucocorticoid neuronal damage in these segments. We found a significant difference in the HH bilaterally after 12 months from trans-sphenoidal surgical selective resection of the adrenocorticotropic hormone (ACTH)-secreting pituitary micro-adenomas. This pre–post surgery difference could contribute to better understand the pathopysiology of CD as an in vivo model for stress-related hypercortisolemic neuropsychiatric disorders.

Making the use of psychotropic drugs more rational through the development of GRADE recommendations in specialist mental healthcare

Introduction

In recent years the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology has often been used by international or national health authorities, or scientific societies, for developing evidence-based treatment recommendations. However, the GRADE approach has never been used by practicing physicians who aim at harmonizing their prescribing behaviours paying due attention to the best available evidence. This paper describes the experience of a working group of psychiatrists who adopted the GRADE approach to develop clinical recommendations on the use of psychotropic drugs in specialist mental healthcare.

Case description

The project was conducted in the Department of Mental Health of Verona, Italy, a city located in the north of Italy. At the beginning of 2012, psychiatrists with a specific interest in the rational use of psychotropic drugs were identified and appointed as members of a Guideline Development Group (GDG). The first task of the GDG was the identification of controversial areas in the use of psychotropic drugs, the definition of scoping questions, and the identification of outcomes of interest. The GDG was supported by a scientific secretariat, who searched the evidence, identified one or more systematic reviews matching the scoping questions, and drafted GRADE tables.

Discussion and evaluation

On the basis of efficacy, acceptability, tolerability and safety data, considering the risk of bias and confidence in estimates, and taking also into consideration preferences, values and practical aspects in favour and against the intervention under scrutiny, a draft recommendation with its strength was formulated and agreed by GDG members. Recommendations were submitted for consideration to all specialists of the Department, discussed in two plenary sessions open to the whole staff, and finally approved at the end of 2012.

Conclusion

The present project of guideline development raised several challenging and innovating aspects, including a “bottom-up” approach, as it was motivated by reasons that found agreement among specialists, those who developed the recommendations were those who were supposed to follow them, and values, preferences and feasibility issues were considered paying due attention to local context variables.

Reduced right posterior hippocampal volume in women with recurrent familial pure depressive disorder

Volumetric changes in mood-relevant distributed limbic/paralimbic structures have been reported in the recent literature on the course of mood disorders. Patients with unipolar and bipolar disorders have been found to have smaller hippocampal and anterior cingulate volumes. We examined hippocampal, amygdalar and anterior cingulate cortex (ACC) volumes in female patients with recurrent familial pure depressive disorder (rFPDD). We used semi-automated software for magnetic resonance imaging (MRI) to measure the volumes of the hippocampus, amygdala, ACC and subgenual prefrontal cortex (SGPFC) in 15 female patients with familial recurrent major depression (MD) and 15 healthy female subjects. Analysis of covariance, with whole brain volume as covariate, was used to compare volumetric measurements in the two groups. Volumes of the right hippocampal body and tail were significantly smaller in female patients with familial depressive disorder than in healthy subjects. Our data provide evidence of structural lateralized hippocampal body and tail abnormalities in women with familial history and recurrent episodes of depression. Although global reduction of hippocampal volume has been widely reported, data on lateralized regional reductions in familial recurrent depression had not been previously reported. Reduced volume of the right posterior hippocampus could be a structural endophenotype for recurrent depressive disorders in women.

Hippocampal remodelling after MDMA neurotoxicity: a single case study

Acute ingestion of MDMA (ecstasy) causes a transient marked increase in serotonin and dopamine at central synapses. Recent studies demonstrated that MDMA induces damage of serotonergic nerve terminals and alters hippocampal processing. Pronounced cognitive deficits in MDMA users affect learning and memory abilities. This pattern of predominant and long-lasting memory dysfunction suggests that the functioning of the hippocampus might be affected by the neurotoxic effects of MDMA. We present the case of a 16-year-old girl who developed an acute organic and psychotic syndrome caused by occasional use of low to moderate dose of MDMA. Serial neuroimaging ((18)F-FDG-PET and brain MRI) were correlated with her neurocognitive performance and clinical evolution. The structural and metabolic changes correlated with a severe cognitive impairment. After 16 months of intensive neuropsychological rehabilitation she showed significant improvement in hippocampal-related memory cognitive functions, which correlated with normalization of her (18)F-FDG-PET and remarkable hippocampal remodelling. This case report indicates that even non-chronic MDMA use may cause subacute toxic encephalopathy in which the clinical evolution is paralleled by neuroimaging changes in specific cerebral areas. The most relevant aspect is the reversibility of the volumetric changes, which may be the structural correlate of an ongoing hippocampal remodelling.

Psychopathology and clinical features in an Italian sample of patients with myofascial and temporomandibular joint pain: preliminary data

OBJECTIVE

Aim of this study was to provide data on the relationships between psychopathological variables and temporomandibular disorders (TMD). Sixty-three TMD patients were investigated using clinical and anamnestical psychiatric informations and psychopathological measures.

METHODS

Three groups of TMD patients were recruited according to the Research Diagnostic Criteria for TMD guidelines: a group of patients presenting myofascial pain alone (RDC/TMD axis I group I), a group with temporomandibular joint (TMJ) pain alone (RDC/TMD axis I group IIIa, IIIb), and a group presenting both myofascial and TMJ pain. Two secondary groups were identified on the basis of the presence/absence of myofascial pain. The study design provided a psychiatric interview and psychometric assessment including the Symptom Check List-90-Revised (SCL-90-R), the Hamilton Depression Rating Scale (HDRS), and the Hamilton Anxiety Rating Scale (HARS).

RESULTS

--Psychiatric evaluation: Myofascial pain patients had higher scores for personal psychiatric history and a history of more frequent psychotropic drug use. --HDRS and HARS: The sample presented scores indicating mild depressive symptoms and moderate anxiety symptoms. --SCL-90-R: The global sample showed acute levels of psychological distress as measured by the GSI score (Global Severity Index). Myofascial pain patients scored higher than TMJ pain patients in the GSI (p = .028), PAR (paranoia; p = .015), PSY (psychoticism; p = .032), and HOS (hostility; p = .034) subscales.

CONCLUSIONS

TMD patients showed elevated levels of depression, somatization, and anxiety. These characteristics did not differ significantly between patients with myofascial or TMJ pain. Other specific psychopathological dimensions, detected with SCL-90-R, appeared to be closely associated to the myofascial component.

Strangulated traumatic hernia of the diaphragm. A report of two cases

The herniation of abdominal viscera in the thorax can immediately follow diaphragmatic rupture or be delayed even years after the injury. The herniated viscera can strangulate; this consequence may lead to a dangerous misdiagnosis which could be lethal for the patient. Radiological procedures, serial chest X-ray studies, CT and MRI scans are mandatory to confirm diagnosis. The insertion of a naso-gastric tube is a very helpful method in ruling out hypertensive pneumothorax in the presence of an air-fluid level in the thorax. We report 2 cases of strangulated traumatic hernia of the diaphragm occurring just a few hours (case 1) and 18 months (case 2) after the trauma. During thoracotomy, a rupture of the left diaphragmatic cupola was demonstrated with herniation of the stomach in case 1, the stomach, spleen and transverse colon in case 2. No postoperative mortality or morbidity were detected.

[Role of surgical splanchnicectomy in the treatment of pancreatic carcinoma]

Palliative surgical procedures offer considerable benefit for the patients with unresectable pancreatic cancer: surgical splanchnicectomy performed in conjunction with biliary-enteric by-pass offers good results as regard pain relief without increased morbidity and mortality. We treated 25 patients with unresectable pancreatic cancer by mean of biliary-enteric by-pass plus bilateral splanchnicectomy performed through different surgical approaches. In this series of patients postoperative mortality was nil, mean survival time was 7.2 months (range 3-14 months). Preoperatively, we assessed all patients as affected by visceral pain: Scott-Huskisson 10 mark-scale value in quantitative assessment of pain was equal or above the 7th mark in 87.5% of patients. One month later in the postoperative follow-up, 96% of the patients had a significant reduction in pain intensity from a preoperative median of 7 mark to a postoperative median of 1.5 mark (p = 0.0001). The mean period free of pain recurrence was 4.8 months. However, after 6 months only 46% of survivors were pain-free with such rate decreasing further to a 10% of survivors after 8 months. Nevertheless, the patients had around 70% of their survival span free of pain. We strongly believe that failure in relief of pain is due to a mistake in preoperative evaluation of the type of pain (somatic and not visceral, or both) and to the onset of somatic pain in the course of the disease rather than to surgical technical errors. Recurrence of pain has been considered inevitable in the biological progression of unresected cancer, and would be treated by combination of therapies, such as non steroidal anti-inflammatory drugs, transaortic coeliac plexus block, narcotics and cervical cordotomy.

Pancreatic abscess and other pus-harboring collections related to pancreatitis: a review of 108 cases

This is a report on 108 cases collected from 1970 to 1987, in the same department, of surgically-detected pancreatic abscesses or pus-harboring collections. The purulent areas were either of a spreading pattern or represented a clearly localized mass. To the spreading pattern belong 47 cases of necrotizing pancreatitis, without discontinuity in the clinical course from the early toxic to the late septic phase, 4 cases of acute pancreatitis, initially in remission and later complicated by septic collections, and 4 cases which developed after an acute attack of chronic pancreatitis. The abscess pattern was made up of 19 each of pseudocysts and predisposing pancreatitis, 10 cases of chronic pancreatitis, and only 5 necrotizing "nonstop" pancreatitis. The surgical treatment in all cases consisted of multiple drainages and postoperative irrigation. We exclude 3 cases of associated open packing. The etiological, clinical, and biochemical features of each group of patients are reported and discussed. Computed tomography availability seems to be the most important improvement reported as regards diagnosis and surgical tactics. The overall mortality rate was 15.7% with a significant difference between the 2 patterns (23.6% for the spreading pattern versus 7.5% for the abscess pattern). On the basis of this experience, it is possible to establish a relationship between the gross appearance of the collection and the underlying pancreatic disease with differences in terms of prognosis, morbidity, and mortality. Finally, a simple nomenclature can be chosen which is capable of distinguishing between the diverse pancreatic purulent collections. While the presence of pus may characterize the course of severe acute pancreatitis in many cases, the low incidence of "true" pancreatic abscess is emphasized.

[Clinical results after proximal selective vagotomy (considerations on 42 cases)]

The authors report the results of a 6-8 year follow-up of 42 patients treated by selective proximal vagotomy with pyloroplasty for gastric or duodenal ulcer disease. On the basis of Visick's classification, the patients broke down into the following categories: Cat. 1: 66.6%; Cat. 2: 26.1%; Cat. 3: 2.3%; Cat. 4: 4.7%, with 92.7% belonging to the first two categories. These data are in agreement with other data reported in the literature, and show no significant differences as compared to follow-up one year after surgery.

[Epithelial splenic cysts]

The authors describe a case of an epithelial cyst of the spleen treated successfully by splenectomy. Diagnostic techniques and the principles adopted in treatment this rare disease are discussed.

[Retroperitoneal neurilemmoma (considerations on 4 cases)]

The authors show 4 cases of retroperitoneal neurilemmoma, surgically treated by simple excision of the tumour. From the general observations, as well as from the analysis of the literature, they can remark the rareness of the location in such anatomical region. The clinical symptoms are common to those of the region retroperitoneal tumours, and are due to the compressive effect developed by the tumour on the contiguous structures. As regards the diagnostic procedures, they emphasize the primary value of axial computed tomography in the evaluation of the retroperitoneal pathology. The diagnosis cannot be but histologic, and is based upon the presence of the typical histologic pictures according to Antoni A and B types.

[Our experience with selective proximal vagotomy]

The authors show a casuistry of 125 operations of SPV, and comment on the clinical and physiopathologic presuppositions justifying the indications to SPV in the field of gastroduodenal peptic pathology. They report the results of the gastric probings, both basal and after stimulation with pentagastrin in the pre- and postoperative phase, and after a year. They face the problem of pyloroplastics, and appraise the elements indicating and contra-indicating it in association to SPV.