Geographic differences in the incidence of Huntington's disease in Sardinia, Italy

BACKGROUND

The frequency of Huntington's disease (HD) may vary considerably, with higher estimates in non-Asian populations. We have recently examined the prevalence of HD in the southern part of Sardinia, a large Italian Mediterranean island that is considered a genetic isolate. We observed regional microgeographic differences in the prevalence of HD across the study area similar to those recently reported in other studies conducted in European countries. To explore the basis for this variability, we undertook a study of the incidence of HD in Sardinia over a 10-year period, 2009 to 2018.

METHODS

Our research was conducted in the 5 administrative areas of Sardinia island. Case patients were ascertained through multiple sources in Sardinia and Italy.

RESULTS

During the incidence period 53 individuals were diagnosed with clinically manifested HD. The average annual incidence rate 2009-2018 was 2.92 per 10⁶ persons-year (95% CI, 2.2 to 3.9). The highest incidence rate was observed in South Sardinia (6.3; 95% CI, 4.2-9.5). This rate was significantly higher (p<0.01) than the rates from Cagliari, Oristano, and Sassari provinces but did not significantly differ (p = 0.38) from the Nuoro rate.

CONCLUSIONS

The overall incidence of HD in Sardinia is close to the correspondent estimates in Mediterranean countries. Our findings highlight also the possibility of local microgeographic variations in the epidemiology of HD that might reflect several factors, including a possible founder effect in the rural areas of South Sardinia and Nuoro.

Prevalence of Huntington's disease in Southern Sardinia, Italy

BACKGROUND

The frequency of Huntington's disease (HD) may vary considerably, with higher estimates in non Asian populations. In Italy, two recent studies performed in Ferrara county and Molise provided different prevalence estimates, varying from 4.2 × 10⁵ to 10.8 × 10⁵. Here we present a study performed in the Southern part of Sardinia, a large Italian mediterranean island that is considered a genetic isolate.

METHODS

The study area included the two neighbouring counties of South Sardinia and Cagliari with 353,830 and 431,955 inhabitants respectively on December 31st, 2017 (prevalence date). Case-patients were ascertained through multiple sources in Sardinia and Italy.

RESULTS

We identified 54 individuals with HD, of whom 47 were alive on prevalence date. The resulting prevalence rate was 5.98 × 10⁵ in the overall study area, however with marked variations between South Sardinia and Cagliari (9.6 × 10⁵ vs. 3.0 × 10⁵, p = 0.02). In the two study areas, we found similar CAG repeat length in normal alleles (17.5 ± 2.1 vs. 17.7 ± 2.2, p = 0.5).

CONCLUSIONS

The overall prevalence of HD in Sardinia is close to the correspondent estimates in Europeans. Our findings also highlighted the possibility of local microgeographic variations in the epidemiology of HD.

LRRK2 mutations and Parkinson's disease in Sardinia—A Mediterranean genetic isolate

The Leucine-Rich Repeat Kinase 2 (LRRK2) Gly2019Ser mutation is frequent among Parkinson's disease (PD) patients from the Arab, Jewish, and Iberian populations, while another mutation, Arg1441Gly, is common in the Basque population. We studied the prevalence of these mutations in Sardinia, a Mediterranean genetic isolate with peculiar structure and similarities with the Basque population. Among 98 Sardinian PD probands we detected one heterozygous Gly2019Ser carrier. This mutation was also found in one of 55 Sardinian controls, an 85-year-old man, later shown to have a positive family history of parkinsonism. No carriers of Arg1441Gly, Arg1441Cys, or Arg1441His mutations were found among cases and controls. Our results suggest that the "Basque"LRRK2 mutation is absent or very rare in Sardinia. The Gly2019Ser mutation is present but its frequency is lower than that in Iberian, Arab, or Jewish populations. The identification of an 85-year-old, healthy Gly2019Ser carrier supports the concept that this mutation displays incomplete penetrance.

Effect of dose and frequency of interferon beta-1a administration on clinical and magnetic resonance imaging parameters in relapsing-remitting multiple sclerosis

There is still debate over the optimal dosage, frequency and route of administration of interferon (IFN) beta in multiple sclerosis (MS). A prospective, non-randomized, comparative study was performed to evaluate differences in magnetic resonance imaging and clinical outcomes of two IFN beta-1a preparations (30mcg intramuscular [im] once-weekly [qw], AVO; and 22 mcg subcutaneous [sc] three-times-weekly [tiw]; R22). Relapsing-remitting MS patients on one of the two IFN preparations (AVO, n=47; R22, n=48) were assessed at baseline and after 6 months of further treatment. There were no significant differences between the two groups at baseline. Both groups showed significantly reduced relapse rates (F=19.5; p<0.001) from baseline (0.6) to 6-month assessment (0.2; p<0.001). Univariate analysis showed a significant difference in favour of R22 on T2 lesion volume (F=14.4; p<0.001) and T1 black hole lesion load (F=8.5; p=0.004), the latter showing a significant increase in the AVO group (p<0.001). The incidence of patients with new T1 black holes was also higher for AVO than R22 (23.5% vs 8.3%; p=0.025). These results from patients receiving AVO or R22 in normal clinical practice are in line with randomized clinical studies that show the benefits of high-dose, high-frequency administration of IFN beta-1a in MS therapy.

Prevalence of primary blepharospasm in Sardinia, Italy: A service-based survey

We performed a service-based epidemiological study of primary blepharospasm in the island of Sardinia (Italy). Due to its favorable geographical location, we are confident we will provide reliable data from patients seeking botulinum toxin treatment. A total of 53 patients were assessed. Prevalence was estimated to be 32.2 per 1 million (95% confidence interval, 23.0-40.8). These results are in line with those obtained in other similar surveys, that is, record-based, and performed in various European regions such as Northern England, the Munich area, as well as the Epidemiologic Study of Dystonia in Europe.

A multivariate analysis of lower urinary tract ageing and urinary symptoms: the role of fibrosis

An investigative trial including 72 patients who underwent open surgery for benign prostatic hypertrophy (BPH) induced urinary symptoms was carried out with the purpose to obtain a deeper insight in the pathophysiology of this clinical picture. Prostate weight, stroma to parenchyma ratio, bladder wall fibrosis, I-PSS score, residual urine and uroflow obtained from these patients were processed by statistical multivariate analysis. The results point out the pivotal impact of prostate and bladder wall fibrosis in conditioning biological and chronological ageing of the lower urinary tract and relative symptoms.

The physic-pathology of continence and anti-reflux mechanisms

– When performing a heterotopic continent urinary diversion there are some crucial moments from a physiopathological point of view, such as the reconfiguration of the low-pressure reservoir, the uretero-enteric anastomoses and making the valve for continence. The low-pressure reservoir is achieved by detubularising an intestinal segment, chosen for its natural characteristics of peristalsis, the possibility of residual contractions and the tensive-elastic features of the tract used. It is traditionally thought that it is the shape given to the neo-reservoir rather than the length of intestinal tract which influences compliance. In turn the uretero-enteric anastomoses should not be assessed purely surgically, but also physiologically for their capacity to preserve renal functionality and prevent reflux. Correctly performed anastomoses adapted to the single techniques of continent diversion are extremely important, bearing in mind parameters such as the length of the intramural tract and the calibre of the ureters. The linchpin, however, is the continence mechanism, achieved by using valves that are physiologically present (ileocecal valve) or by constructing valves from intestinal segments. Careful evaluation of the various methods for this purpose, from the flutter valve to Mitrofanoff's principle, highlights the diversity of these mechanisms, due to different pressor balances, and of their validity and reliability, both physiopathologically and with regard to long-term continence. The outcome is that the choice of intestinal segment to be used, the type of reconfiguration, the uretero-entero anastomosis and the valvular mechanism techniques are not casual and/or preferential, but based each time on pressure factors present in the type of urinary diversion.

Preliminary reports on morphological and ultrastructural changes in the corpora cavernosa of the rat after chronic arterial obstruction

OBJECTIVES

Various authors have investigated the pathological findings of penile tissue after chronic arterial obstruction, but the significance of these changes in the corpora cavernosa remains unclear. In order to evaluate the possible damages in the erectile tissue after chronic arterial obstruction at different levels, we utilized an experimental model in rats to determine the changes in smooth muscle cells and elastic fibers of the erectile tissue by microscopic immunohistochemical and ultrastructural studies.

METHODS

Twelve adult male Wistar rats were employed in this study. Ten were used for the experiments and two as control. The rats were anaesthetized with ether and intraperitoneal 10% chloral hydrate. Microsurgical isolation of the involved vessels was performed with the aid of a Zeiss dissecting microscope. Partial stenosis was achieved with 11/0 nylon and amputation of the penis was performed at previously established time periods. The partial stenosis was carried out at the level of the aortic below the renal vessels (Group A), the common iliac artery on both sides (Group B) and the hypogastric artery on the left side (Group C). Arterial obstruction was maintained in each group for 50, 40 and 25 days, respectively.

RESULTS/CONCLUSIONS

In comparison with normal controls, the histological findings revealed discrete and diffuse interstitial hyalinosis with reducted elastic fibers, while dilated vascular lacunae were also present on TEM (Transmission Electron Microscope) and SEM (Scanning Electron Microscope) examination. The greatest ultrastructural damages were observed in the group with obstruction of the common iliac artery on both sides. The foregoing confirms that an eventual chronic obstruction of these arteries does not allow the formation of collateral vessels for the corpora cavernosa.

[BCG vs. BCG plus recombinant alpha-interferon 2b in superficial tumors of the bladder]

BCG intravesical instillation is a well established therapy for superficial bladder carcinoma as adjuvant and/or prophylactic treatment. However side-effects are frequent when full doses are employed and therefore low dose alternative schedules were proposed. Interferon intraluminal therapy for bladder TCC has been used with similar indication but the results did not encourage further single drug trials. A double arm random study, BCG full dose vs. BCG low dose, is presented. The results point out that the combination treatment is superior to BCG full dose therapy in terms of side effects and similar to BCG full dose as regards efficiency (5/18 vs 4/18 recurrences) after a follow-up of 24.11 +/- 8.15 for BCG and 16.72 +/- 8.7 for BCG + IFN.

[Single-blind study of the effect of doxazosin mesylate in benign prostatic hypertrophy]

The purpose of this single blind study was to verify the efficiency of Doxazosin Mesylate, an alpha-1 adrenergic blocker, in patients with benign prostatic hyperplasia (BPH). This study involved 20 patients non placebo responders. The duration of treatment was 45 days with administration of Doxazosin Mesylate increased every 15 days from 1 to 2 mg and from 2 to 4 mg respectively. At the end of each dosage cycle the following investigations were performed: a) peak urinary flow, b) residual urinary volume, c) funneling of the prostatic urethra by means of permictional transrectal echography, d) Boyarsky's score. The analysis of these data, applying a two way analysis of variance (ANOVA), showed that Doxazosin Mesylate resulted in improvements in both urodynamic and symptomatic parameters. The statistical analysis proved also that there was a good correlation between the dosage of the drug up until 2 mg and the results from each parameter considered.

[Role of echography in the diagnostic-therapeutic management of renal cysts]

Herein we report on the results of 171 out of 214 patients with renal cysts. In 127 cases diameter of cyst being less than < 6 cm, was monitored repeating renal ultrasound every 6 months: 78 patients underwent pecutaneous cyst echoguided puncture, while 9 patients were treated as follows: 4 by open surgery, 3 by laparoscopy and 2 by percutaneous treatment in general anaesthesia. Cysts are classified in 4 types and therapy is different according to Bosniak's classification. When the cyst is less than 6 cm in diameter and symptomatology is absent, we follow the patients up with yearly ultrasound. In our experience cyst sclerotization is carried out by injecting either ethanol or Trombovar or 50% glucose in water alone or associated with 2% Aethoxysclerol. The best results are obtained from the use of ethanol (30% of the volume of cyst). However some relapses are encountered after this kind of procedure. In these cases it is helpful to examine the cystic wall because of the presence of intracystic septa. Percutaneous treatment by means nephroscopy permits to visualize the cystic wall but it is not able to perform a biopsy of its wall. Laparoscopic treatment is performed by inserting 5 trocars with the patient under general anaesthesia. This technique is able to localize and biopsy the cystic wall without causing side-effects or complications. Open surgery was performed only in 4 patients affected with hidatid cyst. At present echoguided cyst puncture permits to approach the renal not complicated cysts, while laparoscopy constitutes a safe treatment in the case of benign recurrent and complicated cysts.(ABSTRACT TRUNCATED AT 250 WORDS)

[Urologic applications of intralaparoscopic echography]

The impossibility to palpate organs and tissues is probably the most important drawback of the laparoscopic approach: laparoscopic sonography represent the only real alternative to manual palpation. The laparoscopic approach in the field of urology was initially limited to the identification of the undescended testes in paediatric urology and to the laparoscopic ligation of varicocele. More recently, it took into account the pelvic lymphadenectomy for staging prostatic and bladder cancer. The upper urinary tract and the retroperitoneum were approached more recently. In a preliminary phase the indications for laparoscopic nephrectomy were limited to benign diseases, such as atrophic kidney in patients with renal hypertension, and scarred pyelonephritic kidney. At present some preliminary experiences are reported about nephrectomy performed for carcinoma of the urether or of the upper collecting system and for renal masses of unknown origin. Another indication for a laparoscopic approach to the kidney is represented by symptomatic renal cysts. These cysts have been usually treated with percutaneous aspiration and/or sclerosis, but a high rate of recurrence is reported. Laparoscopy may be used to approach renal cysts with the advantage that most of the cystic wall could be excised, reducing the change of recurrence. Another possible indication for laparoscopy and laparoscopic sonography is the retroperitoneal lymphadenectomy in testes cancer with staging or therapeutic purposes. Nowadays preliminary experiences in laparoscopic adrenalectomy have been reported in a limited series of cases. In this report the Authors present their initial experience using a 7.5 MHz rigid probe having 400 crystal which can be inserted into a 10 mm trocar.(ABSTRACT TRUNCATED AT 250 WORDS)

[The role of echography in the intraoperative study of non-palpable testicular masses]

Intraoperative ultrasound localization of the non palpable testicular lesions allows to detect small gonadal tumors or to well study benign testicular masses. Several methods have been proposed to study non palpable testicular masses including CT and NMR. Prospective studies of the efficacy of CT vs spermatic venography in localization of cryptorchid testes have also been reported: spermatic venography proved to be the most accurate of the two modalities even if possible neoplastic degeneration of testicular tissue is very difficult to investigate with this method. Herein we describe our clinical experience and particularly four cases in which we adopted intraoperative ultrasonography of testes with different results. M.S. a 28 year old infertile patient underwent testicular ultrasound during a check-up and a little image localized at the level of right testis was found. Even if no mass was palpable we decided to operate on the patient; an intraoperative testicular ultrasound revealed the precise localization so that the little mass was excised and examined at once. Histologic study confirmed the presence of tumoral tissue and orchiectomy was performed: deeper hystological studies confirmed it was a leydigioma. D.C. 27 year old bilaterally cryptorchid patient had been already operated on twice but no testicular structure was encountered at the level of inguinal channels. Neither preoperative abdominal ultrasound nor CT revealed the presence of the testes. At abdominal exploration both testes were localized in the iliac region. Intraoperative testicular ultrasound allowed us to localize a right testicular tumor: right orchiectomy and left autotransplantation were performed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echo-guided puncture of intraprostatic cysts]

The occurrence of an obstruction of the ejaculatory ducts, in spite of its rarity, must be considered by the Urologists in the screening of the etiologic causes of obstructive azoospermia. Nowadays, the diagnostic approach, which includes the biochemical study of seminal plasma and prostatic ultrasound, often leads to the preoperative recognition of the site of obstruction. Various surgical and endoscopic techniques have been adopted for the treatment of ejaculatory duct obstructions in different historical periods. Herein we describe our experience that starts from 1979. 17 infertile patients with intraprostatic cysts and 2 with a stenosis of the veru montanum were treated by us following these criteria: 9 azoospermic patients underwent scrototomy and endoscopy; 10 patients with a severe oligozoospermia underwent echo-guided puncture of an intraprostatic cyst. The patients were placed in the lithotomy position, a 16 G needle was adopted and by means ultrasound was possible to follow the needle entering the cyst. When no spermatozoa was detected in the cystic liquid, sclerosing agents (Sodium-tetradecyl-sulphate 30 mg in 1 l.) was introduced. This easy procedure was carried out on outpatients in local anaesthesia. One out of ten oligozoospermic patients had to repeat the echo-guided puncture of intraprostatic cyst as the first attempt had been followed by recurrence. Eight out of ten subfertile patients who had undergone percutaneous echo-guided treatment had longer than 1 year follow-up: in seven cases an increase in sperms number and motility was obtained; in one case sperm count remained unmodified. In three cases the partners became pregnant.

[Echo-flowmetric control 6 years after percutaneous treatment of varicocele]

Several Authors have discussed the long term efficacy of sclerotherapy; somebody supposes that percutaneous angiographic treatment of spermatic vein is not sure at all because the occlusion due to the sclerosing agents is not retained as long lasting. Studies have been done by other Authors about comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion: it is concluded that venous collaterals are identified easily by renal venography, and knowledge of these collaterals is helpful in planning further radiological treatment. Since 1980 we have always treated left varicocele by means of percutaneous sclerotherapy of the spermatic veins following renal phlebography: the treatment is done on an outpatient basis, in local anaesthesia. Sclerosing agents we usually adopt are: sodium-tetradecyl sulphate and alcohol. At our knowledge long-term results of this treatment have never been published; this is the reason for which long-term follow-up of 27 patients that 6 years ago underwent percutaneous sclerotherapy was done. Only 16 of them have accepted to repeat: a) physical examination; b) Doppler flowmetry; c) scrotal ultrasound. The presence of a varicocele was demonstrated in 2 out of 16 patients (12.5% of the case). These data confirms that percutaneous treatment performed following the procedures we adopted in 1986 has a long term efficacy in 87.5% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bulbocavernosus reflex and somatosensory evoked potential of the pudendal nerve in diabetic impotence]

The present study investigated the sensitivity of the bulvocavernosus reflex (BCR) and the somatosensory evoked potential (SEP) of the pudendal nerve in neurogenic impotence, the study comprised 22 males with diabetes type II. Of these, 11 had neurogenic impotence. The SEP was found to be normal in all cases, whereas BCR changes were observed in 36.4% of the patients who were not impotent and in 63.6% of the impotent males. This difference, however, is not statistically significant. The results show that in diabetic pelvic neuropathy compromise of the vegetative fibers does not necessarily mean injury to the somatic.

[Bilateral abdominal testicles in the adult. Microsurgical and laparoscopic therapy]

B. L. a 27 year old bilaterally cryptorchid patient underwent right testicular autotransplantation in the presence of a quite normal testis. After one year the patency of microsurgical anastomosis was confirmed by means of Doppler flowmetry and scrotal echography demonstrated the presence in the scrotum of a testis provided will normal echogenicity. Left laparoscopic orchiectomy was planned. A small semilunar skin incision was made just below the rim of the umbilicus. Veress needle was introduced: as soon as the needle pierced the parietal peritoneum, its spring mechanism was released allowing the sharp needle point to retract leaving only the blunt tip protruding. Carbon dioxide gas was insufflated through the side part of the Veress needle until adequate abdominal distension was achieved. After having removed the Veress needle, the laparoscope on its sharp-pointed trocar was introduced into the peritoneal cavity and left testis was easily localized. Four trocars were introduced up to proceed to laparoscopic orchiectomy. The patient was discharged two days after. In our opinion in the presence of a bilateral cryptorchism in the adult, is better to plan a monolateral autotransplantation. After having verified the long-term result of microsurgery we can decide if a contralateral orchiectomy has to be planned.

[Role of penile ultrasonography in erection deficit]

The presence of penile nodule, curvature, disorders in blood flow to and from the corpora cavernosa is often correlated with organic sexual impotence. Echography allows to obtain a clear imaging of penile structures: diameters of corpora cavernosa can be measured before and after injection of vasoactive drugs. In our study penile structure were evaluated using a Combison 310 and a Toshiba with 7.5 MHz probe. In a lot of cases echography was repeated after intracavernous injection of PGE 1 or papaverine. The equipment needed for this evaluation is expensive but echography is undoubtedly less invasive than other equivalent examinations like cavernosography. Although the sensitivity and specificity of penile echography have not yet been clearly established this test is generally considered to be an useful and objective one. Penile echography is particularly usefull in discriminating between echogenic and not-echogenic nodules in case of Peyronie disease.

[Impotence: introductory notes]

If we define erectile impotence as the inability to achieve and maintain a firm erection we can distinguish several pathogens of impotence: psychologic disorders, neurogenic sinusoidal disorders, arterial disorders, venous & sinusoidal disorders and systemic diseases and other disorders can cause erectile impotence. An etiologic screening of impotence must be carried out by Urologists in order to adopt the best surgical approach. Especially when surgery has to be planned, a complete, often invasive screening associated with a super-specialist diagnostic study is necessary at the beginning of any procedure. Different approaches to impotence can be adopted on the basis of patient's age, etiology and failure of other devices. The main methods of surgical correction of impotence may be divided as follows: a) percutaneous transluminal angioplasty (P.T.A.); b) revascularization; c) surgical treatment of "venous leakage", d) trans-luminal veno-occlusion (T.L.V.O.); e) correction of penile curvature; f) prostheses placement. The diagnosis of arteriogenic impotence depends upon the arteriographic demonstration of bilateral hemodynamically significant obstruction. In our experience the injection of papaverine during the test has provided a better visualization of cavernous arteries and helicine branches. Reduction of luminal diameter by more than 50% suggest a hemodynamically significant stenosis. Intracavernous injection of vasoactive agents has provided an attractive alternative to surgery. We have employed papaverine alone or with phentolamine or phenoxybenzamine. After short term treatment, some patients have achieved good erections without further injections. For P.T.A. of the distal internal pudendal arteries our approach has been via the ipsilateral or contralateral femoral arteries. Under local anesthesia a penile arteriographic catheter is placed in the internal pudendal artery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Testicular autotransplant and laparoscopic orchiectomy in a case of bilateral adult cryptorchism]

B.L. a 27 year old bilaterally cryptorchid patient underwent right testicular autotransplantation in the presence of a quite normal testis. After one year the patency of microsurgical anastomosis was confirmed by means Doppler flowmetry and scrotal echography demonstrated the presence into the scrotum of a testis provided of a normal echogenicity. Left laparoscopic orchiectomy was planned. A small semilunar skin incision was made just below the rime of the umbilicus. Veress needle was introduced: as soon as the needle pierced the parietal peritoneum, its spring mechanism was released allowing the sharp needle point to retract leaving only the blunt tip protruding. Carbon dioxide gas was insufflated through the side part of the Veress needle until adequate abdominal distension was achieved. After having removed the Veress needle, the laparoscope on its sharp-pointed trocar was introduced into the peritoneal cavity and left testis was easily localized. Four trocars were introduced up to proceed to laparoscopic orchiectomy. The patient was discharged two days after. In our opinion in the presence of a bilateral cryptorchism in the adult, is better to plan a monolateral autotransplantation. After having verified the long-term result of microsurgery we can decide if a contralateral orchiectomy has to be planned.