OUP accepted manuscript

Pyroglutamate amyloid beta3–42 (pGlu-Abeta3–42), a highly amyloidogenic and neurotoxic form of Abeta, is N-terminally truncated to form a pyroglutamate and has recently been proposed as a key target for immunotherapy. Optimized ACI-24, a vaccine in development for the treatment and prevention of Alzheimer’s disease, focuses the antibody response on the first 15 N-terminal amino acids of Abeta (Abeta1–15). Importantly, clinical data with an initial version of ACI-24 incorporating Abeta1–15, established the vaccine’s safety and tolerability with evidence of immunogenicity. To explore optimized ACI-24’s capacity to generate antibodies to pGlu-Abeta3–42, pre-clinical studies were carried out. Vaccinating mice and non-human primates demonstrated that optimized ACI-24 was well-tolerated and induced an antibody response against Abeta1–42 as expected, as well as high titres of IgG reactive with pyroGlu-Abeta. Epitope mapping of the polyclonal response confirmed these findings revealing broad coverage of epitopes particularly for Abeta peptides mimicking where cleavage occurs to form pGlu-Abeta3–42. These data are in striking contrast to results obtained with other clinically tested Abeta targeting vaccines which generated restricted and limited antibody diversity. Taken together, our findings demonstrate that optimized ACI-24 vaccination represents a breakthrough to provide a safe immune response with a broader Abeta sequence recognition compared to previously tested vaccines, creating binders to pathogenic forms of Abeta important in pathogenesis including pGlu-Abeta3–42.

Angiotensin-converting enzyme inhibitors in preclinical myxomatous mitral valve disease in dogs: systematic review and meta-analysis

To determine the efficacy and adverse events of the administration of angiotensin-converting enzyme inhibitors for the management of preclinical myxomatous mitral valve disease in dogs. A comprehensive search using Pubmed/MEDLINE, LILACS and CAB abstracts databases was performed. Randomised clinical trials that assessed efficacy and adverse events of angiotensin-converting enzyme inhibitors for the management of preclinical myxomatous mitral valve disease in dogs were included. Certainty of evidence was rated using GRADE methods. Four randomised clinical trials were included. While safe, angiotensin-converting enzyme inhibitors administration to dogs with myxomatous mitral valve disease and cardiomegaly results in little to no difference in the risk of development congestive heart failure (high certainty of evidence; relative risk: 1.03; 95% confidence interval: 0.87 to 1.23) and may result in little to no difference in cardiovascular-related (low certainty of evidence; relative risk: 1.01; 95% confidence interval: 0.54 to 1.89) and all-cause mortality (low certainty of evidence; relative risk: 0.93; 95% confidence interval: 0.63 to 1.36). Administration of angiotensin-converting enzyme inhibitors to dogs with myxomatous mitral valve disease without cardiomegaly may result in a reduced risk of congestive heart failure development. However, the range in which the actual effect for this outcome may be, the "margin of error," indicates it might also increase the risk of congestive heart failure development (low certainty of evidence; relative risk: 0.86; 95% confidence interval: 0.54 to 1.35). Administration of angiotensin-converting enzyme inhibitors to dogs with preclinical myxomatous mitral valve disease and cardiomegaly results in little to no difference in the risk of the development of congestive heart failure and may result in little to no difference in cardiovascular-related and all-cause mortality. The certainty of evidence of the efficacy of angiotensin-converting enzyme inhibitors administration to dogs without cardiomegaly was low.

Exclusive Neurogenic Bladder and Fecal Incontinency in an Achondroplasic Child Successfully Treated with Lumbar Foraminal Decompression

INTRODUCTION

Achondroplasia is a genetic disorder characterized by defects in the development of endochondral bone resulting in skeletal abnormalities like stenosis of the foramen magnum and of the spine, shortened limb bones, and macrocephaly. Congenital spinal stenosis is frequent and due to premature fusion of the pedicles to the laminae.

CASE PRESENTATION

We report a case of neurogenic bladder and fecal incontinence due to lumbar stenosis successfully treated with L1-L5 partial laminectomy and foraminotomy in a 7-year-old achondroplasic child.

DISCUSSION/CONCLUSION

To our knowledge, this is the first case report of exclusive neurogenic bladder and fecal incontinence in an achondroplasic child. Neurogenic bladder and fecal incontinence without motor impairment may be early and exclusive clinical findings of lumbar stenosis in children with achondroplasia.

Sildenafil improves clinical signs and radiographic features in dogs with congenital idiopathic megaoesophagus: a randomised controlled trial

We evaluated the efficacy of oral sildenafil citrate in dogs with congenital idiopathic megaoesophagus (CIM). Twenty-one puppies were randomly assigned to two groups (treatment and control). The dogs were given sildenafil oral suspension 1 mg/kg every 12 hours for 14 days or placebo in a masked fashion. Clinical signs (frequency of regurgitation and weight gain) and oesophagrams (relative oesophageal diameter, ROD) were evaluated in order to assess the efficacy of drug treatment, by examiners who were unaware of the study protocol. In addition, a set of in vitro experiments on isolated samples of canine lower oesophageal sphincter (LOS) was performed, and the effects of increasing concentrations of sildenafil on basal tone and electrically-stimulated motility were assessed. Sildenafil administration significantly reduced the number of regurgitation episodes (0.88±1.40 v 2.65±1.56, P<0.0001) and significantly increased weight gain in the treated dogs compared to controls (79.76±28.30 per cent v 53.40±19.30 per cent, P=0.034). ROD values, at the end of the treatment period, were significantly decreased in the sildenafil group, compared to pre-treatment values (0.97±0.19 v 0.24±0.14, P<0.0001), in contrast to control subjects (0.98±0.17 v 1.10±0.25, P=0.480). In accordance with the in vivo findings, sildenafil dose-dependently reduced basal tone and increased electrically-induced relaxation of dog LOS samples. These results suggest that sildenafil citrate helps ameliorate clinical and radiographic signs in dogs with CIM by reducing LOS tone, and could represent a novel therapeutic tool for the treatment of this disease.

Spinal tumors in children: long-term retrospective evaluation of a series of 134 cases treated in a single unit of pediatric neurosurgery

BACKGROUND CONTEXT

Spinal tumors in childhood are rare and heterogeneous, and their treatment is very demanding. It is necessary to both manage the disease and preserve the spinal stability so that the spine can grow normally. As a consequence, results in terms of both mortality and morbidity are often suboptimal.

PURPOSE

The results of a single pediatric neurosurgery institution are reported to highlight the peculiarities and pitfalls of the management of this disease. Tumors are analyzed from the point of view of their localization, histology, and outcome in terms of mortality and morbidity, with a special focus on postoperative spinal deformity.

STUDY DESIGN

The study design was retrospective.

PATIENT SAMPLE

Between 1995 and 2011, 134 children (75 males and 59 females) were admitted for spinal tumors, accounting for 7.7% of all the patients admitted for central nervous system malignancies. The mean age was 8.5 years (14 days-26 years), and the mean follow-up was 28 months (3 months-13 years).

OUTCOME MEASURES

Clinical and radiological outcomes were evaluated to assess mortality, morbidity, and surgical outcomes. A special interest was directed toward morbidity related to spinal deformity and neurologic deficits.

METHODS

Patients were divided into four groups: intramedullary (46 patients), intradural extramedullary (25 patients), extradural (53 patients), and paravertebral tumors (10 patients). Data were obtained retrospectively from medical records and radiological archives.

RESULTS

Low-grade glioma was the most common histology (14.1%). One hundred seventeen patients were surgically treated, with a total of 138 surgical procedures. A posterior approach was chosen in 111 cases, with osteoplastic laminotomy in 80. Radiotherapy was administered to 22 patients and chemotherapy to 26. At the last follow-up, 16 patients (11.9%) had died. A good control of the tumor with clinical improvement was reported in 100 patients (74.6%). Five patients developed a spinal instability (3.7%).

CONCLUSIONS

The goals of surgery should be histology, spine and nerve root decompression, and preservation of spinal stability. In our experience, osteoplastic laminotomy was a good surgical approach to perform the resection of the tumor with a low risk of secondary spinal instability.

Adenocarcinoma of the cervix associated with a neuroendocrine small cell carcinoma of the cervix in the spectrum of Muir-Torre syndrome

Muir-Torre syndrome (MTS) is an autosomal genodermatosis that is diagnosed by the presence of at least one sebaceous gland tumor and at least one visceral malignancy. The most frequent visceral malignancies reported in literature are low-grade colon-rectal and genitourinary cancers, with prolonged survival. The authors report the case of a 52-year-old female, with a positive familial history for MTS, who developed a cutaneous sebaceous carcinoma, a synchronous colon-rectal adenocarcinoma, and a metachronous endocervical adenocarcinoma associated with a neuroendocrine small cell carcinoma of the cervix (SCNC), with lymph node metastasis. The rare occurrence in literature of the cervical SCNC and the rarest occurrence of a neuroendocrine carcinoma in the context of a MTS deviate from the usual and low-grade types of cancers normally described with MTS. It should be always appropriate to assess any symptoms that might reveal an underlying malignancy, although not within the spectrum of neoplasms most associated with this rare syndrome.

Dermo Beta Brachytherapy with 188Re in extramammary Paget's disease

AIM

Extramammary Paget's disease (EMPD) is a rare neoplastic pathology involving the vulva, scrotum, and perianal areas, and it is characterized by a slow and insidious course. EMPD may also be associated with internal malignancy, and its clinical presentation features long-standing pruritic lesions, eczema-like, refractory to any therapy. The pathogenesis is unclear, and univocal standardization of treatment is yet to be determined. As regard to the patients who suffer from it, women are more often affected than men. The therapeutic approach depends on the extent of involvement; wide surgical excision is the first choice among treatments, but other forms of therapy, alone or in combination, include imiquimod 5%, photodynamic therapy, Mohs surgery as well as external beam radiotherapy and Brachytherapy. In the present paper a new therapeutic alternative is proposed: Dermo-Beta-Brachytherapy (DBBT) with 188Re.

METHODS

Five patients with EMPD, one secondary and four primary cases, have been treated by Brachytherapy with DBBT. This therapy has been successfully used for non-melanocytic skin tumors and basically consists in the topical application of a specially designed, tailor-made mould containing a radioactive beta-emitting isotope, rhenium-188.

RESULTS

The patients healed completely, after one session in one case and after two sessions in four cases, with 34 months mean follow-up.

CONCLUSION

Brachyterapy could represent a new alternative therapy, instead than invasive treatments as surgery and conventional radiotherapy, capable to treat EMPD independently of its extension, with aesthetic and functional satisfactory results.

Lichen sclerosus and the risk of malignant progression: a case series of 159 patients

AIM AND METHODS

We analyzed 159 stored specimens of Lichen Sclerosus (LS) collected in the period 1999-2011 from 159 patients, in order to evaluate the histological patterns, clinical outcomes and possible associations with malignancies. The histopathologic analysis revealed 145 cases (males and females) with LS alone, 7 in whom penile LS was associated with spinocellular carcinoma (SCC), and 7 in whom LS was associated with a pseudocarcinomatous-hyperplasia (PCH). Extragenital LS was found in 20% (17/85) of the males and 78% (58/74) of the females. In the cases of SCC, immunohistochemical analyses was performed.

RESULTS AND CONCLUSION

The results showed very low positivity to p16INK4A and Ki-67; biomolecular PCR was positive in only two cases, and in both cases the non-oncogenic genotype HPV 100 was detected. No important additional risk factors for malignancies were found (e.g., hormones, infections, other autoimmune diseases).

hMena: altered expression in psoriatic skin

Psoriasis is a chronic inflammatory skin disease, characterized by an enhanced proliferation and a deregulated differentiation of keratinocytes. hMena is an actin regulatory protein involved in the control of cell motility and adhesion. hMena results up-modulated in several human tumors with respect to normal tissues and its expression has been positively correlated to proliferation rate, tumor size and aggressiveness in response to mitogenic stimuli, such as epidermal growth factor. The hyperproliferation of keratinocytes observed in psoriasis prompted us to evaluate hMena expression on biopsies collected from involved and uninvolved skin of 12 patients with active plaque-type psoriasis with respect to healthy skin. We analyzed the expression of hMena at transcript and protein levels by quantitative RT-PCR and immunohistochemistry. We correlated the expression of hMena to Ki67 proliferation index and to keratin 10 (K10) and keratin 16 (K16) used as markers of keratinocyte differentiation and activation. We demonstrated the expression of hMena in a hyperproliferative skin condition not related to neoplastic transformation. Interestingly, we observed that hMena is not expressed in healthy skin, but it becomes detectable in non-lesional areas and it is even more expressed in lesional psoriatic skin. In addition, we found that hMena expression is correlated to the rate of keratinocyte proliferation and activation. Hence, our observations indicate hMena as a new possible player, involved in the development and/or maintenance of the hyperproliferative state of psoriatic keratinocytes.

SURGICAL MANAGEMENT OF CONGENITAL MEDIAN PERISELLAR TRANSSPHENOIDAL ENCEPHALOCELES WITH AN EXTRACRANIAL APPROACH

OBJECTIVE

Median perisellar congenital transsphenoidal encephalocele (CTE) is a rare entity associated with multiple endocrine, visual, and respiratory deficits. The most likely causative factor for these pathological alterations is distension of neural structures (hypothalamic-pituitary system, optic pathway), resulting in protrusion of the dural sac through a sphenoid bone defect into the pharynx. The continuity with the extracranial space can be associated with an increased risk of tearing of the sac, with consequent cerebrospinal fluid leakage and subsequent increase in the risk of infection. We retrospectively reviewed the surgical treatment of CTE in our hospital using either an extracranial transoral or transnasal approach.

METHODS

We retrospectively reviewed our database. Between July 1994 and June 2005, CTE we identified 6 patients. Five of them were treated by a surgical intervention. The first patient was treated via a transcranial approach but had a relapse of the prolapse 11 years later. The relapse was treated with an extracranial transpalatal approach. Four patients were treated with an extracranial surgical approach: an extracranial transoral approach was performed in 2 cases, and an extracranial transnasal approach was used in the other 2 cases. Surgery was not performed in 1 patient because the parents refused to consent to the procedure.

RESULTS

Preoperative symptoms remained stable or improved in all of the patients after the surgical procedure and worsened in the patient who did not have a surgical intervention. Two patients experienced a palatal dehiscence. No mortality was recorded in this series of patients.

CONCLUSION

The surgical treatment of CTE is indicated to stop the progression or improve symptoms related to this disease entity. If approached correctly, the extracranial approach is a safe procedure with subsequent low morbidity.

Elevation of serum gamma-glutamyltranspeptidase activity is frequent in chronic hepatitis C, and is associated with insulin resistance

BACKGROUND AND AIMS

Serum gamma-glutamyltranspeptidase level is often increased in patients with chronic hepatitis C, and we aimed to identify factors associated with this phenomenon in patients completely abstinent from alcohol (teetotaller).

PATIENTS AND METHODS

71 teetotaller patients have been identified by personal history, questioning of relatives, CAGE questionnaire administration and unscheduled alcoholemia measurements.

RESULTS

39 patients (55%) had elevated (>50IU/L) gamma-glutamyltranspeptidase level. Body mass index, insulin and C-peptide level, insulin resistance, piecemeal necrosis score > or =3, fibrosis score > or =2 and steatosis score > or =1 were significantly higher in these patients than in those (n=32) with normal gamma-glutamyltranspeptidase. At multiple linear regression analysis gamma-glutamyltranspeptidase level was associated with C-peptide level, insulin resistance and histopathologic grading. At multiple logistic regression analysis, C-peptide level (OR=2.13) and piecemeal necrosis score > or =3 (OR=4.59) were the only factors independently associated with elevated gamma-glutamyltranspeptidase. Sustained virological response during pegylated interferon plus ribavirine treatment was achieved by 97% and 49% patients with normal and elevated gamma-glutamyltranspeptidase, respectively (p=0.0001).

CONCLUSION

Serum gamma-glutamyltranspeptidase level is often elevated in chronic hepatitis C and is associated with metabolic and inflammatory factors; this phenomenon may contribute to explain and to predict resistance to treatment in this subgroup of patients.

Dermatological high-dose-rate brachytherapy for the treatment of basal and squamous cell carcinoma

BACKGROUND

Basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are among the most common cancers in humans. Various therapies are currently being used to treat these tumours including surgery, topical treatments and radiotherapy. We describe a new treatment for BCC and SCC. This consists of superficial radiotherapy, using synthetic resin containing a radioactive beta-emitting isotope. The resin is applied to the lesion to perform a selective beta-irradiation brachytherapy treatment.

METHODS

In total, 53 patients with histologically confirmed diagnosis of BCC and of SCC were enrolled for the treatment.

RESULTS

In all treated cases, an apparent clinical remission occurred in approximately 3 months, and complete healing was obtained in 100% of the treated patients; in 82% of the cases, this occurred after a single application. No disfiguring scars or any side-effects were seen. After a follow-up of 20-72 months (mean 51 months), no clinical relapses were observed in the treated patients. Histological examination confirmed complete tumour regression.

CONCLUSION

The results indicated that brachytherapy is an effective treatment for BCC and SCC.

Inspiratory capacity predicts mortality in patients with chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) severity is usually graded upon the FEV(1) reduction and FEV(1) has been considered the most important mortality predictor with age in COPD. Recent studies suggest other factors as more powerfully related to mortality than FEV(1) in COPD patients.

AIM

To assess the impact of inspiratory capacity (IC) on mortality and morbidity in COPD patients during a 5-year follow-up period.

METHODS

We recruited 222 patients with mild-to-moderate COPD from January 1995 to December 2001 with an average follow-up period of 60 months (range 30-114 months). Among different respiratory parameters measured in stable conditions FEV(1), FEV(1)/FVC%, IC and PaO(2), PaCO(2) and BMI were chosen and their relationships with all-cause and respiratory mortality and with morbidity were assessed.

RESULTS

All these variables were associated with mortality at the univariate analysis. However, in a multivariate regression analysis (Cox proportional hazards model) for all-cause mortality age (year), IC (%pred.) and PaO(2) (mmHg) remained the only significant, independent predictors (HR=1.056, 95%CI: 1.023-1.091; HR=0.981, 95%CI: 0.965-0.998; HR=0.948, 95%CI: 0.919-0.979, respectively). According to the same analysis, IC (%pred.) and PaO(2) (mmHg) were significant independent predictors for respiratory mortality (HR=0.967, 95%CI: 0.938-0.997; HR=0.919, 95%CI: 0.873-0.969) together with FEV(1)/FVC% and BMI (kg/m(2)) (HR=0.967, 95%CI: 0.933-1.022; HR=0.891, 95%CI: 0.807-0.985, respectively). IC (%pred.), FEV(1)/FVC%, and PaO(2) (mmHg) were also significantly related to morbidity, as independent predictors of hospital admissions because of exacerbations (OR=0.980, 95%CI: 0.974-0.992; OR=0.943, 95%CI: 0.922-0.987; OR=0.971, 95%CI: 0.954-0.996, respectively).

CONCLUSION

IC (%pred.) is a powerful functional predictor of all-cause and respiratory mortality and of exacerbation-related hospital admissions in COPD patients.

[Skin adnexal tumors]

Adnexal skin tumors are rare neoplasms that develop from hair follicles, sebaceous glands and sweat glands. In the majority of cases these tumors are benign, although metastases have been reported in rare occasion. The diagnosis in always histologic and often it is sufficient to report the lesion simply as benign or malignant. Radical surgery is the treatment of choice. When the tumor is large, the Mohs technique can be used. Local recurrence is frequent in case of incomplete surgical removal. Etastatic disease, although rare, has a poor prognosis. Chemotherapy and radiotherapy experience is very limited. Overall, combination chemotherapy seems to be superior to single agent treatment.

Giant cyst of the cavum septi pellucidi, cavum Vergae and veli interpositi

The authors report a case study of a giant cyst of the cavum septi pellucidi, cavum Vergae and veli interpositi spreading to the posterior fossa, and initially treated elsewhere by ventriculoperitoneal shunt, with no resolution of the symptomatology. A few months later the patient was successfully treated by fenestration into the ventricular system through a neuroendoscopic technique, at the Pediatric Neurosurgical Center of the Meyer Children's Hospital in Florence. Symptomatic midline cysts are quite rare and different techniques have been proposed for their treatment, i. e., direct craniotomy, conventional shunting, stereotactic approaches as well as endoscopic fenestration. In such cases neuroendoscopy obtains a good symptom resolution level, avoiding at the same time the risks of damage to endoventricular structures and often eliminates the need for a definitive ventriculoperitoneal shunt. In the present research the authors analyze the anatomy of the midline cavities and the mechanism through which a cyst may become symptomatic. The surgical endoscopic technique and the clinical and radiological assessments which confirmed the patency of the fenestration are also discussed. The authors conclude that endoscopic ventricular fenestration may represent the treatment of choice for this pathology.

Loss of heterozygosity and p53 polymorphism Pro72Arg in a young patient with medulloblastoma

Differently from conventional primary neuroectodermal tumors (PNETs), molecular features of undifferentiated lesions have been poorly studied. Medulloblastoma and PNET neoplasms showed a high incidence of loss of heterozygosity (LOH) on chromosome 17p13, in the region of tumor suppressor gene p53. Recent studies have shown a significant correlation between the presence of p53 Arg72Pro polymorphism and several undifferentiated carcinomas. We performed molecular analysis in an anaplastic tumor of posterior fossa in a patient with a constitutional maternal translocation [46,XX,t(5;19)] and a history of headache, nausea and vomiting. We identified the presence of LOH at 17p13 and Pro72Arg polymorphism in tumor DNA. These molecular findings helped us better characterize this undifferentiated tumor and led to a more aggressive therapy.

Carbapenems in the treatment of severe community-acquired pneumonia in hospitalized elderly patients: a comparative study against standard therapy

In this open, prospective, study were enrolled 204 hospitalized elderly patients with severe (88 males, 116 females, age range 70-94). Patients were randomized to receive one of the following antibiotic treatment regimens: meropenem 500 mg i.v. t.i.d. (52); imipenem/cilastatin 500 mg i.v. t.i.d. (51), clarithromycin 500 mg + ceftriaxone 1 g i.v. b.i.d. (52), clarithromycin 500 mg + amikacin 250 mg i.v. b.i.d. (49). In 99 cases causative germs were isolated (24 meropenem, 26 imipenem, 23 clarithromycin + ceftriaxone, 26 ceftriaxone + amikacin). A satisfactory clinical, bacteriological response was achieved respectively in 86.5% 77% in meropenem; 86.3% 71% in imipenem/cilastatin; 69% 61% in ceftriaxone + clarithromycin and in 85.7% 77% in clarithromycin + amikacin. The mean total cost for each patient was $1,560; $1,620; $1,760 and $1,792 in meropenem, imipenem/cilastatin, clarithromycin + ceftriaxone and clarithromycin + amikacin respectively. This study shows that treatment with either meropenem or imipenem is as efficacious as conventional therapy in the treatment of community acquired pneumonia (CAP), and that meropenem is the most cost-effective.

High frequency ultrasound in the preoperative staging of primary melanoma: a statistical analysis

High frequency sonography has been shown to be a useful tool in the preoperative staging of malignant melanoma. In the present study sonometric and histometric data concerning tumour thickness were compared, using appropriate statistical methods, in order to assess the accuracy of ultrasonography. From December 1997 all pigmented lesions suspected of being melanoma were preoperatively assessed by a 20 MHz ultrasound B scan. The results of these ultrasound examinations were compared with histometric data. Pearson's correlation coefficient and absolute and relative differences were used for statistical analysis. Of the 261 examined lesions, 193 were malignant melanoma. A high correlation between sonometry and histometry was computed (r = 0.95), with an absolute difference of 0.32 +/- 0.03 mm (mean +/- SEM) and a mean relative difference of 27.2% (95% confidence interval 23-31.4%). The highest correlation was found in melanoma > or = 1.51 mm thick and the lowest correlation in melanoma < or = 0.75 mm. In conclusion, the high accuracy of this technique in the preoperative staging of malignant melanoma would offer a basis for defining the surgical margins of > or = 0.76 mm thick lesions. The limited accuracy of sonometry in the preoperative staging of thin melanoma < or = 0.75 mm has emerged by applying adequate statistical methods.

Vibrotactile perception thresholds in four non-exposed populations of working age

The purpose of this study was to establish a basis for the use of a device for measuring vibrotactile perception thresholds for epidemiological purposes on a series of non-exposed populations. Vibrotactile perception thresholds (VPTs) were measured with a vibrometer in 218 men and 160 women belonging to two non-exposed male blue collar populations, one white-collar population and one age and gender stratified sample of the general population. VPTs were measured on the middle and the little finger of the dominant hand at 31.5 and 125 Hz. The VPTs were expressed in dB and the effect of a series of factors including the population, age, gender and digital temperature was assessed in a regression analysis weighted by the inverse variance of the measurements. Adjusted for age, no significant difference between the VPTs in the four male populations was observed. At frequency 125 Hz, the effect of age (0.3 dB per year) was more important than at frequency 31.5 Hz (0.2 dB per year). In the two female populations, the results were less stable than among males and the VPTs were higher than among males. However, the age-dependence was similar among males and females. The within-test variance is a valuable indicator of the quality of the VPT measurements. Weighting by its inverse improved the fit of the regression models. Normal values for VPTs in non-exposed populations were obtained, which were reproducible in four separate populations.

[Head injuries in children. Considerations on 3,715 consecutive cases]

BACKGROUND

The authors present their personal experience of 3715 cases of head injury in pediatric patients, occurring during the last three years (1997-1999), admitted to the Emergency ward at the "Anna Meyer" children's hospital in Florence.

METHODS

A prospective study was made, starting from the evaluation made by the paediatric surgeon and following the subsequent diagnostic and clinical course. Depending on the severity of injury, this took the form of immediate discharge with a written sheet of instructions, "short observation" (up to 12 hours) in an Emergency ward and/or admission to neurosurgery or general medicine or to intensive care. The authors also analyse the diagnostic and instrumental tests carried out at the various stages (cranial X-ray, direct cranial CT, EEG) and the specialist consultations required (neurosurgery, neurology, paediatrics, resuscitation). Data for injured children transferred from other hospitals for neurosurgery were excluded from the study which only included patients examined primarily at our hospital. If admitted for more than 48 hours, a neurosurgical outpatient check-up was programmed one week later. In more severe cases, patients were admitted to day hospital between six months and one year later.

RESULTS

Injuries were minor in 91% of cases and the age of patients ranged between 5 days and 14 years; moreover, 60% of the patients observed were male. Only 1.5% of cases seen in Emergency were admitted to hospital and 8.4% of all head injuries, with a total stay of between 1 and 6 days. There were 4 deaths in severely polytraumatised patients. There was only one case of firearm injury which was not fatal. Head X-rays were performed in 13.4% of patients showing evidence of fracture in 19.1% of cases. Direct cranial CT was performed in 10.2% of cases with pathological findings in 23.9% of cases. Neurosurgery was performed in one of the 5.9% patients admitted to hospital. The late sequelae to head injury included one case of epilepsy that occurred 7 months after injury.

CONCLUSIONS

Anamnesis showed that the most frequent reason leading to head injury was lack of adult supervision and that the majority of severe injuries were caused by road accidents, both as pedestrians and as passengers. Lastly, the authors emphasise the importance of recognising and correctly treating so-called secondary cerebral damage, which has a non-immediate onset but is potentially severe, and identifying the risk factors for head injury in order to reduce the incidence and severity.

Response function technique for calculating the random-phase approximation correlation energy

We develop a scheme to exactly evaluate the correlation energy in the random-phase approximation, based on linear response theory [Y. R. Shimizu, J. D. Garrett, R. A. Broglia, M. Gallardo, and E. Vigezzi, Rev. Mod. Phys. 61, 131 (1989)]. It is demonstrated that our formula is equivalent to a contour integral representation recently proposed [F. Donau, D. Almehed, and R. G. Nazmitdinov, Phys. Rev. Lett. 83, 280 (1999)] being numerically more efficient for realistic calculations. Examples are presented for pairing correlations in rapidly rotating nuclei.

Effective nucleon mass in deformed nuclei

The coupling of vibrations to nucleons moving in levels lying close to the Fermi energy of deformed rotating nuclei is found to lead to a number of effects: (i) shifts of the single-particle levels of the order of 0.5 MeV towards the Fermi energy and thus to an increase of the level density, (ii) single-particle state depopulation of the order of 30%, and thus spectroscopic factors approximately 0.7, etc. These effects, which we have calculated for 168Yb, can be expressed in terms of an effective mass, the so-called omega mass ( m(omega)), which is approximately 40% larger than the bare nucleon mass in the ground state. It is found that m(omega) displays a strong dependence with rotational frequency, eventually approaching the bare mass for Planck's over 2piomega(rot) approximately 0.5-0.6 MeV.

Neck motion evaluation after whiplash: a radiographic and kinematic protocol

Evaluation of functional damage is the main aspect in the diagnosis of whiplash injury, therefore some type of instrumental testing is strongly needed. We describe an instrumental protocol to test subjects with whiplash, to support clinical evaluation, in order to solve the difficulty of evaluating the functional injury and the lack of fixed parameters capable of identifying this kind of injury. Eighty subjects suffering from after effects of whiplash and seventy five normal subjects undergo two instrumental tests: kinematic examination of neck mobility, and measurements of extension-flexion X-rays of the cervical spine. The results exhibited by the traumatized patients have been compared with the normal range of motion obtained from the data bank of the normal subjects. This is a report in progress of a larger research on whiplash evaluation in a clinical setting.

Endoscopic third ventriculostomy for hydrocephalus

The authors report on 125 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in three Italian Neurosurgical Centers. The series includes 77 cases of primary aqueductal stenosis, 33 with triventricular hydrocephalus due to external tumor compression, and 15 with tetraventricular hydrocephalus. The operations were carried out mainly under general anesthesia, using a flexible endoscope. Decrease of size of the third ventricle and the presence of a signal void at the level of the fenestration are the main postoperative MRI findings. Signs of intracranial hypertension, increased head circumference and Parinaud syndrome respond more frequently to the endoscopic treatment. The overall rate of good results (shunt-independent patients) in this series is 86.4%; primary aqueductal stenosis (93.5%) and triventricular hydrocephalus due to external compression (84.8%) are associated to the higher rate of good postoperative results than tetraventricular hydrocephalus (53.3%). Because of the very low invasivity of this technique, the absence of postoperative mortality and the scarce and usually transient postoperative complications, the authors advise to enlarge the indications for endoscopic third ventriculostomy to all patients with obstructive hydrocephalus when the third ventricle is large enough and there are no alterations of the CSF resorption.

Subjective assessment of fork-lift truck seats under laboratory conditions

A subjective assessment of fork-lift truck seats has been carried out to assess the range of preferred seat dimensions and the acceptability of different seat adjustments to fork-lift truck drivers. Twelve fork-lift truck seats fitted to a fixed bench were assessed by twelve fork-lift truck drivers. For each seat, each driver completed a questionnaire that covered the following areas: eleven seat dimensions, four seat adjustments and other features (arm rests, safety belts and safety wings). The drivers assessed the dimensions of a seat chosen at random, before moving to the adjacent seat in either a clockwise or anticlockwise direction. Before each assessment, they were asked to look forward and backward in the seat as though they were driving a fork-lift truck. In general, significant correlations were obtained between the subjective assessments and objective measurements of the seat dimensions. This enabled preferred seat dimension ranges to be defined. Fork-lift truck drivers ranked the forward-backward and the backrest inclination adjustments as most important. The results showed that although the drivers had previous experience in the use of suspension seats, they did not understand the purpose of the weight adjustment. All adjustments should be easy to find, accessible, easy to move and they should enable a range of adjustments. In addition, clear and simple information on the seat is needed, especially for the weight adjustment. The most recently designed seats generally had dimensions within the preferred ranges compared with the older generation seats, mainly because they had more adjustments. However, the results show that adjustments on fork-lift truck seats could be improved further. Some tentative conclusions are made for the preferred fork-lift truck seat dimensions and adjustment ranges which are based on the evidence from this restricted sample of fork-lift truck drivers. They may be useful for seat and truck designers in the preparation of a standard on fork-lift truck seat dimensions.

[Role of high-definition and high frequency ultrasonography in determining tumor thickness in cutaneous malignant melanoma]

PURPOSE

We investigated the predictive capabilities of high frequency, high resolution ultrasound (US) in the preoperative assessment of tumor thickness in cutaneous malignant melanomas. This evaluation is a valuable help for correct surgical planning.

MATERIAL AND METHODS

December 1997 to August 1998, we studied with US over 120 pigmented skin lesions and collected the data, including the final histologic diagnosis, of 78 of them, which make our series. Sixty-six of 78 lesions were histologically defined as cutaneous malignant melanomas with superficial spread and the other 12 as melanocytic nevi. All examinations were carried out with an Esaotebiomedica AU 5 Harmonic scanner equipped with a 20-MHz annular array probe and a linear 13-MHz probe; B-mode, color and power Doppler images were always acquired.

RESULTS

The statistical analysis of the comparative US and histologic measurements of tumor thickness showed very good agreement, with a high Pearson's coefficient (R: .93). However, US frequently underestimated the actual thickness relative to histology, which is in contradiction with previous literature reports. We could study with US the melanoma in situ, which has never been described before. Last but not least, low-thickness melanomas had very few color and power Doppler signals.

CONCLUSIONS

US is the correct tool for the preoperative assessment of the thickness of cutaneous malignant melanomas because it provides high agreement with histologic data even in lesions thinner than 1 mm.

Neuroendoscopy. Personal experience, indications and limits

The authors report a series of 40 patients treated by endoscopic neurosurgery. It includes 31 cases of obstructive hydrocephalus, 4 paraventricular or intraventricular CSF cysts, 3 cases of multiloculated hydrocephalus, one suprasellar arachnoid cyst and one cystic astrocytoma with mural tumor nodule. Third ventriculostomy is the most frequent indication of the endoscopic neurosurgery, which is very useful also for performing fenestration of CSF cysts and multiloculated hydrocephalus. The surgical endoscopic techniques in the different above mentioned pathologies are exposed. The criteria for patient selection, the clinical results and the postoperative radiological findings, that confirm the patency of the fenestration, are discussed.

Measurement reliability of dynamic x-rays of the cervical spine: an experimental model

A blind test of measurement reliability was performed in vitro using lateral x-rays of cervical vertebrae. Dry specimens of C3 and C4 were mounted in a movable frame and flexion/extension was simulated. Lateral x-rays were taken for each degree from 15 degrees flexion to 15 degrees extension. Then the x-rays were measured by four raters. The results show a high level of absolute measurement error. This suggests caution in accepting existing literature data on cervical x-ray measurements unless some indicator of the personal measuring accuracy of the rater is specified. The procedure described in this paper can be used to ascertain such accuracy.

Fibroelastolytic papulosis of the neck: a report of 20 cases

The clinical and histological features of the entities known as 'white fibrous papulosis of the neck' (WFPN) and 'acquired elastolysis of the papillary dermis simulating pseudoxanthoma elasticum' (PDE) are not clearly defined. This study was conducted to compare our experience of WFPN/PDE with those described in the literature. Twenty patients presented at our institution with papular eruptions involving the neck. The asymptomatic lesions, which ranged in colour from normal skin tones to yellowish, were isolated or coalescent. Microscopically, the papules showed elastolysis and fibrosis of the upper reticular and papillary dermis. A review of the literature shows similar characteristics in cases reported as WFPN and PDE. This study indicates that WFPN and PDE are variants of a single disorder that can be more precisely defined as 'fibroelastolytic papulosis of the neck' and which appears to be a manifestation of intrinsic skin ageing.

Widespread microsatellite instability in sebaceous tumours of patients with the Muir-Torre syndrome

Muir-Torre syndrome (MTS) is an autosomal dominant disorder characterized by the presence of at least one sebaceous gland tumour and a minimum of one visceral malignant tumour. Recently, microsatellite instability (MSI) has been detected in the tumours of patients with MTS and germline mutations of the hMSH2 and hMLH1 mismatch repair genes have been detected in some patients with this syndrome. To determine if the tumours of patients with MTS have widespread genomic instability and whether loss of heterozygosity (LOH) in the chromosomal regions containing hMSH2 and hMLH1 is detectable, MSI and LOH were examined at 10 dinucleotide repeats on chromosomes 2p, 3p, 5q, 9p, 17p and 18q. Data were obtained from six sebaceous gland tumours and two adenocarcinomas of the colon from three patients of two Muir-Torre families. MSI was detected at more than half of the loci tested in all sebaceous tumours examined. In addition, there was LOH at D2S119 in one sebaceoma and one sebaceous carcinoma from one patient. The colon carcinomas from two patients showed MSI at five of the 10 loci analysed. These results show that widespread MSI is a feature of tumours in patients with MTS. In addition, the finding of LOH at D2S119, a marker located in the vicinity of hMSH2, in sebaceous tumours of one patient indicates that this gene may have a pathogenetic role in this patient.

Interleukin-11 production is increased in organ cultures of lesional skin of patients with active plaque-type psoriasis as compared with nonlesional and normal skin. Similarity to interleukin-1 beta, interleukin-6 and interleukin-8

Increased levels of several cytokines, mainly proinflammatory mediators, have been reported in psoriatic lesions. Little information, if any, is available concerning other cytokines, especially those initially studied as marrow differentiation agents. Using the experimental approach of measuring cytokines released by skin organ cultures. IL-11 and three other proinflammatory cytokines (IL-1 beta, IL-6 and IL-8) were determined using commercially available ELISA kits in supernatants of ten biopsies from lesional and nonlesional psoriatic skin areas and in supernatants of biopsies from ten normal volunteers. The results obtained showed that the amounts of IL-11 and the other three modulators were significantly increased in the material from the lesional areas (P < 0.01). The amounts of IL-11, which is known to have functional activity similar to the proinflammatory cytokines and to share a receptor component with IL-6, were also correlated with the disease severity index (R = 0.69, P = 0.04). In addition, a nearly significant correlation was noted between the amounts of IL-11 released by the lesional and the nonlesional skin biopsies (R = 0.66, P = 0.05). More detailed studies are needed to clarify whether IL-11 plays a specific functional role in psoriasis, but this study emphasizes the complexity of the pathogenesis of psoriasis and the cytokine network, including activation of proinflammatory and haemopoietic biological response modifiers, in this disease.

Cyst of the velum interpositum treated by endoscopic fenestration

BACKGROUND

The cavum veli interpositi is a not infrequent radiologic finding in both children and adults, as confirmed by computed tomography (CT) and magnetic resonance (MR). A moderate enlargement of the cavum may sometimes be observed; on the other hand, a true large cyst may be considered exceptional, with only one reported case.

CASE HISTORY

This 9-year-old boy with psychomotor retardation and epileptic seizures had a large CSF cyst in the region of the cavum veli interpositi, diagnosed by CT and MR. The patient was treated by endoscopic surgery, with introduction of the endoscope into the occipital horn of the right lateral ventricle and multiple fenestrations from the right ventricle to the cyst, and then from the cyst to the left lateral ventricle. The surgery resulted in decrease in the size of the cyst and reduction of the frequency of seizures.

DISCUSSION AND CONCLUSIONS

Children with dilated or cystic cavum veli interpositi present with a large head, mental retardation, seizures, and hydrocephalus. On CT and MR, the cyst shows a typical triangular configuration on the axial plane and lies on the roof of the third ventricle in the coronal plane. Endoscopic ventricular fenestration is the treatment of choice for these as well as all other intraventricular and intracerebral CSF cysts, because it ensures communication between the cyst and the ventricular system and avoids definitive shunting of the cyst.

Prevention of hand-arm vibration hazards: from laboratory to practice

Many studies were made throughout the world regarding the medical and technical aspects of hand-arm vibration since the first description by Loriga in 1911 of the vibration syndrome. Despite that the protection of operators against vibration hazards had progressed very slowly in practice with one notable exception, the case of chain saw users for whom several countries developed a comprehensive programme to eradicate the diseases successfully; regulations, antivibration tools, medical screening, preventive treatment. If all these actions are not carried out simultaneously in an industrial sector the transmission of knowledge from the laboratory to practice may be a failure or very costly in money, time and energy, as this article will show it in the case of suspended rammers and breakers.

Endoscopic ventricular fenestration of intracranial fluid cysts

The authors report 5 patients with paraventricular or intraventricular fluid cysts, successfully treated by fenestration into the ventricular system using a neuroendoscopic technique. The series includes three paraventricular malformative CSF cysts, a cyst of the velum interpositum and a cystic astrocytoma with small, deeply located and unresectable mural nodule. In all cases the endoscopic fenestration was the unique treatment and allowed to avoid the definitive ventriculoperitoneal shunt. The surgical endoscopic technique and the postoperative radiological findings which indirectly confirm the patency of the fenestration are discussed. The authors conclude that endoscopic ventricular fenestration represents the treatment of choice for most paraventricular and intraventricular CSF collections.

Adenoma of anogenital mammary-like glands

The authors describe a benign adenomatous neoplasm arising from anogenital mammary-like glands. These glands have been recently recognized in the anogenital region and may play an important role in the development of some neoplastic disorders peculiar to this anatomical area. Important features of the tumor are adenomatous tubular and cystic structures with apocrine-like cytologic features, a lobular configuration, and abundant fibrous stroma.

[Follow-up study of pulmonary function in individuals subjected to lobectomy in infancy and childhood]

Experimental research in animals have demonstrated that pulmonary development continues after birth. This happens in man as well: alveolar proliferation and enlargement go on until the eighth year of age, furthermore complete pulmonary development is achieved until the 20-22 years of age. It is therefore possible to hypothesise that respiratory deficit following pulmonary exeresis in children would regress with time. In the Pediatric Surgery of IRCCS Policlinico S. Matteo of Pavia eight children, 4 days to 8 years of age, underwent lobectomy for pulmonary hypertensive emphysema (3), lung abscess (2), bronchogenic cysts (2) and hystiocytoma (1). One of them was lost to follow-up; the remainders were controlled from 3 to 25 years after surgery: all of them enjoy a normal active life. Respiratory function was evaluated through blood chemistry, blood gas analysis, basal and after strain ECG, chest X-ray, spirometry, basal and after strain pulmonary scintigraphy. Basal and after strain ECG, chest X-ray, and arterial blood gas were normal in every examined subjects; spirometry, although results are quite variable, did not show serious respiratory deficits; basal after strain pulmonary scintigraphies weren't homogeneous. These results, although they aren't univocally interpretable, positively confirmed that the residual lung after lobectomy has a satisfactory possibility of functional recovery.