Comparison of genioglossus muscle activity and efficiency of dexmedetomidine or propofol during drug-induced sleep endoscopy in patients with obstructive sleep apnea/hypopnea syndrome

OBJECTIVE

The purpose of this study is to evaluate the haemodynamic and respiratory effects of dexmedetomidine vs. propofol in patients with OSAHS during the drug-induced sleep endoscopy (DISE), and analyze simultaneously the electromyography of genioglossus muscle.

PATIENTS AND METHODS

We conducted a study on 50 patients with OSAHS; patients were subjected to DISE with simultaneous polygraphic cardiorespiratory measurement and electromyography of genioglossus muscle. Patients undergoing DISE were divided in two groups: in Group A (19 M; 8 W) was administered propofol TCI and in Group B (16 M; 7 W) was administered dexmedetomidine TCI.

RESULTS

In Group A, a mean minimal SpO2 decreasing of 3.7% (p=0.000) and a mean SpO2 decreasing of 1.6% (p 0.001) was noticed, while there was an increase in BP20 of 14.8% (p=0.000) and HR20 of 11.1% (p=0.000). In Group B, it was showed a decreasing of mean minimal SpO2 and mean SpO2 values, about 1.8% (p=0.000) and 1.1% (p 0.009) respectively, while there was an increase of BP20 and HR20, about 8.7% (p=0.000) and 8% (p 0.002), respectively. Despite EMG activity comparing spontaneous sleep with propofol-DISE, there is a statistically significative change for the amplitude (p=0.040) and an increase of 7.01% for the area under the curve (AUC). Comparing spontaneous sleep with dexmedetomidine-DISE induced one, there is only an increase of 25.87% in the AUC.

CONCLUSIONS

A greater worsening of the cardio-respiratory basal values was noted after sleep induction with Propofol and same results were obtained confronting EMG of genioglossus muscle data.

Blink reflex recovery cycle to differentiate progressive supranuclear palsy from corticobasal syndrome

BACKGROUND AND PURPOSE

Progressive supranuclear palsy (PSP) and corticobasal syndrome (CBS) may share similar clinical findings and tests to distinguish between the two disorders could be useful. We evaluated the blink reflex and R2 blink reflex recovery cycle (R2BRRC), determining diagnostic sensitivity, specificity and positive and negative predictive value of R2BRRC in differentiating patients with PSP from those with CBS.

METHODS

This was a prospective data collection study investigating blink reflex and R2BRRC at interstimulus intervals (ISIs) of 100, 150, 200, 300, 400, 500 and 750 ms in 12 patients with PSP, eight patients with CBS and 10 controls.

RESULTS

Patients with PSP have earlier recruitment of R2BRRC as compared with patients with CBS (ISI: 100 ms, P = 0.002; 150 ms, P < 0.001; 200 ms, P < 0.001; 300 ms, P = 0.02) and controls (ISI: 100 ms, P < 0.001; 150 ms, P < 0.001; 200 ms, P < 0.001; 300 ms, P = 0.004). The presence of an early recovery of the R2 differentiated PSP from CBS with a specificity and sensitivity of 87.5% and 91.7%, respectively.

CONCLUSIONS

The R2BRRC curve might be considered to be a useful tool in differentiating patients with PSP from those with CBS.

Combining Clinical and Molecular Data to Predict the Benefits of Carmustine Wafers in Newly Diagnosed High-Grade Gliomas

PURPOSE OF REVIEW

The purpose of this study was to retrospectively evaluate the use of carmustine wafers (CWs) in the management of high-grade gliomas (HGGs). The data from our monoinstitutional series was compared with studies reported in the literature. Special emphasis was placed on the evaluation of side effects and the analysis of extent of resection and molecular profile as risk factors.

RECENT FINDINGS

The implantation of CWs into the resection cavity during HGG treatment to deliver localized chemotherapy, followed by the Stupp protocol, remains debated in a clinical setting, largely due to the lack of appropriate phase III studies. Given the high expense and poorly characterized side effects associated with CW treatment, identification of patients most likely to benefit from this therapy could be clinically relevant. CWs may represent an effective and safe first-line treatment for patients with HGG that exhibit complete tumor resection and harboring a methylated MGMT promoter. Our investigation showed a much larger group of patients exhibiting long-term survival (> = 36 months), strongly supporting a potential survival benefit conferred via CW treatment. The pre-surgical definition of the MGMT promoter status could be of clinical use in identifying "good responders" to CW implantation.

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

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

Quantitative Diffusion Tensor Imaging Analysis of Low-Grade Gliomas: From Preclinical Application to Patient Care

BACKGROUND

Preoperative diffusion tensor tractography (DTT) has recently been used to aid in the mapping of functional pathways to limit damage associated with resection of low-grade gliomas (LGGs).

OBJECTIVE

To assess the predictive capacity of DTT as a biomarker of postoperative motor outcomes in patients with LGGs involving the corticospinal tract (CST). CST parameters obtained using a quantitative fiber tracking approach were used to investigate the reliability of the DTT biomarker by comparing their values in the tumoral (Tcst) and healthy (Hcst) hemispheres.

METHODS

Thirty-seven patients with LGGs involving the CST were enrolled. Quantification of structural differences between the Tcst and Hcst were analyzed according to the novel biomarker (NF index), defined as follows: (Hcst NF - Tcst NF)/Hcst NF, where NF represents the number of fibers in each region. Logistic regression analysis was used to examine associations among clinical postoperative outcomes and NF index values, tumoral patterns, and premotor/motor evoked potentials.

RESULTS

NF values significantly differed between the Tcst and Hcst. Analysis of the NF index showed that patients with a preoperative NF index <0.22 had a significantly lower risk of developing transient postoperative deficits (area under the curve, 0.92; 95% binomial confidence interval, 0.834-1). Patients with less pronounced differences in NF between the Tcst and Hcst also experienced better clinical outcomes.

CONCLUSIONS

The NF index may be a useful biomarker for predicting clinical outcomes in patients with LGGs. Furthermore, the NF index may provide a preoperative estimate of the patient's potential for recovery from possible postsurgical neurologic deficits.

Obsessive compulsive personality disorder in Progressive Supranuclear Palsy, Multiple System Atrophy and Essential Tremor

INTRODUCTION

aim of the study was to evaluate the presence of the Obsessive Compulsive Personality Disorder (OCPeD) in Multiple System Atrophy (MSA), Progressive Supranuclear Palsy (PSP) and Essential Tremor (ET) and in a group of healthy subjects.

METHODS

patients affected by MSA, PSP and ET diagnosed according to currently accepted diagnostic criteria and a group of healthy controls were enrolled in the study. Patients with cognitive impairment were excluded from the study. The Structured Clinical Interview for Personality Disorders-II (SCID-II) has been performed to evaluate the presence of personality disorders (PeDs). The diagnosis of OCPeD was confirmed by a psychiatric interview.

RESULTS

fifteen MSA patients (8 men and 7 women; aged 62.9 ± 7.6 years), 14 PSP patients (8 men and 6 women; aged 69.8 ± 4.4 years), 16 ET patients (10 men and 6 women; aged 70.4 ± 6.4 years) and 20 healthy subjects (10 men and 10 women; aged 65.5 ± 6.0 years) were enrolled. OCPeD was recorded in 5 (35.7%) PSP patients, 2 (13.3%) MSA patients, 2 (12.5%) ET patient and 2 (10%) controls.

CONCLUSION

a low frequency of OCPeD, close to those recorded in healthy subjects, was recorded in both MSA and ET patients. Conversely an higher frequency of OCPeD, similar to PD was found among PSP patients, supporting the possibility of an impairment of common basal ganglia network possibly involving the orbito-frontal circuits.

Validation of the UPDRS section IV for detection of motor fluctuations in Parkinson's disease

INTRODUCTION

The UPDRS-IV represents the most common screening tool to assess motor fluctuations in patients with PD despite the lack of a clinimetric validation.

OBJECTIVES

We evaluated sensitivity and specificity of UPDRS-IV using a 12-h waking-day motor assessment as the gold standard.

METHODS

We consecutively enrolled PD patients who underwent a 12-h waking-day motor assessment in the study. Patients were clinically evaluated every 2 h for 12 h using the UPDRS-III. Motor scores were reported as a line graph and six blinded raters classified patients as having or not having motor fluctuations. The UPDRS-IV was used in order to assess the presence of predictable and unpredictable motor fluctuations according to items 36-38.

RESULTS

Sixty two PD patients were enrolled in the study. According to the raters' evaluations, 39 (62.9%) were classified as having motor fluctuations, while according to the UPDRS-IV 47 (75.8%) presented a motor fluctuation giving a sensitivity of 87.2% (95%CI 72.6-95.7) and a specificity of 43.5% (95%CI 23.2-65.5).

CONCLUSION

Our study results confirm the high level of sensitivity with a lower level of specificity of UPDRS-IV to screen motor fluctuations in PD patients.

Looks can be deceiving: three cases of neurological diseases mimicking Guillain-Barrè syndrome

Guillain-Barrè syndrome (GBS) is an acute, paralyzing, inflammatory peripheral nerve disease, featured by monophasic disease course, symmetrical limb weakness and areflexia. Several pathologies can mimic the clinical presentation of GBS, making hard the differential diagnosis for patients complaining of acute flaccid paralysis. In this paper we describe three cases of different neurological diseases presenting with acute motor symptoms mimicking GBS, reviewing the relevant literature on misdiagnosis of GBS.

Bilateral tubular minimally invasive approach for decompression, reduction and fixation in lumbosacral lythic spondylolisthesis

This video demonstrates the minimally invasive surgical technique used in a 56-year-old woman suffering from L-5 spondylolysis and grade 2 L5-S1 spondylolisthesis. The first author used expandable tubular retractors bilaterally to perform neural decompression, mini-open TLIF, spondylolysthesis reduction and L5-S1 pedicle screw fixation. L-5 cement augmentation was performed through cannulated and fenestrated screws to enhance resistance to screw pull-out secondary to reduction maneuvers. Sequential surgical steps related to microsurgery, spondylolysthesis reduction and instrumentation are shown and commented. We submit that in cases of lythic spondylolisthesis a bilateral traversing and exiting nerve roots decompression is a safer option prior to performing the deformity reduction and fixation; the proposed minimally invasive technique may help in reducing surgical morbidity and improving postoperative recovery. The video can be found here: http://youtu.be/G4Qdg-A-Y3M.

Double-level cervical total disc replacement for adjacent segment disease: is it a useful treatment? Description of late onset heterotopic ossification and review of the literature

We report a rare case of double-level adjacent segment disease (ASD), occurring ten years later an anterior cervical discectomy (ACD) without fusion, treated by cervical arthroplasty, highlighting the outcome at long-term follow-up and focusing on heterotopic ossification. In 1995 a 25-year-old man satisfactorily underwent ACD at C4/C5. At that time MRI also showed signs of degenerative disc disease (DDD) at C3/C4 and C5/C6. Ten years later, a new MRI scan showed a large C3/C4 and a smaller C5/C6 soft disc hernia together with spondylotic changes at the level above and below the site of the first surgery. At C4/C5 imaging revealed a kyphotic stable "pseudoarthrosis" with anterior bridging osteophyte. The patient underwent double-level arthroplasty with ProDisc-C. Clinical and radiological outcome was satisfactory. 3 and 5 years after surgery, X-rays and CT scan documented the progressive development of heterotopic ossification, with gradual reduction of range of motion. A late onset heterotopic ossification can neutralize the theoretical advantages of cervical arthroplasty, which should be considered an effective surgical option only in selected cases. ACDF and restoration of normal lordosis can be a viable alternative in cervical revision surgery, as motion preservation can not be always mantained for a long time.

Anterior, extracanalar, cervical spine osteochondroma associated with DISH: description of a very rare tumor causing bilateral vocal cord paralysis, laryngeal compression and dysphagia. Case report and review of the literature

INTRODUCTION

Osteochondromas are common benign bone tumors, rarely involving the spine.

BACKGROUND

Osteochondroma account for about 35% of bone benign tumors and 9% of all bone tumors. Spinal involvement is described in 1%-4% of cases and their origin from the anterior surface of cervical vertebral bodies is exceedingly rare.

AIM

We describe the rare case of an osteochondroma arising from the anterior surface of the C4 and C5 vertebral bodies, and not involving the spinal canal, in a 68-year-old male patient suffering from Diffuse Idiopathic Skeletal Hyperostosis (DISH).

MATERIALS AND METHODS

The patient presented with acute onset of respiratory distress due to laryngeal compression exerted by the lesion, dysphagia and paralysis of left vocal cord. Imaging revealed the unusual lesion compressing and dislocating the air ways. An anterior approach to cervical spine was performed to remove the tumor.

RESULTS

Postoperatively, the patient sustained a progressive improvement of respiratory function and recovery of the vocal cord paralysis.

DISCUSSION

We believe that this case holds some interesting peculiarities: firstly, the anterior location of a cervical osteochondroma could be considered exceptional; yet, the resulting clinical picture should be remembered for differential diagnosis. Secondly, we hypothesized a possible correlation between the tumorigenesis of osteochondroma and the co-existence of DISH. Indeed, the abnormal bone turnover in cervical segments due to DISH could explain the unusual occurrence of osteochondromas in adult age.

CONCLUSIONS

The occurrence of an osteochondroma should be considered in patients suffering from DISH and harbouring large osteophytes.

[A polymorphism study of the DNA extracted from dental tissues]

Often teeth are the only items which can be used for personal identification in forensic medicine. In the present work we describe a method to extract and amplify DNA from dental elements ranging from 2 weeks to 5 year from the avulsion. PCR (polymerase chain reaction) was used to amplify VNTR sequences; the alleles products were electrophoresed, visualized by traditional methods and compared to the amplified products obtained from the matching blood sample. Our results give a new and powerful investigative tool for personal identification in the field of forensic odontostomatology, since such a procedure can be successfully applied both to recent and to ancient teeth.

[DNA extraction from hard dental tissues]

Two different standard ways of DNA extraction (salting out and phenol-chloroform methods) were assayed in order to recovery nucleic acids from dental tissues. The DNA extracted was tested for purity by means of transverse alternating field electrophoresis (TAFE) using Saccharomyces cerevisiae chromosomes as markers. Both extraction methods give similar qualitative and quantitative results being a DNA yield from hard dental tissues approximately 30% of those extracted from the whole tooth. Our results indicate salting out as a preferable method due to its rapidity and usefulness.

Influence of different counterions on the fluorescent probe-DNA complex

Studies carried out on both linear and covalently closed DNA have clearly revealed at least two different types of probe-DNA complexes depending on the different experimental procedure adopted, and two main types of binding of the probe have been clearly established and referred to as intercalative and external binding. In order to investigate the influences of the different counterions on the stability of the probe-DNA complex, a set of static fluorimetric measurements were performed in a wide range of concentrations (1 mM to 2 M) of different alkaline-earth chlorides. At low salt concentrations (in the range of millimolar values) no detectable fluorescence intensity changes were evidenced by the use of alkaline salts, but a marked decrease was detected by using alkaline-earth salts. The present work investigates moreover the role played by the different salt, in first place Calcium salts, on the stability of ethidium-DNA complex, by the use of the static fluorimetric titration procedure which is able to discriminate between the two strong and weak binding sites on DNA. Our experimental results have been interpreted in terms of a peculiar Calcium-DNA interaction, involving not only the electrostatic charges of phosphate moiety but also the aromatic rings of the bases, i.e., the intercalation sites on double helix DNA.

[Correlation between serum glutathione reductases and bone densitometry values]

Free radicals, because of their marked chemical activity, have often been found to be involved in many human diseases. Enzymatic antioxidant systems, namely glutathione-reductase, present both in red blood cells and in serum, have been demonstrated to play a key role as free radicals scavengers. The present work has been carried out in order to evaluate the possible role played by free radicals in the demineralization process of the bone matrix. Glutathione-reductase activity, assayed by a slightly modified Horn's method, was related to bone density measurements. All the subjects with reduced densitometric values showed reduced glutathione-reductase levels. Our results seem to support the hypothesis of a strict relationship between low activity of antioxidant systems and demineralization process of the bone, in consequence of enhanced free radical levels.