Changes in community and hospital-based health care use during the COVID-19 pandemic for adults with and without intellectual and developmental disabilities

BACKGROUND

Due to the functional, cognitive and communication impairments associated with intellectual and/or developmental disabilities (IDD), adaptations to service delivery during the COVID-19 pandemic may impact people with IDD differently than others. For community and hospital-based services, this study describes the proportion of adults with and without IDD who used health care in the year pre-COVID-19 and the first year of the pandemic.

METHODS

This retrospective cohort study used linked health administrative databases to identify adults aged 18-105 years with and without IDD using unique encoded identifiers. Counts and proportions of adults who used health care services were reported for the pre-COVID-19 year (16 March 2019 to 14 March 2020) and the first COVID-19 year (15 March 2020 to 15 March 2021).

RESULTS

Across services, the proportion of adults who used services was lower during the first COVID-19 year compared with the year prior, except for virtual physician visits that increased markedly for people with and without IDD. While the proportion of adults who used services was higher for those with IDD compared with those without IDD for both years, differences were greatest for mental health emergency visits and hospitalisations; adults with IDD were 6.3 to 10.9 times more likely to use these services than others with no IDD during the pandemic.

CONCLUSIONS

During the first COVID-19 year in Ontario, Canada, service use decreased for all service types, except for virtual physician visits. In both years, adults with IDD remained more likely to use services than other adults, with the largest differences in use of mental health hospitalisations and mental health emergency department visits.

P13.18 Inhibition of epidermal growth factor receptor and platelet-derived growth factor receptor-alpha exerts synergistic efficacy in glioblastoma

BACKGROUND

Despite our understanding of the genetic changes that precipitate gliomagenesis, targeted therapy has failed in glioblastoma (GBM) with median survival not significantly improved over the past two decades. Epidermal growth factor receptor (EGFR) alterations, including amplification and activating mutations, are among the most common genetic changes in GBM, occurring in more than half of cases. EGFR is located on Chr. 7, and Chr. 7 gain is one of the earliest events precipitating gliomagenesis. Various EGFR inhibitors, including tyrosine kinase inhibitors, monoclonal antibodies, vaccines, and CAR-T cells have failed in GBM due to intrinsic heterogeneity and receptor tyrosine kinase bypass pathways that mediate therapeutic resistance. New targeted therapeutic approaches to leverage synergistic combinations are desperately needed to improve GBM prognosis. Using the TCGA and other GBM databases, we have previously demonstrated that the presence of PDGFRAamplification in patients with EGFR-amplified GBM carries significantly worse survival. EGFR and PDGFRA co-expression occur in more than one-third of GBM patients. The PDGFRA ligand PDGFA is also located on Chr. 7, and its expression is significantly increased with Chr. 7 gain and EGFR copy number increase. Therefore, Chr. 7 gain inherently leads to co-activation of both EGFR and PDGFRA signaling pathways.

MATERIALS AND METHODS

We used models of patient-derived glioblastoma cells to test combined inhibition of epidermal growth factor receptor and platelet-derived growth factor receptor-alpha in vitro.

RESULTS

Using patient-derived GBM models with Chr. 7 gain, we found that combined inhibition of both EGFR and PDGFRA using a variety of FDA-approved EGFR-targeted agents (Erlotinib, Gefitinib, Dacomitinib, Neratinib, and Osimertinib) and Crenolanib, respectively, leads to synergistic cytotoxicity in vitro. We found that inhibition of either EGFR or PDGFRA alone led to receptor cross-activation, and EGF and PDGF-AA-induced receptor tyrosine kinase activation was blocked by Neratinib and Crenolanib. Immunoprecipitation experiments and proximity ligation assays demonstrated that combined inhibition prevents EGFR and PDGFRA heterodimerization and pathways of therapeutic resistance. This combined inhibition led to decreased activation of downstream signaling pathways, including phosphatidylinositol 3-kinase and mitogen-activated protein kinase.

CONCLUSIONS

We show that combined inhibition of EGFR and PDGFRA exerts synergistic cytotoxicity in GBM and prevents resistance pathways that emerge during single-agent targeted therapy against these receptor tyrosine kinases. These pathways are targetable with FDA-approved agents that could be used in patients with GBM with Chr. 7 gain.

P13.07 Cysteine induces glioblastoma cytotoxicity through mitochondrial reductive stress

BACKGROUND

Glioblastoma (GBM) remains a poorly treatable disease with high mortality. Tumor metabolism in GBM is a critical mechanism responsible for accelerated growth because of upregulation of glucose, amino acid, and fatty acid utilization. However, therapies targeting GBM metabolism, whether through the use of small-molecule compounds or dietary interventions to limit nutrient sources, have failed in clinical trials. Metabolic bypass is an important mechanism that is often overlooked in GBM trials, since many trials have focused instead on combining anti-metabolic therapy with cytotoxic treatments. The goal of this research is to use a multi-pronged treatment approach with targeted drug and dietary therapy to leverage metabolic susceptibilities in GBM.

MATERIALS AND METHODS

We first interrogated the TCGA database and a cancer metabolite database for alterations in glucose and amino acid signatures in GBM relative to other human cancers and relative to low-grade glioma. We identified the amino acid cysteine as contributing to a novel metabolic susceptibility pathway in GBM. To study the role of cysteine in GBM pathogenesis, we treated patient-derived GBM cells with a variety of FDA-approved cysteine-promoting compounds in vitro, including N-acetylcysteine (NAC). We measured cell proliferation, energy production, mitochondrial metabolism, and reactive oxygen species to study mechanisms of oxidoreductive stress. Results: From our TCGA and cancer metabolite database analyses, we found that GBM exhibits the highest levels of cysteine and methionine pathway gene expression of 32 human cancers and that GBM exhibits high levels of cysteine-related metabolites compared to low-grade gliomas. Cysteine compounds, including NAC, reduce growth of GBM cells, which is exacerbated by glucose deprivation. This growth inhibition is associated with reduced mitochondrial metabolism, manifest by reduction in ATP generation, NADPH/NADP+ ratio, mitochondrial membrane potential, and oxygen consumption rate. Through measurement of mitochondrial hydrogen peroxide, we found that NAC-treated cells exhibit a paradoxical increase in mitochondrial hydrogen peroxide levels, likely due to inhibition of thioreductase and glutathione reductase systems. Through genetic and pharmacological studies, we found that induction of thioredoxin-2 rescues NAC-mediated cytotoxicity and that inhibition of thioreductase and glutathione reductase exacerbates mitochondrial toxicity and reductive stress.

CONCLUSIONS

We show that cysteine compounds reduce cell growth and induce mitochondrial toxicity in GBM through reductive stress. This metabolic phenotype is exacerbated by glucose deprivation. This pathway is targetable with FDA-approved cysteine-promoting compounds and could synergize with glucose-lowering treatments, including the ketogenic diet, for GBM.

Almond by-product composition impacts the rearing of black soldier fly larvae and quality of the spent substrate as a soil amendment

BACKGROUND

Insect biomass is a sustainable alternative to traditional animal feeds, particularly when insects are produced on low-value high-volume agricultural by-products. Seven samples of almond by-product (hulls and shells) were obtained from processors in California and investigated for larvae production. Experiments were completed with and without larvae and spent substrate samples were assessed for their potential as soil amendments based on standard compost quality indicators.

RESULTS

On average, specific larvae growth and average larval harvest weight were 158% and 109% higher, respectively, when larvae were reared on Monterey and pollinator hulls compared to nonpareil hulls and mixed shells. Larvae methionine and cystine contents were highest when larvae were reared on Monterey hulls and mixed shells, respectively. Available phytonutrients in spent substrate were affected by feedstock sample and larvae rearing. Spent nonpareil substrate without larvae had the highest NH₄ -N levels and spent pollinator substrate incubated without larvae had the highest PO₄ -P levels. Spent mixed shell substrate had the lowest availability of phytonutrients.

CONCLUSION

The findings demonstrate that by-product composition has a significant impact on larvae growth and the properties of the spent substrate, and that spent substrate from larvae rearing requires further stabilization before application as a soil amendment. © 2020 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Universal hepatitis B screening in a high risk community

244

Background: 2015 ASCO guidelines for Hepatitis B (HBV) screening in patients (pts) receiving chemotherapy recommend a risk-adaptive strategy considering patient and treatment-specific factors. The University of Illinois Cancer Center (UICC) is an academic center with largely underserved, minority and socioeconomically disadvantaged pts. UICC implemented a universal HBV screening policy in 2016. We aimed to increase HBV screening from 60% to 95% over 18 months. Methods: A multidisciplinary team of oncologists, hepatologists, fellows, nurses and pharmacists created an ideal process map for universal HBV screening in all pts starting chemotherapy outlining screening parameters, laboratory tests required and follow-up for positive screens. Four Plan-Do-Study-Act cycles were tested. Interim analysis was done targeting specific providers for additional education. Results of screening were analyzed by chart review. Results: A total of 589 treatment-naive pts were screened for HBV between Aug 2017 and Feb 2019. Educational sessions were held for nurses, pharmacists and fellows to review ideal process maps between Jan and March 2018. 0% of pts had insurance denials for HBV screening coverage. Screening rates improved from 65% in Aug 2017 to 100% in Feb 2019. Positive HBV screen rate was 3% (N = 18) and all were new diagnoses. 61% (N = 11) of positive screens had no risk factors for HBV exposure and would not have met risk adaptive criteria for screening. 27% (N = 3) of positive screens without prior risk factors were initiated on prophylactic ART. 50% (N = 9) of all new HBV diagnoses initiated prophylactic ART to prevent reactivation, while 50% received active surveillance on chemotherapy. 0% of pts on active surveillance developed reactivation. Conclusions: Implementing and sustaining a universal HBV screening program was feasible and effective in identifying pts at risk for reactivation in a high risk population. 61% of positive screens lacked traditional risk factors. Risk-adaptive screening may miss cases in diverse populations where HBV is not endemic, precluding appropriate management. Further evaluation will include expanding screening to inpatient chemotherapy starts and cost-benefit analysis of universal screening in this unique population.

Managing high fiber food waste for the cultivation of black soldier fly larvae

Increases in global human population are leading to increasing demands for food production and waste management. Insect biomass is a sustainable alternative to traditional animal feeds when insects are produced on lignocellulosic by-products. Resources high in lignocellulose have high carbon to nitrogen ratios and require nitrogen supplementation to accelerate bioconversion. Here we report on studies that examine the influence of nitrogen supplementation of almond hull-based feedstocks on black soldier fly larvae (Hermetia illucens L.) cultivation and composition. Decreasing carbon to nitrogen ratio from 49 to 16 increased larvae harvest dry weight, specific larvae growth, and yield by 36%, 31%, and 51%, respectively. However, the decrease in carbon to nitrogen ratio decreased larvae methionine and cysteine contents by 11% and 13%, respectively. The findings demonstrate that carbon to nitrogen ratio can be managed to enhance bioconversion of lignocellulose to larvae, but that this management approach can reduce larvae amino acid content.

Cultivation of black soldier fly larvae on almond byproducts: impacts of aeration and moisture on larvae growth and composition

BACKGROUND

The increasing production of almonds worldwide has resulted in the significant generation of byproduct streams that require end uses. One potential use for byproducts is for cultivation of additional food sources including insects. Studies were performed to determine if black soldier fly larvae (Hermetia illucens L.) could be cultivated on almond byproducts (hulls and shells) and to examine the effect of aeration and moisture on larvae growth and hull composition.

RESULTS

Increasing aeration from 0.04 to 0.36 mL min^-1 g dry weight^-1 tripled the harvest weight of larvae and increased larvae yield by a factor of five. Larvae calcium content increased by 18% with an increase in aeration from 0.04 to 0.95 mL min^-1 g dry weight^-1 . Moisture content also affected harvest dry weight and yield; increasing moisture content from 480 g kg^-1 (wet basis) to 680 g kg^-1 increased harvest weight by 56% and yield by a factor of 2. Variables did not affect larvae methionine and cysteine content. Low moisture content and aeration rate yielded an environment that supported microbial consumption of hulls over larvae consumption and growth.

CONCLUSIONS

The results demonstrate that almond hulls are a suitable feedstock for larvae production under controlled management of moisture content and aeration. © 2018 The Authors. Journal of The Science of Food and Agriculture published by John Wiley & Sons Ltd on behalf of Society of Chemical Industry.

Interactive effects of herbivory and substrate orientation on algal community dynamics on a coral reef

Herbivory is a significant driver of algal community dynamics on coral reefs. However, abiotic factors such as the complexity and orientation of the benthos often mediate the impact of herbivores on benthic communities. We experimentally evaluated the independent and interactive effects of substrate orientation and herbivorous fishes on algal community dynamics on a coral reef in the Florida Keys, USA. We created horizontal and vertical substrates, mimicking the trend in the reduction of vertical surfaces of coral reefs, to assess how algal communities developed either with herbivory (open areas) or without herbivory (herbivore exclosures). We found that substrate orientation was the dominant influence on macroalgal community composition. Herbivores had little impact on community development of vertical substrates as crustose algae dominated these substrates regardless of being in exclosures or open areas. In contrast, herbivores strongly impacted communities on horizontal substrates, with upright macroalgae (e.g., Dictyota spp., articulated coralline algae) dominating herbivore exclosures, while filamentous turf algae and sediment dominated open areas. Outside of exclosures, differences between vertical and horizontal substrates exposed to herbivores persisted despite similar intensity of herbivory. Our results suggest that the orientation of the reef benthos has an important impact on benthic communities. On vertical surfaces, abiotic factors may be more important for structuring algal communities while herbivory may be more important for controlling algal dynamics in flatter areas. Thus, the decline in structural complexity of Caribbean coral reefs and the flattening of reef substrates may fundamentally alter the impact that herbivores have on benthic community dynamics.

Using a family history questionnaire to identify adult patients with increased genetic risk for sarcoma

BACKGROUND

Sarcomas in adults can be associated with hereditary cancer syndromes characterized by early-onset predisposition to numerous types of cancer. Because of variability in familial presentation and the largely unexplained genetic basis of sarcomas, ascertainment of patients for whom a genetics evaluation is most indicated poses challenges. We assessed the utility of a Sarcoma Clinic Genetic Screening (scgs) questionnaire in facilitating that task.

METHODS

Between 2008 and 2012, 169 patients (median age: 53 years; range: 17-88 years) completed a self-administered scgs questionnaire. A retrospective chart review was completed for all respondents, and descriptive statistics were reported. Probands were divided into two groups depending on whether they did or did not report a family history of Li-Fraumeni syndrome-type cancers.

RESULTS

A family history of cancer (as far as 3rd-degree relatives) was reported in 113 of 163 sarcoma patients (69%). Eeles Li-Fraumeni-like (lfl) criteria were fulfilled in 46 probands (28%), Chompret lfl in 21 (13%), Birch lfl in 8 (5%), and classic Li-Fraumeni in none. In the 10 probands tested for TP53 mutations, 1 pathogenic mutation was found. Further investigation of selected families led to the discovery of germline mutations in MLH1, MSH2, and APC genes in 3 individuals.

CONCLUSIONS

The scgs questionnaire was useful for ascertaining probands with sarcoma who could benefit from a genetic assessment. The tool allowed us to identify high-risk families fitting the criteria for lfl and, surprisingly, other hereditary cancer syndromes. Similar questionnaires could be used in other cancer-specific clinics to increase awareness of the genetic component of these cancers.

Characterization of a novel founder MSH6 mutation causing Lynch syndrome in the French Canadian population

We identified an MSH6 mutation (c.10C>T, p.Gln4*) causing Lynch syndrome (LS) in 11 French Canadian (FC) families from the Canadian province of Quebec. We aimed to investigate the molecular and clinical implications of this mutation among FC carriers and to assess its putative founder origin. We studied 11 probands and 27 family members. Additionally 6433 newborns, 187 colorectal cancer (CRC) cases, 381 endometrial cancer (EC) cases and 179 additional controls, all of them from Quebec, were used. Found in approximately 1 of 400 newborns, the mutation is one of the most common LS mutations described. We have found that this mutation confers a greater risk for EC than for CRC, both in the 11 studied families and in the unselected cases: EC [odds ratio (OR) = 7.5, p < 0.0001] and CRC (OR = 2.2, p = 0.46). Haplotype analyses showed that the mutation arose in a common ancestor, probably around 430-656 years ago, coinciding with the arrival of the first French settlers. Application of the results of this study could significantly improve the molecular testing and clinical management of LS families in Quebec.

Operative case of Langerhans'cell histiocytosis of the skull with dural invasion. An immunohystochemical study of ki-67 expression of eosinophilic granuloma: case report and review of the literature

Eosinophilic granuloma (EG), Letterer-Siwe disease and Hand-Schuller-Christian disease are collectively called Langherans-cell histiocytosis (LCH). While the latter two are systemic diseases, the former is a localized form of histiocytosis. Solitary EG of the skull are rare lesions characterized by a natural history not well defined yet. In this context, we report a case of a 23-year-old male suffering for a recurrent and progressive right parietal headache. On computed tomography (CT) it was observed an ostelytic lesion which on magnetic resonance imaging (MRI) appeared as an hyperintense soft mass on both T1 and T2 weighted images. The lesion showed a marked and heterogeneous enhancement after gadolinium administration. The surgical excision was complete and the severe headache disappeared. Immunohistochemical analysis of the specimen indicated an eosinophilic granuloma characterized by Ki-67 nuclear antigen expression with a labeling index of 20%. In the pertinent literature we have found two aggressive cases of EG showing the Ki-67 expression with a respectively 6.2% (occipital bone granuloma) and 10% (parietal bone granuloma) labeling index. That high proliferative activity suggests a local Langherans' cell proliferation along with an exuberant inflammatory response and also explains the aggressive clinical course and the rapid expansion of the lesion observed in some rare cases of solitary EG. This is the third case-report of calvarial EG characterized by Ki-67 nuclear antigen expression.

Glucocorticoid resistance in Crohn's disease and ulcerative colitis: an association study investigating GR and FKBP5 gene polymorphisms

The aim of this study is to investigate the role of single-nucleotide polymorphisms (SNPs) of the glucocorticoid receptor (GR) and of the related co-chaperone FKBP5 genes in the development of glucocorticoid (GC) resistance in Crohn's disease (CD) and ulcerative colitis (UC) patients. We have developed a high-resolution DNA melting method that allows simultaneous identification of GR (BclI, N363S and ER22/23EK) and FKBP5 (rs3800373, rs1360780 and rs4713916) polymorphisms. Genotype frequencies were determined in 100 consecutive CD and 100 UC patients under GCs therapy (50 responders and 50 resisters). The variation of FKBP5 polymorphism rs4713916 (G/A), in the putative promoter region of FKBP5, is significantly associated with resistance to GC treatment in CD (responder=17% versus resister=35%; P=0.0043). No significant differences were found in UC patients. If these preliminary findings will be confirmed, the combination of GR and FKBP5 mutational analyses could help to identify subgroups of CD patients with higher chances to benefit from GC treatment.

Cellular and intracellular distribution of growth hormone in the adult chicken testis

Endocrine actions of growth hormone (GH) have been implicated during the development of adult testicular function in several mammalian species, and recently intracrine, autocrine, and paracrine effects have been proposed for locally expressed GH. Previous reports have shown the distribution of GH mRNA and the molecular heterogeneity of GH protein in both adult chicken testes and vas deferens. This study provides evidence of the presence and distribution of GH and its receptor (GHR) during all stages of spermatogenesis in adult chicken testes. This hormone and its receptor are not restricted to the cytoplasm; they are also found in the nuclei of spermatogonia, spermatocytes, and spermatids. The pattern of GH isoforms was characterized in the different, isolated germ cell subpopulations, and the major molecular variant in all subpopulations was 17 kDa GH, as reported in other chicken extra-pituitary tissues. Another molecular variant, the 29 kDa moiety, was found mainly in the enriched spermatocyte population, suggesting that it acts at specific developmental stages. The co-localization of GH with the proliferative cell nuclear antigen PCNA (a DNA replication marker present in spermatogonial cells) was demonstrated by immunohistochemistry. These results show for the first time that GH and GHR are present in the nuclei of adult chicken germinal cells, and suggest that GH could participate in proliferation and differentiation during the complex process of spermatogenesis.

Post-traumatic interemispheric subdural hematoma: report of two cases and review of the literature

The interhemispheric subdural hematomas (ISHs) are located along the whole interhemispheric scissure. The ISHs are a rare complication of head traumas. Possible predisposing factors such as coagulopathies, alcohol abuse or anticoagulant therapy are favouring factors. ISHs are rarely accompanied by changes in consciousness and it usually manifests itself with signs of "Falx Syndrome" (controlateral monoparesis of lower extremity or controlateral hemiparesis with lower limb weakness predominating). The treatment can consist of conservative observation or craniotomy and is dictated by the neurological evolution. In literature are described 140 cases since 1940 including our two conservatively managed patients. The salient aspects of ISHs are discussed in an analysis of the pertinent literature.

Schwannoma of median nerve at the elbow. Case report and short review of the literature

The Authors present a case of rare elbow localization of schwannoma of the median nerve, in 42 year old woman. The surgical treatment and the short follow-up are presented.

Therapeutic strategy of late cerebral radionecrosis. A retrospective study of 21 cases

AIM

Late cerebral radiation necrosis (LCR) is a serious complication of radiation treatment for brain tumors. This study investigates the diagnosis and management of patients with late clinical and neuroradiological cerebral radionecrosis after primary removal of brain neoplasm. The authors discuss the clinical features and long-term outcome of 21 patients with late cerebral radionecrosis and emphasize the importance of surgical and medical therapy.

METHODS

Twenty-one patients with brain tumor treated by surgical resection or brain biopsy alone after radiotherapy during follow-up developed radionecrosis. The magnetic resonance imaging (MRI), surgical and clinical findings of these patients with radionecrosis are reviewed.

RESULTS

MRI showed radionecrosis in 21 patients, 9 of which had undergone craniotomy for lesion removal.

CONCLUSION

Late radionecrosis is infrequent following radiation therapy and may simulate tumor recurrence on MRI scans. From the authors' experience it is evident that, once begun, radiation treatment of neoplastic lesions can lead to complications such as late cerebral radionecrosis which often require surgical treatment. As correct diagnosis is necessary for appropriate treatment, a fair balance needs to be struck when considering ionizing radiation, medical therapy, surgery and diagnostic imaging.

Chronic emispheric subdural hematoma in a patient with antibodies antiphospholipid syndrome: case report

The treatment of chronic subdural hematoma (CSDH) was developed through a wide range of methods and technique. The excellent surgical treatment of CSDH is still controversial. The authors report a case of chronic subdural hematoma in a patient with antibodies antiphospholipidis syndrome (S. of Hughes). Antiphospholipid syndrome is characterized by arterial or venous thrombosis, and the presence of antiphospholipid antibodies (APL). APL are considered to be a cause of an acquired hypercoagulable state leading to stroke and transient ischemic attack (TIA).

Total occlusion of a conus medullaris pial arteriovenous malformation obtained with one session of superselective embolization

The authors report about a case of the endovascular treatment of a pial arteriovenous malformation (AVM). The lesion was located on the conus medullaris. This injury is a rare spinal AVM. The diagnostic management and surgical treatment was chosen with a collaboration between neurosurgeons and neuroradiologists. The diagnostic management was based on clinical validation and magnetic resonance with angiographic technique as a gold standard. With regard to the surgical treatment of spinal AVM, endovascular and radiotherapy is a decision which should be taken multidisciplinarily. The treatment is crucial in resolving this lesion. The authors describe the case of a 38-year-old girl with clinical findings of progressive radiculomedullary ischemic process caused by the presence of spinal AVM. The angiographic images showed a pial AVM of the conus medullaris fed by an anterior radiculomedullary artery (Adamckiewiz artery) originated from a left T11 dorsospinal artery and by a posterior radiculopial artery originated from the left L1 artery. The draining veins were posterior pial veins, and accessory anterior subpial veins. Even if the first treatment of a pial arteriovenous malformation (AVM) of conus medullaris can be the surgical treatment for posterior localization, a neurointerventional angiographic and modern materials make it possible to reach pial AVMS of conus medullaris avoiding surgery. The authors describe a successful treatment of conus medullaris arteriovenous malformation with a one session of superselective embolization.

Passage of mannitol into the brain around gliomas: a potential cause of rebound phenomenon. A study on 21 patients

AIM

Widespread use of mannitol to reduce brain edema and lower elevated ICP in brain tumor patients continues to be afflicted by the so-called rebound phenomenon. Leakage of mannitol into the brain parenchyma through an altered BBB and secondary reversal of osmotic gradient is considered the major cause of rebound . This has only been demonstrated experimentally in animals. As a contribution to this issue we decided to research the possible passage of mannitol into the brain after administration to 21 brain tumor patients.

METHODS

Mannitol (18% solution; 1 g/kg) was administered as a bolus to patients (ten had malignant glioma, seven brain metastases and four meningioma) about 30 minutes before craniotomy. During resection, a sample of the surrounding edematous white matter was taken at the same time as a 10 ml venous blood sample. Mannitol concentrations were measured in plasma and white matter by a modified version of the enzyme assay of Blonquist et al.

RESULTS

In most glioma patients, mannitol concentrations in white matter were 2 to 6 times higher than in plasma (mean 3.5 times). In meningioma and metastases patients plasma concentrations of mannitol were higher than white matter concentrations except in three cases with infiltration by neoplastic cells.

CONCLUSIONS

The results of our study show that even after a single bolus, mannitol may leak through the altered BBB near gliomas, reversing the initial plasma-to-blood osmotic gradient, aggravating peritumoral edema and promoting rebound of ICP.

Chronic subdural hematoma: comparison of two surgical techniques. Preliminary results of a prospective randomized study

AIM

The optimal treatment for chronic subdural hematoma (CSDH) is not yet well defined and research for efficient surgical solutions continues. Burr hole craniotomy (BHC) is a common treatment and twist drill craniostomy (TDC) is a less invasive alternative. A closed-system drainage with subdural expansion catheter and suction reservoir can be used to enhance the TDC procedure.

METHODS

We report preliminary results of a prospective study comparing BHC and TDC with suction drainage, in a series of 47 patients randomized into two treatment groups. One group of 22 patients underwent TDC with closed-system drainage and suction reservoir (14 men, 8 women, mean age 78.7 years). Another group of 24 patients underwent BHC with subdural irrigation and closed drainage (16 men, 8 women, mean age 76.3 years). Neurological status was assessed by Markwalder's Grading Scale on admission and at follow-up. All patients underwent computed tomography (CT) before surgery, within 4 days after it, and 1 and 2 months later.

RESULTS

Preoperative clinical and radiological data were similar in the two groups. Operating times were shorter in the TDC group, while drainage time was shorter in the BHC group (P<0.0001). Length of hospitalization was similar. Recurrence rate, mortality, and neurological recovery were similar, with non significant differences in favor of the TDC group. After 2 months, CT showed complete regression of subdural effusion in 66.6% of cases in the TDC group and in 31.8% in the BHC group (P<0.05).

CONCLUSIONS

Preliminary results indicate TDC and BHC as at least equally effective, however TDC favors faster regression of residual subdural effusion, is a faster procedure, and seems to be associated with fewer recurrences. If confirmed at the end of the study, these results could indicate TDC with suction as the elective surgical treatment for CSDH.

Preliminary results of a soft novel lumbar intervertebral prothesis (DIAM) in the degenerative spinal pathology

The authors report a series of 43 patients suffering from lower limb pain, almost constantly associated with chronic or acute backpain, treated by microsurgical nerve root decompression and by implantation of a soft intervertebral prothesis (DIAM). Satisfying results were obtained in 97% of cases, inducing the authors to consider the device a reliable tool for curing low-back pain and sciatica. Selection criteria are exposed and discussed.

Wrist median nerve motor conduction after end range repeated flexion and extension passive movements in Carpal Tunnel Syndrome. Pilot study

Carpal Tunnel Syndrome (CTS) can be due to a variety of different pathological conditions. These etiological and epidemiological differences may explain the non-homogeneous response to ordinary conservative therapeutical options observed in this syndrome. The aim of our study was to investigate on the possibility of identifying different sub-groups of patients among conservatively treatable CTS with different susceptibility to physiotherapeutic treatments. We decided to utilize an objective approach measuring some median motor nerve function parameters. Short term variations of Compound Motor Action Potential (CMAP) from the thenar eminence were compared in two groups of 55 hands (CTS patients and normal controls) after performance of two different types of end range passive movement. We found a different distribution of CMAP amplitude modifications within a sub-group of patients that suddenly improved more than the controls after two series of 10 end range passive flexions or after two series of ten end range passive extensions. Amplitude changes proved to be much more useful than latency variation studies in the provocative test neurophysiological approach. The method we propose appears to be useful for better surgical indication and/or for improvement of conservative therapeutic choice.

Locked nucleic acids (LNA): versatile tools for designing oligonucleotide decoys with high stability and affinity

Double-stranded oligodeoxynucleotides (ODN) containing the consensus binding sequence of a transcription factor are valuable tools for the manipulation of gene expression at the transcriptional level by means of the decoy strategy. The approach involves flooding the cells with enough ODN decoy to compete for binding of the transcription factor with its consensus sequence in target genes. The technique has been proven effective in vitro and in vivo, suggesting its use in therapy. Therefore, great attention has been recently focused on chemical modifications enhancing biostability of the oligonucleotides so as to improve their pharmacological properties. Unfortunately, benefits in terms of nuclease resistance have been often negated by a decrease in the affinity and/or specificity of transcription factor binding. To circumvent these problems, circular dumbbell and chimeric decoy oligonucleotides, the latter comprising a central stretch of transcription factor recruiting deoxynucleotides flanked by modified nucleotides, have been introduced. Nevertheless, these approaches have the limitation of leaving the ODNs still sensitive to endonuclease cleavage. To address these concerns, we have recently investigated the use of a new class of nucleotide analogs termed locked nucleic acids (LNA) in the designing of decoy molecules for the transcription factor kappaB (NF-kappaB). In this article, we review the advantages of LNA in the design of ODN decoys pointing to the feasibility of introducing modifications in the transcription factor binding sequence in order to obtain molecules with increased stability compared to end-capped ODNs, while remaining efficiently recognized by NF-kappaB.

Long-term follow-up of childhood cerebellar astrocytomas after incomplete resection with particular reference to arrested growth or spontaneous tumour regression

BACKGROUND

The long-term prognosis for incompletely excised benign cerebellar astrocytomas in children remains largely unpredictable as the incidence of symptomatic recurrence ranges from 18 to 100%. Arrested growth and spontaneous tumour regression are a recognized but neglected phenomenon, the incidence and objective demonstration of which have received relatively little attention in the literature. With the aim of providing more information on this question, we reviewed our experience with incompletely resected benign cerebellar astrocytomas in children.

CLINICAL MATERIAL AND METHODS

Our series consisted of 31 children with long-term follow-up. None had signs of type 1 neurofibromatosis (NF1). Histology included 22 classic pilocytic and nine diffuse astrocytomas. Seventeen children had symptomatic recurrence after 25 to 450 months and fourteen children remained in good health for 84 to 516 months. In looking for evident clinical differences that could help elucidate the different courses, we also examined recent radiographic images to assess tumour status. The literature was reviewed to obtain further information on nonrecurring and on regressing cerebellar astrocytomas after partial resection in the setting of modern surveillance imaging resources.

FINDINGS

No differences in factors that could elucidate the different clinical courses were found between the two groups of children. Recent negative CT scans or NMR images were reported in seven cases. In two cases arrested growth or regression of a previously visible neoplastic remnant was noted. Review of the literature showed that radiographic follow-up has revealed arrested growth or spontaneous regression of benign cerebellar astrocytoma remnants in 32.5% and 14% of cases, respectively.

CONCLUSIONS

As hypothesized by Cushing, our study shows that a large proportion of cerebellar astrocytomas do not progress or even regress after partial excision. This phenomenon is not understood and unfortunately cannot be anticipated. However, it suggests that a policy of "wait and see" with serial MR imaging can reasonably be recommended in children with cerebellar astrocytoma after partial resection, if the remnant is too risky to be removed by second-look surgery.

Non-Hodgkin lymphoma in a child presenting with acute paraplegia: a case report

Spinal cord compression is a rare presentation of non-Hodgkin lymphoma. Extradural location at onset is a rare but devastating event in pediatric oncology. The authors describe a girl with acute spinal cord compression due to epidural non-Hodgkin lymphoma, emphasizing the encouraging perspective for a complete recovery in children with this condition. A 5-year-old girl presented with pain followed by progressive hyposthenia and paraplegia after a trauma. CT scan and MRI showed homogeneous tissue extending from T2 to L4, occupying the entire vertebral canal and extending to the para- and peri-vertebral soft parts. Emergency surgical debulking was carried out through T6-L1 laminectomy. The patient began chemotherapy (LMB 89 Protocol) and the tumor quickly disappeared. The patient is maintaining a complete remission 42 months after diagnosis. Significant results may be obtained with the chemotherapy treatment of epidural non-Hodgkin lymphoma when the disease is promptly diagnosed. Considering the effectiveness of chemotherapy, the authors believe that a neuro-surgical approach should be employed only when rapid worsening of symptoms is observed or for diagnostic purpose.

Operative results without invasive monitoring in patients with frontal lobe epileptogenic lesions

PURPOSE

To further explore the still controversial issues regarding whether all or most candidates for epilepsy surgery should be investigated preoperatively with invasive long-term video-EEG monitoring techniques (ILTVE).

METHODS

We studied five patients with intractable seizures since early childhood using the same protocol: clinical evaluation, magnetic resonance imaging (MRI) with fluid-attenuated inversion recovery (FLAIR) sequences, long-term video-EEG (LTVE) monitoring with scalp electroencephalogram (EEG), interictal single photon emission computed tomography (SPECT), positron emission tomography (PET), and neuropsychological testing. The patients' seizures had clinical features suggesting a frontal lobe (FL) origin. MRI scans revealed focal cortical dysplasia (CD) in four patients and a probable gliotic lesion in the fifth. The findings in both PET and SPECT images were congruent with those of the MRI. Scalp LTVE failed to localize the ictal onset, although the data exhibited features suggestive of both CDs and FL seizures. On the basis of these results, surgery was performed with intraoperative corticography, and the cortical area exhibiting the greatest degree of spiking was ablated.

RESULTS

Histopathologic study of four of the resected specimens confirmed the presence of CD, whereas in the fifth, there were features consistent with a remote encephaloclastic lesion. There were no postoperative deficits. Seizures in three of the patients were completely controlled at 2-3.5 years of follow-up; a fourth patient is still having a few seizures, which have required reinstitution of pharmacotherapy, and the fifth has obtained > or =70% control. All patients have had significant improvement in psychosocial measures. For comparison, five patients with generally similar clinical and neuroradiologic features to the previous group underwent preoperative ILTVE monitoring. The surgical outcomes between the two groups have not differed significantly.

CONCLUSIONS

We conclude that patients with FL epilepsies may be able to undergo successful surgery without preoperative ILTVE monitoring, provided there is high concordance between neuroimaging tests (MRI, SPECT, PET) and the seizure phenotypes, even when routine EEGs and scalp LVTE fail to localize ictal onset unambiguously. The surgical outcomes of these patients generally paralleled those of the other subjects who also had FL epilepsy but who were operated on only after standard ILTVE monitoring.

Papillary thyroid carcinoma metastatic to the parapharyngeal space

Nodal metastases from head and neck primary cancer presenting as a parapharyngeal space mass are rare. This paper reports two cases of papillary thyroid carcinoma metastatic to the parapharyngeal space. This finding can be related to Rouviere's description of a direct lymphatic pathway from the posterior surface of the superior thyroid lobe to the lateral retropharyngeal nodes. Metastatic thyroid cancer should be considered in the differential diagnosis of a parapharyngeal space mass.

Serum cytokeratins determination in differentiated thyroid carcinoma

To assess the potential value of cytokeratins (CK) 8,18,19 as tumor markers for thyroid diseases, a study was performed comparing serum CK 8,18,19 levels in patients affected from thyroid carcinoma, adenoma, other benign thyroid diseases and healthy volunteers as controls. One hundred cases (65 patients and 35 controls) were examined. Thirty patients had thyroid carcinoma (18 papillary--PTC, 8 follicular--FTC, 4 medullary--MTC), 19 non-toxic goiter, 10 thyroid adenoma, 6 chronic thyroiditis and 35 healthy volunteers as controls. These controls were matched by age and sex. The mean value of CK in benign thyroid diseases (46.1 U/L) was significantly higher (p<0.02) than that in healthy controls (29.6 U/L). The mean value of CK in carcinomas (68.1 U/L) was significantly higher than that in healthy controls (p<0.01) and benign thyroid diseases patients (p<0.05). The positive rate of CK in thyroid carcinomas was 28.1%, while in benign thyroid diseases was 17.8%. The CK sensitivity for thyroid carcinomas was 28.1%, with a specificity of 80% and accuracy of 70.4%. In PTC patients the mean CK value was not significantly higher than in the benign diseases' group and in healthy subjects. No evident correlation between CK levels and tumor mass was found. In FTC patients the mean value was significantly higher than in the benign diseases' group and in healthy subjects. Large tumors showed the highest levels, while small tumor values were similar to the control ones. In MTC patients the mean value was significantly higher than in the benign diseases' group and in healthy subjects, with the highest peaks in large tumors and metastatic tumors. The detection of increased values in thyroid carcinomas with high metastatic potential (FTC and MTC) seems to confirm the role of these antigens in predicting the malignancy's degree of the neoplasm. These findings, if confirmed in larger series, could play an important role in assessing the CK 8,18,19 serum level as a real prognostic factor. Further repeated serum determinations after total thyroidectomy might indicate the role of CK 8,18,19 as serum markers predicting the risk of metastases.

Psychological impact of the hurricane Mitch in Nicaragua in a one-year perspective

BACKGROUND

Whereas natural disasters more commonly occur in low-income countries, almost all studies on psychological consequences have been conducted in the Western world. In countries where resources are poor it is of importance to know which groups should be targeted for early intervention after a disaster. The study aims at assessing the prevalence of post-traumatic stress disorder PTSD and of post-traumatic symptoms among people afflicted by hurricane Mitch in Nicaragua and at identifying risk factors for PTSD symptoms 6 months following a disaster.

METHOD

At four primary health care centres, 496 consecutive adult patients were interviewed 6 months after hurricane Mitch regarding PTSD symptoms (Harvard Trauma Questionnaire, HTQ), disaster experiences and post-disaster help-seeking.

RESULTS

All individuals resident in the area during Mitch were judged to have experienced a trauma fulfilling A criteria for PTSD. Regarding more specific traumas, 39% reported a close relative to be dead or seriously injured and 72% had their house partly or completely destroyed. Prevalence of PTSD ranged from 9.0% in the worst afflicted area to 4.5% in a less damaged area. From a dimensional perspective, PTSD symptoms according to HTQ 6 months after the disaster were significantly associated with the death of a relative (beta-coefficient 0.257, P = 0.000), a house destroyed (beta-coefficient 0.148, P = 0.001), female sex (beta-coefficient 0.139, P = 0.001), previous mental health problems (beta-coefficient 0.109, P = 0.009) and illiteracy (beta-coefficient 0.110, P = 0.009). Those with previous mental health problems (OR = 4.84; 95% CI = 3.04-7.66) were more likely than others to seek from help, any source whereas the opposite was true for illiterate people (OR = 0.38; 95% CI = 0.21-0.69). Of all respondents, 8.5% reported that they had thought of taking their lives, and illiterates (OR 2.84; 95% CI = 1.12-4.37) and those with previous mental health problems (OR 2.84; 95% CI = 1.12-4.57) were at particular risk for suicidal problems. One year after Mitch, half of those identified as PTSD cases at 6 months still fulfilled the criteria for a PTSD diagnosis.

CONCLUSION

PTSD represents a serious mental health problem after a disaster. Those with illiteracy, females and those with previous mental health problems should be targets for early post-disaster intervention.

Anti-p53 and anti-heat shock proteins antibodies in patients with malignant or pre-malignant lesions of the oral cavity

BACKGROUND

Evaluation of circulating anti-p53 antibodies is an easy-to-perform, widely employed, procedure to assess the p53 status in cancer patients.

MATERIALS AND METHODS

Levels of circulating anti-p53 antibodies in patients affected either by oral SCC or by pre- malignant oral lesions were assayed using a commercial ELISA kit. Autoantibody titers to Hsp60 and Hsp72 were determined by conventional ELISA.

RESULTS

Anti-p53 antibodies were detected in 3 out of 16 SCC-bearing patients (18.7%) and in 9 out of 13 patients suffering from pre-malignant oral lesions (69.2%). High titers of anti-Hsp60 autoantibodies were detected in 3 out of 29 patients (10.3%), while in all patients anti-Hsp72 titers were in the normal range.

CONCLUSION

The presence of anti-p53 antibodies in both SCC-bearing patients and in patients with pre-malignant lesions support the notion that p53 gene mutation is an early event in oral tumorigenesis and suggest that this assay could be useful for diagnostic screening of pre-neoplastic lesions at high risk of recurrence and/or transition towards overt malignancy.

Abnormalities of the soleus H-reflex in lumbar spondylolisthesis: a possible early sign of bilateral S1 root dysfunction

Using routine electrodiagnostic procedures, the authors searched for physiologic evidence of nerve root compromise in patients with chronic mechanical perturbation to the lumbar spine. They examined 37 patients with spondylolisthesis and various degrees of degenerative changes in the lumbar canal. Clinical and neurophysiologic findings were compared with data obtained from 36 healthy persons. The soleus H-reflex appeared to be a sensitive indicator of sensory fiber compromise at the S1 root level, because changes correlated well with the focal sensory signs and preceded clinical and electromyographic signs of motor root involvement. When these occurred, the clinical findings were consistent with a more severe nerve root deficit and with radiographic evidence of neural compression. The greater sensitivity of the soleus H-reflex may be related to the pathophysiologic events that occur at the lesion site.

The importance of surgery in supratentorial ependymomas. Long-term survival in a series of 23 cases

In view of the widely recognized correlation between extent of surgical resection and length of survival of children with intracranial ependymoma and the statement that total resection is more likely to be achieved in supratentorial than infratentorial primaries, we decided to review our experience with supratentorial ependymomas and the pertinent literature to verify the importance of surgery in treating this subgroup of pediatric ependymal neoplasms. Of 23 patients operated on, 12 are still alive without evidence of disease 72-357 months after surgery (mean 227, median 237 months). One girl treated by surgery alone was lost to follow-up after 234 months when she, and 7 other patients in the series, had already passed the end of the period of risk for recurrence according to Collins' law. Six surviving patients (2 with subependymoma and 4 with ependymoma) were treated by surgery alone and only 1, the oldest in the series, had to undergo a second operation for recurrence after 10 years. The idea of treating intracranial ependymoma by surgery alone was favored by eminent neurosurgeons in the past and has recently received renewed attention. This was in part the consequence of recognizing that unlike diffuse astrocytoma, in which neoplastic cells can be found up to several centimeters away from the apparent tumor borders, ependymoma has more or less well-defined margins and grows mainly by expansion. Early experience with the policy of electively deferring adjuvant therapy after radiologically controlled total resection of ependymoma seems encouraging, although postoperative MRI does not yet indicate absolute certainty. Close surveillance is recommended. The majority of ependymomas so far treated by surgery alone, with relatively good success, have been supratentorial. In conclusion, on the basis of our experience and a review of the literature we favor a change in attitude to the management of intracranial ependymomas, especially of the cerebrum, with radiologically controlled radical surgery alone followed by close surveillance with periodic MR imaging until the child passes the period of risk for recurrence according to Collins' law as the initial option. In children less than 3 years old the period of surveillance should be doubled. In case of recurrence, reoperation should be considered first, particularly for supratentorial primaries. Radiotherapy continues to be a major option in malignant ependymoma and unresectable primary or recurrent benign ependymoma.

[Exercise test: abnormal ST segments restricted to recovery phase]

PURPOSE

To determine the incidence of atherosclerotic coronary artery disease (CAD) and or myocardial ischemia in patients (pt) with abnormal ST segments restrict to recovery phase (RRAST) of exercise testing (ET).

MATERIAL AND METHOD

Retrospective study in 19 non consecutive pt with RRAST, related to coronary arteriography or exercise planar scyntillography (18 men, 58 +/- 9 years, 18 asymptomatic).

RESULTS

RRAST corresponded to ST segment depression from 1 to 4 mm, with T inversion during early recovery (2 pt); late (14 pt) or both (4 pt). It was documented CAD (14 pt and 9) with artery-by-pass surgery); hypertensive myocardiopathy with normal coronary (3 pt), and mitral prolapse valve (1 pt). In 13 pt with coronary arteriography or exercise scyntillography, within the first 6 months from exercise testing, myocardial ischemia was confirmed in 8 pt in 3 pt, successive exercise testing showed RRAST reproductive in 2 cases.

CONCLUSION

The authors report the high incidence of CAD and or transitory hypoperfusion during myocardial scyntillography in symptomatic men with middle age with RRAST during exercise testing.

Aspecific inflammatory lesion (histiocytosis?) simulating intramedullary astrocytoma. Case report

We report an exceptional case of aspecific inflammatory lesion of the thoracic spinal cord simulating an intramedullary glial tumor. Patient history was characterized by progressive spastic paraparesis with urinary incontinence; MR imaging (T4-T5) showed an enhancing intrinsic mass lesion. Myelotomy enabled partial resection of grayish astrocytoma-like tissue. Only light microscope examination was possible and disclosed aspecific inflammatory tissue composed of eosinophils, lymphocytes and histiocytes. After the operation, the patient improved promptly and no further therapy was administered. Control MRI after four months, one year and two years showed complete disappearance of the intramedullary mass lesion and the patient remained clinically stable with no other signs of disease. Since electron microscopic as well as immunohistochemical studies were not available, a definitive histological diagnosis was not possible. However on the basis of some clinical similarities with cases of isolated histiocytosis X of the CNS reported in the literature, we suggest that a diagnosis of isolated intramedullary eosinophilic granuloma could be reasonable.

Trends in surgical management of astrocytomas and other brain gliomas

In recent years, surgical treatment of cerebral gliomas has made significant technical advances (e.g. microsurgery and neuronavigation) and has also benefitted from improvement in diagnostic techniques and biopathology. Thanks to this progress, there has been a reduction in the surgical mortality and morbidity of highly malignant neoplasms such as glioblastoma multiforme and medulloblastoma, although there has not been any significant improvement in survival. On the other hand, for a specific group of circumscribed and resectable brain gliomas, modern neurosurgery is potentially curative in a high proportion of cases, even if the gliomas are located in deep and previously inaccessible brain regions. These "benign" variants of cerebral gliomas occur mainly in children and young adults, i.e., in subjects with a long life-expectancy. Astrocytoma, oligodendroglioma and ependymoma are a third group of cerebral gliomas for which modern neurosurgery offers interesting new possibilities.

Ultrastructural changes of tissues produced by inhalation of thinner in rats

Thinner is a substance that is used for industrial purposes and for drug abuse; addiction is of young people (average age, 7.5 years). Although the health problem of voluntary or nonvoluntary solvent sniffing is important, great attention has been paid to the epidemiology and pharmacology of paint thinner or industrial solvents inhalation, but studies at the morphological and biochemical level are scarce. This work describes the morphological changes in the lung, liver, kidney, adrenal glands, and central nervous system induced by short- (up to 4 weeks) and long-term (up to 14 weeks) periods of thinner inhalation in rats.

Localization of laminin alpha 2 chain in normal human central nervous system: an immunofluorescence and ultrastructural study

Recently, a rare form of congenital muscular dystrophy has been shown to be associated with a deficiency of laminin alpha 2 chain, a tissue-specific component of the basal lamina. Besides muscular dystrophy, children affected with this disorder also show electrophysiological and magnetic resonance imaging evidence of white matter involvement in the central nervous system (CNS). We have studied the precise localization of laminin alpha 2 chain in normal human brain, using specific electron microscopic techniques including thin-section fracture labeling and cryoultramicrotomy, in parallel with immunohistochemical techniques. We found that this laminin chain was localized to the basal lamina of all cerebral blood vessels, whereas blood vessels of the choroid plexus did not show any reaction. No positive reaction was found in meningeal blood vessels either. We hypothesize that in normal brain, laminin alpha 2 may be important for the selective filtration capability of the blood-brain barrier. The lack of laminin alpha 2 in cerebral vessels of children with laminin alpha 2-deficient congenital muscular dystrophy may cause impaired selective filtration, leading to leakage of plasma components and damage to the CNS. Further studies should be performed on patients affected by congenital muscular dystrophy associated with laminin alpha 2 deficiency to test this hypothesis.