P269 LOCAL ULTRASOUND–FACILITATED THROMBOLYSIS IN ACUTE PULMONARY EMBOLISM: HAS A SPACE?

Acute pulmonary embolism (PE) has an annual incidence of 48 patients per 100,000 with a mortality rate of 10%, few hours after the onset of symptoms. The use of full dose of thrombolytic agent is currently the treatment of choice in acute PE at intermediate and high risk, although its contraindications are well known. An alternative choice is delivered, via percutaneous femoral or jugular venous access, infusion catheters in the pulmonary artery (PA), in order to perform a local thrombolysis (based on a map of thrombus distribution observed at pulmonary CT), with a lower dose of trobolytic agent (rTPA) in a limited time, with a core for emission of ultrasound waves capable of breaking the mesh of the thrombus. Data from the KNOCOUT PE registry show a reduced frequency of fatal intracranial hemorrhage (ICH 2.5%), compared with the full dose of rTPA. Since February 2021 we have treated 7 patients with PE, all with cTnI, D–dimer and high NT–ProBNP and with pulmonary CT finding of large thrombus burden with pruning of peripheral pulmonary branches compatible with the diagnosis of PE at high and intermediate risk in patients with complex comorbidities (significant PESI and simplified PESI). On admission to the ICU all patients were with BP < 100 mmHg, RR > 20/min, satO2 < 90% and HR > 100 bpm. In echocardiogram all were with impaired RV (RV/LF ratio >1 and TAPSE <15mm). All patients was treated with UHF, 1 in fondaparinux for thrombocytopenia. At time between 4h and 8gg from the onset of symptoms, all patients underwent placement of 1 or 2 catheters in right and/or left PA, 106 cm and 135 cm length with zone of interest between 18/32 cm. When possible, hemodynamic parameters were evaluated: PAPm, cardiac output, and stroke volume to characterize the associated hemodynamic deterioration. 12mg of rtPA per catheter was administered over 12 hours. In 3 patients an echocardiogram was performed at 6 hours. In all at 24 hours, vital and laboratory parameters were measured, and in one patient, right heart catheterization was repeated. In no patient was treatment discontinued early, nor were ICH or minor bleeding recorded. Low dose of rtPA allowed use of the technique in patients with severe comorbidities at the limit of thrombolysis use, in the presence of marked RV distress and severe hemodynamic instability. Trials are in progress to shorten the time and therefore reduce the dose of rTPA with equal effectiveness on the clinical course of acute PE.

Liver transplantation in neurological Wilson's Disease: is there indication? A case report

Wilson's disease (WD) is an autosomal recessive disorder characterized by copper overload. In this disease, inadequate hepatic excretion leads to copper accumulation in the liver, brain, kidney, and cornea. Severe neurological symptoms can develop in patients with WD, often in the absence of relevant liver damage: it is unclear whether liver transplantation (LT) could reverse neurological symptoms, and at present LT is not recommended in this setting. We report a case of regression of neurological symptoms in a patient affected by WD with prevalent neurological involvement. A 19-year-old man with disabling neuropsychiatric symptoms from WD that included frontal ataxia, akinesia, dystonia, tremors, and behavioral disorders in the presence of preserved liver function (Model for End-Stage Liver Disease score=7; Child-Turcotte-Pugh score=A5) underwent LT in November 2009. At the time of LT, encephalic magnetic resonance imaging (MRI) indicated diffuse neurodegenerative alterations involving subtentorial and supratentorial structures; bilateral Kayser-Fleischer ring was present. Four years after LT, laboratory tests show normalized copper metabolism and excellent liver function test results. Encephalic MRI shows a substantial improvement of already-known signal alterations at nuclei thalamus and putamen, mesencephalon, and pons. Kayser-Fleischer ring disappeared from the right eye, but a little remnant is still visible in the left eye. At neurological examination, all of the previous symptoms and signs are no longer present and behavioral disorders are no longer present; psychosocial functions are completely restored. The present case provides some evidence that LT may be a valid therapeutic option for WD patients with marked neurological impairment, particularly in those no longer responsive to chelation therapy.

Attenuation of blood flow pulsatility along the Atlas slope: a physiologic property of the distal vertebral artery?

BACKGROUND AND PURPOSE

Physiologic and pathologic arterial tortuosity may attenuate blood flow pulsatility. The aim of this prospective study was to assess a potential effect of the curved V3 segment (Atlas slope) of the vertebral artery on arterial flow pulsatility. The pulsatility index and resistance index were used to assess blood flow pulsatility.

MATERIALS AND METHODS

Twenty-one healthy volunteers (17 men, 4 women; mean age, 32 years) were examined with a 3T MR imaging system. Blood velocities were measured at 2 locations below (I and II) and at 1 location above the V3 segment (III) of the vertebral artery by using a high-resolution 2D-phase-contrast sequence with multidirectional velocity-encoding.

RESULTS

Pulsatility and resistance indices decreased along all measurement locations from proximal to distal. The pulsatility index decreased significantly from location II to III and from I to II. However, the decrease was more pronounced along the Atlas slope than in the straight-vessel section below. The decrease of the resistance index was highly significant along the Atlas slope (location II to III). The decrease from location I to II was small and not significant.

CONCLUSIONS

The pronounced decrease in pulsatility and resistance indices along the interindividually uniformly bent V3 segment compared with a straight segment of the vertebral artery indicates a physiologic attenuating effect of the Atlas slope on arterial flow pulsatility. A similar effect has been described for the carotid siphon. A physiologic reduction of pulsatility in brain-supplying arteries would be in accordance with several recent publications reporting a correlation of increased arterial flow pulsatility with leukoencephalopathy and lacunar stroke.

Incidence of ocular pathologies in Italian children with Down syndrome

PURPOSE

This study identifies the incidence of primary ocular pathologies in a population of Italian children with Down syndrome.

METHODS

A total of 157 Italian children with Down syndrome, age between 1 month and 18 years, were screened between February 2005 and October 2006. The ophthalmologic evaluation included a global inspection of orbit and bulbus oculi, evaluation of ocular motility and visual acuity, slit lamp biomicroscopy, cycloplegic skiascopy, tonometry, and indirect ophthalmoscopy.

RESULTS

The overall incidence of ocular abnormalities was epicanthal fold (132 patients, 84%), hyperopia (93 patients, 59%), astigmatism (44 patients, 28%), myopia (14 patients, 9%), strabismus (56 patients, 36%, 45 cases of esotropia and 11 cases of exotropia), congenital nasolacrimal duct obstruction (35 patients, 22%), cataract (18 patients, 11%), nystagmus (9 patients, 6%), blepharitis and conjunctivitis (6 patients, 4%), and retinal anomalies (10 patients, 6%). Unlike previous reports in patients with Down syndrome, no congenital glaucoma, keratoconus, or Brushfield spots were observed.

CONCLUSIONS

Compared to other studies in patients with Down syndrome, we observed a higher incidence of hyperopia and a lower incidence of myopia. The incidence of nystagmus, blepharitis,and conjunctivitis was less than that reported in other studies, while strabismus, especially exotropia (20%), had a high incidence in our cohort. We also frequently observed obstruction of the nasolacrimal duct (22%), but no keratoconus or glaucoma.

Executive function impairment in early-treated PKU subjects with normal mental development

Executive functions were studied in 14 early and continuously treated PKU subjects (age 10.8 years, range 8-13) in comparison with controls matched for IQ, sex, age and socioeconomic status. Brain MRI examination was normal in all PKU patients. Neuropsychological evaluation included Wisconsin Card Sorting Test, Rey-Osterreith Complex Figure Test, Elithorn's Perceptual Maze Test, Weigl's Sorting Test, Tower of London, Visual Search and Motor Motor Learning Test. Whatever the IQ, PKU subjects performed worse than controls in tests exploring executive functions. Subgrouping the PKU subjects according to the quality of dietary control for the entire follow-up period (using 400 micromol/L as cut-off value for blood phenylalanine (Phe) concentration) showed that patients with worse dietary control performed more poorly than both the PKU group with the best dietary control and the control group. However, a mild impairment of executive functions was still found in PKU patients with a good dietary control (Phe <400 micromol/L) compared to controls. Concerning the PKU group as a whole, no linear correlation was found between neuropsychological performance and historical and concurrent biochemical parameters. We conclude that (a) PKU patients, even when treated early, rigorously and continuously, show an impairment of frontal lobe functions; (b) a protracted exposure to moderately high levels of Phe can affect frontal lobe functions independently of the possible effect of the same exposure on IQ; (c) in order to reduce the risk of frontal lobe dysfunction, the target of dietary therapy should be to maintain blood Phe concentration below 400 micromol/L.

Chemistry of verongida sponges. 10. Secondary metabolite composition of the caribbean sponge Verongula gigantea

A detailed analysis of the secondary metabolites of the Caribbean sponge Verongula gigantea has been performed. A number of bromotyrosine derivatives, 1, 2, and 6-17, were identified, one of which (17) is a novel compound. Its structure was determined on the basis of spectroscopic evidence. Additionally, aureol (18) and 5, 6-dibromo-N,N-dimethyltryptamine (19) were isolated from one of the five analyzed specimens.

Chemistry of verongida sponges. 9.1 secondary metabolite composition of the caribbean sponge aplysina cauliformis

A detailed analysis of the secondary metabolites of the sponge Aplysina cauliformis has been performed. Eight compounds were identified, two of which (13 and 14) are new bromotyrosine derivatives whose structures were determinated from spectroscopic evidence, including 2D NMR. The new compounds were analyzed for cytotoxic activity, and compound 14 was shown to inhibit mammalian protein synthesis and cell proliferation.

Sterols from the Caribbean sponge Neofibularia nolitangere. Isolation of two novel polyhydroxysteroids

The sterol composition of the Caribbean sponge Neofibularia nolitangere has been investigated. In addition to usual sterols this sponge elaborates comparable amounts of 24-methylene-4 alpha-methyl-5 alpha-cholest-8-en-3 beta-ol (1), which is very unusual among sponge sterols, and lesser quantities of two new polyoxygenated sterols, (24S)-24-ethyl-5 alpha-cholest-8-ene-5,6 beta,7 alpha-triol (2) and (24S)-24-ethyl-5 alpha-cholest-8(14)-ene-5,6 beta,7 alpha-triol (3).

Three new D-ring unsaturated sterols from the Mediterranean sponge Topsentia aurantiaca: structure determination and complete nuclear magnetic resonance assignment

Three novel sterols with a rare D-ring unsaturation were isolated from the marine sponge Topsentia aurantiaca and identified as 5 alpha-cholest-14-ene-3 beta,16 alpha-diol (2), 24R-ethyl-5 alpha-cholest-14-ene-3 beta,16 alpha-diol (3), and 24S-ethyl-5 alpha-cholest-14-ene-3 beta,16 alpha-diol (4). The sponge also elaborates a further D-ring unsaturated sterol, 5 alpha-cholest-15-en-3 beta-ol (1), which has been previously described only as a synthetic product. All the 1H and 13C nuclear magnetic resonances of compounds 1 and 2 were assigned to the relevant protons and carbons by bidimensional COSY, HETCOR, and HMQC nuclear magnetic resonance experiments.

The true threshold of the slow nystagmic component-L

The fast component of nystagmus begins where the slow component stops, at the point called the threshold of the fast component R. The fast component should last until the eye is brought back into the position of azimuth zero, where the slow component begins anew. This point can be called the threshold of the slow component L. So the fast component has a span from R to L and is presented as a side of a triangle r. An additional corrective procedure in electronystagmography is suggested to avoid failures and to define the true position of L. This is the way to correct the false information on nystagmic elements and to learn the unknown features of the fast component.

The treatment of Meniere's disease by acupuncture

34 patients suffering from Meniere's disease were treated by acupuncture. Prior to acupuncture most of them had been treated with various other medical means without satisfactory results. After acupuncture treatment their condition greatly improved. The classic symptoms of Meniere's disease are vertigo, tinnitus and deafness, but for all the treated patients vertigo was the most uncomfortable and distressing symptom. In all our cases vertigo stopped after a few acupuncture courses; but in our opinion it is more important to follow and control hearing threshold, since if it remains stable the other symptoms of Meniere's disease also do not persist. All our patients were regularly followed by careful audiometric studies several years after acupuncture treatment. In most cases hearing level had not greatly varied, so the other symptoms of Meniere's disease were not present in any large degree.

Electronystagmography in the pathology of the central nervous system

The program of the electronystagmographic examinations in the pathology of the central nervous system contains 11 groups of tasks. Sixty signs of central impairments are listed, from which 26 nystagmic irregularities had a small diagnostic value. No sign occuring alone could be taken as pathognomonic, only a group of signs can be used for the impairment localization. Besides for the peripheral vestibular and the peripheral vestibulocochlear impairments, the authors succeeded to make a group containing pathogomonic signs for mixed vestibular impairments as well as for multiple sclerosis affecting vestibular structures.