Low dose aspirin and clinical outcomes in patients with SARS-CoV-2 pneumonia: a propensity score-matched cohort analysis from the National SIMI‑COVID‑19 Registry

BACKGROUND

SARS- CoV-2 virus has had dramatic consequences worldwide being able to cause acute respiratory distress syndrome (ARDS), massive thrombosis and pulmonary embolism and, finally, patients' death. In COVID-19 infection, platelets have a procoagulant phenotype that can cause thrombosis in the pulmonary and systemic vascular network. Aspirin is a well-known anti-platelet drug widely used for the prevention of cardiovascular events and systematic reviews suggest a possible benefit of low-dose aspirin (LDA) use in the prevention and treatment of ARDS in patients with COVID-19 infection. However, several studies are available in the literature which do not support any benefits and no association with the patients' outcome. Therefore, currently available data are inconclusive.

MATERIALS AND PATIENTS

Data from the nationwide cohort multicenter study of the Italian Society of Internal Medicine (SIMI) were analyzed. We conducted a propensity score-matched cohort analysis to investigate the impact of chronic assumption of LDA on mortality of adult COVID-19 patients admitted in Internal Medicine Units (IMU). Data from 3044 COVID-19 patients who referred to 41 Italian hospitals between February 3rd to May 8th 2020 were analyzed. A propensity score-matched analysis was conducted using the following variables: age, sex, hypertension, hyperlipidemia diabetes, atrial fibrillation, cerebrovascular disease, COPD, CKD and stratified upon LDA usage, excluding anticoagulant treatment. After matching, 380 patients were included in the final analysis (190 in LDA group and 190 in no-LDA group).

RESULTS

66.2% were male, median age was 77 [70-83]. 34.8% of the population died during the hospitalization. Cardiovascular diseases were not significantly different between the groups. After comparison of LDA and no-LDA subgroups, we didn't record a significant difference in mortality rate (35.7% vs 33.7%) duration of hospital stay and ICU admission. In a logistic regression model, age (OR 1.05; 95% CI 1.01-1.09), FiO2 (OR 1.024; 95% CI 1.03-1.04) and days between symptoms onset and hospitalization (OR 0.93; 95% CI 0.87-0.99) were the only variables independently associated with death.

Uso de extratos herbais e butirato de sódio em suínos na fase de 7 a 10kg

Objetivou-se avaliar o efeito da adição de um complexo contendo extratos herbais de Acacia minearnsii e Castanea sativa, associados a um blend de ácidos orgânicos contendo os ácidos butírico, cítrico, fumárico e ascórbico em substituição a antibióticos em dietas de leitões na fase de 7 a 10kg de peso corporal. O experimento foi executado nas instalações de uma granja comercial, situada no município de Xanxerê, Santa Catarina, Brasil. Foram utilizados 400 animais, na faixa de 7 a 10kg de peso, distribuídos em delineamento inteiramente ao acaso em quatro tratamentos com quatro repetições cada, compostas por 25 animais cada. Os tratamentos experimentais foram: T1: Controle Positivo (Colistina + Florfenicol) (1000ppm); T2: Complexo herbal + Butirato (300ppm); T3: Complexo herbal + Butirato (600ppm); T4: Complexo herbal + Butirato (1200ppm). Foram avaliados parâmetros sanguíneos (hemograma, leucograma, contagem plaquetária, glicemia e colesterolemia), parâmetros de desempenho (ganho de peso, consumo de ração e conversão alimentar) e ocorrência de diarreias. Os dados experimentais foram submetidos à análise de variância, e na presença de diferença significativa, as médias foram submetidas ao teste SNK a 5% de significância. Não foram constatadas alterações significativas sobre os parâmetros hematológicos ou leucocitários dos suínos avaliados. Não houve alteração na contagem plaquetária, nos níveis de glicose e de colesterol sanguíneos .O desempenho e a ocorrência de diarreias não foram afetadas pelos níveis do blend de extratos herbais e ácidos orgânicos em substituição aos antibióticos. Conclui-se que estes compostos podem ser utilizados como promotor de crescimento em substituição aos antibióticos, sem causar comprometimento nos parâmetros sanguíneos e no desempenho de leitões na fase pós-desmama.

Risonanza magnetica funzionale: Localizzazione dell'area motoria primaria in pazienti portatori di lesioni espansive cerebrali Risultati preliminari

La Risonanza Magnetica Funzionale (RMF) ha dimostrato di poter localizzare la sede di aree corticali funzionali in numerosi protocolli su volontari sani. La identificazione prechirurgica di aree corticali eloquenti è molto importante al fine della realizzazione di un intervento il meno lesivo possibile per la funzione. Il sowertimento più o meno grossolano della regione anatomica da parte di un processo espansivo rende spesso difficile la identificazione di determinati reperi anatomici.

Ci siamo proposti di studiare con RMF, su tomografo convenzionale, pazienti affetti da neoplasie intra ed extrassiali che interessavano il lobo frontale posteriore o quello parietale. Sono stati studiati quindici pazienti, tutti destrimani, di età compresa tra i 15 ed i 64 anni. Sono state ottenute mappe di attivazione, che hanno evidenziato aree di significativo aumento del segnale in regione parieto-frontale posteriore.

La morfologia delle aree di significativo aumento di segnale era il più delle volte di tipo serpiginoso. Quando l'effetto massa era netto, l'area attivata nell'emisfero patologico appariva dislocata rispetto a quella nell'emisfero controlaterale. Sino ad ora sono stati ripetuti gli esami di RMF dopo l'intervento chirurgico in tre pazienti che non presentavano deficit motori significativi all'arto superiore.

Neoplasms compressing or infiltrating cerebral cortex often alter the normal anatomy in such a way that the neurosurgeon can not easily localize and spare functional areas. Moreover, the results of mass effect on brain functional anatomy have not been extensively investigated in vivo yet.

Utilization of multiparametric prostate magnetic resonance imaging in clinical practice and focal therapy: report from a Delphi consensus project

Purpose

To codify the use of multiparametric magnetic resonance imaging (mpMRI) for the interrogation of prostate neoplasia (PCa) in clinical practice and focal therapy (FT).

Methods

An international collaborative consensus project was undertaken using the Delphi method among experts in the field of PCa. An online questionnaire was presented in three consecutive rounds and modified each round based on the comments provided by the experts. Subsequently, a face-to-face meeting was held to discuss and finalize the consensus results.

Results

mpMRI should be performed in patients with prior negative biopsies if clinical suspicion remains, but not instead of the PSA test, nor as a stand-alone diagnostic tool or mpMRI-targeted biopsies only. It is not recommended to use a 1.5 Tesla MRI scanner without an endorectal or pelvic phased-array coil. mpMRI should be performed following standard biopsy-based PCa diagnosis in both the planning and follow-up of FT. If a lesion is seen, MRI-TRUS fusion biopsies should be performed for FT planning. Systematic biopsies are still required for FT planning in biopsy-naïve patients and for patients with residual PCa after FT. Standard repeat biopsies should be taken during the follow-up of FT. The final decision to perform FT should be based on histopathology. However, these consensus statements may differ for expert centers versus non-expert centers.

Conclusions

The mpMRI is an important tool for characterizing and targeting PCa in clinical practice and FT. Standardization of acquisition and reading should be the main priority to guarantee consistent mpMRI quality throughout the urological community.

Electronic supplementary material

The online version of this article (doi:10.1007/s00345-016-1932-1) contains supplementary material, which is available to authorized users.

Oxysterols and redox signaling in the pathogenesis of non-alcoholic fatty liver disease

Oxysterols are oxidized species of cholesterol coming from exogenous (e.g. dietary) and endogenous (in vivo) sources. They play critical roles in normal physiologic functions such as regulation of cellular cholesterol homeostasis. Most of biological effects are mediated by interaction with nuclear receptor LXRα, highly expressed in the liver as well as in many other tissues. Such interaction participates in the regulation of whole-body cholesterol metabolism, by acting as "lipid sensors". Moreover, it seems that oxysterols are also suspected to play key roles in several pathologies, including cardiovascular and inflammatory disease, cancer, and neurodegeneration. Growing evidence suggests that oxysterols may contribute to liver injury in non-alcoholic fatty liver disease. The present review focuses on the current status of knowledge on oxysterols' biological role, with an emphasis on LXR signaling and oxysterols' physiopathological relevance in NAFLD, suggesting new pharmacological development that needs to be addressed in the near future.

Anaphylactic shock during hyperbaric oxygen therapy

A case of a 38-year-old woman is reported who was treated with hyperbaric oxygen therapy to cure a dehiscent wound. She suffered from "oral-allergy syndrome" (OAS) while eating certain fruits, and from itching when wearing latex gloves to handle hair dyes. Fifteen minutes after the start of compression, malaise, anxiety, dyspnoea, tachycardia, cold sweating and laryngeal stridor occurred. Despite intensive care treatment, face angioedema persisted for several days. On the basis of history, radioallergosorbent test (RAST) and prick tests, latex was assumed to be responsible for the anaphylactic reaction. To our knowledge, this is the first extensive report of an anaphylactic reaction to latex in a hyperbaric chamber. The lesson drawn from this case record can be summarized as follows: 1) never fail to collect a thorough history; 2) set up a latex-safe hyperbaric chamber when needed; 3) have an emergency kit always near at hand.

Skull changes and intellectual status in hydrocephalic children following CSF shunting

A total of 76 shunt-treated hydrocephalic children were examined at least once between two and 12-years after surgery to determine what skull changes had occurred and to assess the children's intellectual status. The high incidence of skull changes in shunt-treated, non-tumoral, hydrocephalic children was confirmed. A strict relationship existed between skull changes and low intracranial pressure. The results indicate that impairment of mental development parallels the degree of skull changes, suggesting a close relationship between impaired mental development and cerebrospinal fluid hypotension.

Is there a possibility for a glutaraldehyde-free porcine heart valve to grow?

OBJECTIVE

A challenging issue is to create a heart valve with growth and remodeling potential, which would be of great interest for congenital heart valve surgery. This study was performed to evaluate the growth and remodeling potentials of a decellularized heart valve.

METHODS

In 4 juvenile sheep (age 12 +/- 1 weeks) with a weight of 24.3 +/- 4.4 kg, a 17-mm diameter decellularized porcine valve was implanted as pulmonary valve replacement. Valve growth was evaluated by transthoracic echocardiography. At explantation, valves were evaluated by gross examination, light microscopy (hematoxylin and eosin, von Kossa, Sirius red, Weigert and Gomori staining), electron microscopy and immunohistochemistry. Atomic absorption spectrometry was performed to evaluate calcium content.

RESULTS

All animals showed fast recovery. The mean follow-up was 9.0 +/- 1.8 months. All sheep at least doubled their weight (54.3 +/- 9.2 kg). Echocardiography showed no regurgitation and a flow velocity of 0.7 +/- 0.1 m/s at the latest follow-up. The valve diameter increased from 17.6 +/- 0.5 to 27.5 +/- 2.1 mm (p < 0.018). Gross examination showed a similar wall thickness of the implanted valve and native pulmonary wall, with smooth and pliable leaflets. Histology showed a monolayer of endothelial cells, fibroblast ingrowth and production of new collagen. No calcification was seen at von Kossa staining, confirmed by low calcium content levels of the valve wall and leaflets at atomic absorption spectrometry.

CONCLUSIONS

This glutaraldehyde-free heart valve showed not only the absence of calcification, but also remodeling and growth potential.

Glomus tumor of the lower lip. A case report

A glomus tumor is a benign neoplasm originating from the modified smooth muscle cells of the vascular glomus. This neoplasm was firstly considered by Masson in 1924, and generally it has a solitary lesions but in some cases multiple lesions were described. Differential diagnosis is usually made with Kaposi sarcoma and hemangiopericytoma. The histopathologic examination is essential together with the immunohistochemical study. The clinical case of a 65-year-old man with a glomus tumor of the lower lip is described.

One-step nested PCR for detection of 2 LTR circles in PBMCs of HIV-1 infected patients with no detectable plasma HIV RNA

A highly sensitive nested PCR was carried out in order to detect 2 LTR circles as a marker of recent and ongoing viral replication in HIV-1 infected patients with HIV plasma RNA undetectable. This "in house" two-step nested PCR is very sensitive, but it is not feasible for routine tests and presents a high risk of contamination. In order to reduce the time of reactions and crossover contamination, the possibility was explored to carry out a single step nested PCR, in which the two successive amplification rounds are carried out in the same tube. This single step nested PCR has the same sensitivity of the two-step nested, is easy to conduct and requires a short time of reaction. The two different PCR methods were compared and the clinical use of monitoring 2 LTR DNA circles in HIV-1 infected patients with undetectable plasma viral load is discussed.

Long-term inhibition of glioma growth by systemic administration of human PEX

AIM

The growth of gliomas depends on the balance of factors stimulating or inhibiting angiogenesis, tumor cell invasion and proliferation. The administration of endogenous inhibitors to experimental human gliomas in animal models resulted in a significant inhibition of tumor growth. It is becoming apparent that resistance can develop over time to many types of endogenous inhibitors and seems to be influenced by the tumor type and system of delivery.

METHODS

We recently isolated a potent endogenous inhibitor, called human PEX, from human glioma cells in culture. Human PEX is a potent inhibitor of angiogenesis, tumor and endothelial cell proliferation and migration. In this paper, we investigated the ability of human PEX to sustain inhibition of glioma growth for a prolonged period of time. We initially developed a recombinant form of the inhibitor and showed that this form had similar in vitro and in vivo activities to the natural one. Human PEX was then administered to nude mice intracranial human glioma model, in combination with metronomic chemotherapy, for a period of 185 days, starting 15 days after tumor cells implantation.

RESULTS

Our data showed that the systemic administration of human PEX mantained a very prolonged inhibition of glioma growth (50% survival of animals treated with 2 mg/kg/days was 160 days vs 24 days of the control) and had a synergistic effect with low dose chemotherapy. Histological analysis of tumors, showed that treatment with PEX was associated with a decrease of vascularity, cell proliferation, and increase in apoptosis.

CONCLUSION

These data indicate that human PEX controls tumor growth by separate mechanisms. In addition, treatment with PEX produced well delineated tumors, indicating the persistence of a direct anti-invasive effect of the molecule even after a prolonged period of treatment.

Low-dose chemotherapy combined with an antiangiogenic drug reduces human glioma growth in vivo

This study evaluates the efficacy of the combination of an antiangiogenic drug and conventional chemotherapeutics for the treatment of experimental human gliomas. As an antiangiogenic, we used recombinant human PEX, a fragment of matrix metalloproteinase-2 that we have previously shown to have a significant antimitotic, anti-invasive, and antiangiogenic properties against human glioblastoma in vitro and in vivo. We used carboplatin and etoposide as the two chemotherapeutic drugs routinely used in our institution (Ospedale Maggiore de Milano) for the treatment of malignant gliomas. Conventional chemotherapeutic drugs were administered at high dose or at a low and semicontinuous regimen. Combined treatment of high-dose chemotherapy and PEX did not produce an improvement of survival in comparison with chemotherapy alone, but it was associated with a decrease in tumor volume, vascularity, and proliferative index and an increased apoptosis. All of these animals experienced severe side effects. The longest survival was documented in animals submitted to low and semicontinuous chemotherapy and antiangiogenic treatment. This regimen was associated with no side effects, marked decrease in tumor volume, vascularity, and proliferative index, and an increased apoptosis. Our data suggest that low-dose chemotherapy in combination with PEX can be successfully used against human malignant glioma in vivo.

Alpha(v)beta3 and alpha(v)beta5 integrin expression in glioma periphery

OBJECTIVE

This study analyzed the expression of integrins alpha(v)beta3 and alpha(v)beta5 in glioma tissue and focused on the periphery of high-grade gliomas.

METHODS

The analysis was performed with Western blot, immunohistochemistry, and immunofluorescence, by use of two monoclonal antibodies able to recognize the functional integrin heterodimer. The expression of integrin-related ligands and growth factors also was studied. Sections from the tumor periphery were classified as either tumor periphery (light tumor infiltrate or scant visible cells) or peritumor (heavy tumor infiltration).

RESULTS

Our data on glioma tissues demonstrated that both integrins were expressed in glioma cells and vasculature and their expression correlated with the histological grade. Alpha(v)beta3 expression was prominent in astrocytic tumors. Both integrins were markers of tumor vasculature, particularly of endothelial proliferation. A high-grade glioma periphery demonstrated a prominent expression of integrin alpha(v)beta3. Cells demonstrating alpha(v)beta3 positivity were identified as tumor astrocytes and endothelial cells by double imaging. The same cells were surrounded by some alpha(v)beta3 ligands and co-localized fibroblast growth factor 2. Matrix metalloproteinase 2 also was found to be co-localized with alpha(v)beta3 in the same cells. Alpha(v)beta3 expression was more relevant in tumor astrocytes. Alpha(v)beta3 integrin and vascular endothelial growth factor expression increased from the periphery to the tumor center.

CONCLUSION

Our data support the role of integrins alpha(v)beta3 and alpha(v)beta5 in glioma-associated angiogenesis. In addition, they suggest a role for integrin alpha(v)beta3 in neoangiogenesis and cell migration in high-grade glioma periphery.

Neuroendocrine, immunohistochemical, and ultrastructural study of pineal region tumors

Thirteen patients with tumors in the pineal region were submitted to pre- and post-operative blood sampling (08:00, 14:00, 20:00, and 02:00 hr) for three or four consecutive days. A single cerebrospinal fluid (CSF) sample was collected at surgery, and melatonin levels determined. In all patients, serum and CSF beta subunit of human chorionic gonadotrophin (betaHCG), carcino embryonic antigen (CEA), and alpha-fetoprotein (AFP) levels were measured. Histology revealed four pineocytomas, one pineoblastoma, four germinomas, one immature teratoma, one pilocytic astrocytoma, one lymphoma, and one meningioma. Serum and CSF levels of serological biomarkers were normal, except for one of the germinoma cases. In most patients, alteration either in the circadian rhythm or in the melatonin concentration was observed before surgery. In benign neoplasms the circadian rhythm was conserved. In pineoblastoma, lymphoma, and three out of four germinomas, melatonin concentrations were undetectable. In one case of germinoma, melatonin levels were high, with the circadian rhythm being abolished. According to conventional histology, all germinomas were similar. Therefore, in a rare case of pineal germinoma with high melatonin levels, the tissue was subjected to an in depth investigation (immunohistochemical and ultrastructural) in order to determine the pathology and the possible differences from the other typical germinomas. Results were compared to those provided from other pineal neoplasms. Electron microscopy examination detected the presence of clusters of intermediate filaments and numerous electrondense granules only in the case of a germinoma producing melatonin.

Prognostic factors in oligodendroglioma

BACKGROUND

A reliable marker for tumor oligodendroglial cells is not yet available, so that the histological recognition of the tumor still encounters uncertainties. There is no general agreement also on prognostic factors in oligodendroglioma. The inconsistency concerns mainly the histopathological factors. The aim of the study was recognition of prognostic factors in oligodendroglioma.

METHODS

In a series of ninety-eight oligodendrogliomas, including twenty mixed oligoastrocytomas, clinical [sex, age at surgery, tumor location, symptoms at presentation], therapeutic [extent of resection, year of surgery, post-operative Karnofsky score, post-operative radiotherapy, post-operative chemotherapy], histological [cell density, nuclear pleomorphism, vascular endothelial proliferation, necrosis, microcysts, mitoses, mitotic index (MI), apoptosis, apoptotic index (AI)] and immunohistochemical parameters [MIB-1 and PCNA Labeling Indexes (LIs), staining for GFAP, positivity for p53] were correlated with survival in uni- and multivariate analysis in order to identify their prognostic significance.

RESULTS

Age at surgery, extent of surgical resection, year of surgery, post-operative Karnofsky score and MIB-1 LI were associated with survival in both uni- and multivariate analysis. Location, symptoms at presentation, mitoses, MI, AI, and PCNA LI showed a significant correlation with survival in uni- but not in multivariate analysis. The twenty cases of oligoastrocytomas did not show any difference in survival from pure oligodendrogliomas.

CONCLUSIONS

Some clinical and therapeutic factors together with MIB-1 LI play a prognostic role. MIB-1 LI is prognostic with a cutoff of 8%. Histology gives a limited contribution to the prognosis. Oligoastrocytomas had the same outcome and prognostic factors as pure oligodendrogliomas.

[Hypokinetic arrhythmia, paradoxical chronotropic reaction and hypotension during dobutamine stress test]

AIM

The aim of this study was to evaluate the incidence of hypokinetic arrhythmias, bradycardiac (BR) and hypotensive reactions in a population of 775 patients during dobutamine stress test (DST): 281 patients (36.2%, group I) were symptomatic for thoracic pain without any history of coronary artery disease (CAD); 494 patients (63.8%, group II) were evaluated 3-4 weeks after an acute myocardial infarction (AMI) to stratify ischemic risk. None of these patients was receiving coronarodilating therapy.

MATERIALS AND METHODS

DST was performed using an infusion of 5, 10, 20, 40 micrograms/kg/min for 5 minutes during the first two stages and for 3 minutes during subsequent stages, and was accompanied by EKG and echocardiographic monitoring. BR was defined as severe when heart rate diminished more than 40 b/min, moderate when the decrease ranged between 20 and 39 b/min, and mild when the decrease was less than 20 b/min.

RESULTS

A total of 34 (4.38%) BR were observed, 19 (55%) in group I and 15 (45%) in group II. BR were severe in 12 patients (35.9%), 3 with recent AMI (2 inferior and 1 anterior) and 9 without a history of CAD. Fifteen (45%) presented moderate BR, 8 with recent AMI (6 inferior and 2 anterior); 7 cases were in group I. Mild BR was observed in 7 patients (20%), 2 with recent AMI (1 inferior, 1 anterior), of which 5 were in group I. Episodes of junctional rhythm were also observed in 10 patients (29.4%) and 1 patient (2.9%) presented 2nd degree AV block during DST positive for ischemia. The mean duration of bradycardic episodes was 89.6 seconds (+/- 29.8) and only 3 patients (8.8%) presented significant hypotension. In 13 patients (38.2%) arrhythmia was observed during dobutamine-induced ischemia. In spite of the often severely diminished heart rate, no significant hypotension was evident during the bradycardiac episode in 19 patients (55%). Only one patient (2.9%) showed a decrease of more than 40 mmHg.

CONCLUSIONS

In conclusion, we found that the incidence of BR during DST (4.38%) is higher than that reported in the literature; moreover, patients with recent inferior AMI showed a higher incidence of BR compared to patients with AMI in other sites (9 vs 4, p = n.s.). We feel that ischemia alone may not be responsible for hypokinetic arrhythmia during DST, but that dobutamine-induced neurovegetative reflexes may also contribute to the pathophysiological mechanisms underlying the phenomenon.

Transcallosal approach to tumors of the third ventricle. Surgical results and neuropsychological evaluation

A series of 34 patients with tumours of the third ventricle were operated on by a transcallosal route. Basal extrinsic lesions compressing or invading the ventricle as well as tumours located in the pineal area were excluded from this review. Tumours were approached by a transforaminal entry in 16 cases (47%), by an interforniceal route in 11 (32%), by a subchoroidal entry in 4 (14%) and by a combined transforaminal and subchoroidal entry in 3 (9%). Four out of 34 patients were submitted to a second operation, through the same approach corridor: 2 for an incomplete removal of an intrinsic tumour and 2 for a late regrowth. Postoperative mortality rate accounted for 5.8% (2 patients). Major post operative complications were hemiparesis (4 patients) and diabetes insipidus (4 patients), that were transient in 3. Akinetic mutism like status was observed in only 1 patient. Postoperative psychic disturbances were noticed in 5 cases. Nine out of 21 patients (62%) with preoperative hydrocephalus required a permanent CSF shunt. Histology revealed that 21 tumours (62%) were intraaxial (4 pilocitic astrocytoma, 10 low grade glioma, 1 giant cell astrocytoma, 1 subependymoma, 4 ependymoma/ependymoblastoma, 1 neurocitoma) and 13 (38%) were extraaxial (8 colloid cyst, 2 craniopharingioma, 1 ectopic pituitary adenoma, 1 lymphocytic hypophysitis and 1 metastasis). Total excision of third ventricle tumours was achieved in all patients with extraaxial tumours and in 62% and 71% of intraaxial tumours with the first and second surgical procedure respectively. Ten out of 34 patients of this series were submitted to a complete neuropsychological evaluation at an interval of 2-9 years after surgery. Memory tests were pathological in 2. Disconnection signs were constantly absent. Control function were preserved. Transcallosal approach remains the best microsurgical method of third ventricle tumours treatment. This route provides the capability for a superior visualization of the entire cavity of the third ventricle through different corridors. Permanent neurological and neuropsychological deficits are not frequent. Epilepsy, that accounted for 28% in patients submitted to transcortical transventricular approach to third ventricle tumours, was never noticed in this series operated on through a transcallosal route.

Functional MRI: primary motor cortex localization in patients with brain tumors

PURPOSE

Our goal was (a) to test the ability of functional MRI (fMRI) to localize the hand primary motor cortex in patients with brain neoplasms using a conventional scanner and (b) to compare within the same subject the location and morphology of the activated motor areas in the affected hemisphere with the contralateral ones.

METHOD

Seventeen right-handed patients with frontoparietal intra- and extraaxial tumors were studied. Hand motor performance ranged from normal to slight impairment of finger dexterity. The fMRI study was based on a series of FLASH images. Two or three contiguous slices parallel to the bicommissural plane were acquired through the level of frontoparietal cortex. Each patient was requested to perform with each hand a finger-tapping task or a simpler repetitive flexion-extension of the last four fingers. Pseudo-color activation maps were then calculated by a Z-score method and superimposed on high resolution images.

RESULTS

Five patients were excluded because of gross motion artifacts. In all other patients, areas of significant signal increase were detected on the precentral gyrus. They had a spot-like appearance, and no substantial side-to-side differences in shape or extension could be observed. In the presence of severe compression of the gyri, a displacement of the activated areas in the affected hemisphere with respect to the contralateral ones was noticeable.

CONCLUSION

fMRI localization of the primary motor area using a conventional scanner can be obtained also in patients with brain tumors, although with a lower success rate than in normal volunteer studies, mainly because of subject compliance problems. Areas of significantly increased signal are detectable even in cortex where normal anatomical patterns are lost.

Long-term outcome in aqueductal stenosis

In this study, 78 patients with aqueductal stenosis were submitted to detailed neurodevelopmental assessment with a follow-up of 5-25 years. Sixty-eight percent of patients were categorized as normal; they either attended normal school courses or had regular jobs. Among these, 34% had some motor abnormalities (ataxia, mild hemiparesis, visual disturbances). Twenty-four percent (19 cases) were moderately disabled (trainable retardation) and 8% (6 cases) were severely handicapped. Epilepsy was observed in 13% of the cases. Incidence of recurrent and generalized seizures paralleled neurodevelopmental outcome (5% in normal, 16% in moderately disabled and 50% in severely disabled patients). Endocrine dysfunctions were evident in 28% of the cases and were characterized by precocious or delayed puberty, amenorrhea and somatic underdevelopment. No patient with ventricular enlargement and a cortical mantle width below 20 mm showed a good outcome. Large ventricles were compatible with normal mental development when compensated with a corresponding cranial vault enlargement. In patients with normal mental status and motor abnormalities, long-term CT scan findings revealed the presence of focal brain abnormalities (poroencephaly, brain atrophy, calcifications, extracerebral collections).

[Primary antiphospholipid syndrome and cardiac involvement. Description of a clinical case of right atrial thrombosis]

Antiphospholipid syndrome is a well-defined clinical and serological entity characterized by venous and arterial thrombosis, recurrent abortion and thrombocytopenia. The immunological feature shows the presence of anticardiolipin antibodies and lupus anticoagulant. Cardiac involvement includes pericardial effusion, myocardial dysfunction, valvular disease, coronary artery occlusion. The literature reports only a few cases of intracardiac thrombosis associated with primary antiphospholipid syndrome. Here we describe a case of a 54 year-old woman with thrombocytopenia and history of recurrent abortions. When she was 51 she presented a left deep iliac venous thrombosis, followed by recurrent pulmonary embolism; a caval filter was placed in the inferior vena cava. Transthoracic and transoesophageal echocardiogram showed 3 masses in the right atrium: the first one was connected with the atrial wall, hyperechogenic and extending to the right ventricle in diastole: th second was connected with the interatrial septum and less echogenic; the third was in connection with septum-tricuspid valve junction and it was floating in the atrium. The immunological feature showed the presence of lupus anticoagulant and antiphospholipid antibodies; the histological examination of the masses, surgically removed, proved they were thrombi coated by endothelial cells. The case reported is very uncommon and offers the opportunity to emphasize the difficulty of diagnostic differentiation of intracardiac masses using echocardiographic imaging: thrombotic masses may present similar characteristics of seat, morphology and echogenicity of other cardiac masses. For these reasons it can be useful to look for antiphospholipid antibodies and lupus anticoagulant in such clinical conditions.

[Infectious endocarditis following artificial insemination. A clinical case report and review of the literature]

We describe a case of infective endocarditis in a 33 year old patient, with mitral valve prolapse (MVP), who underwent nine attempts of artificial insemination with semen by donor. Several blood cultures demonstrated the presence of Enterococcus faecalis; the same agent was identified in some vaginal cultures. Despite antibiotic therapy, infective endocarditis was complicated by severe mitral regurgitation, followed by the rupture of a chorda tendinea. The patient underwent cardiac surgery: valvuloplasty of posterior mitral cusp, chordae tendineae in Goretex and anulus reinforcement with autologous pericardium. MVP is the most common heart disease associated with infective endocarditis in non-drug addict patients (32-54%). The review of the literature did not show any other case of infective endocarditis after artificial insemination procedures. Because of the large spread of these procedures, we think antibiotic prophylaxis of infective endocarditis should be considered in patients with MVP.

Serum cortisol concentration and testosterone to cortisol ratio in elite prepubescent male gymnasts during training

Serum cortisol concentrations and testosterone:cortisol concentration ratios of eight prepubescent elite male gymnasts (mean age 10 years 11 months) and 11 controls (mean age 11 years 1 month) were examined during 5 consecutive training days. During this period, the gymnasts trained 3 h each day with moderate intensity mobility, strength and skill exercises while the controls were relatively sedentary. Blood samples were taken from all the boys in both groups before (1630 hours) and 30 min after (2000 hours) training on 4 days. Serum cortisol concentrations of the gymnasts were not significantly different from those of the controls throughout the experiment. Serum cortisol concentrations of both groups were significantly larger (P < 0.05) at 1630 hours than at 2000 hours, indicating that cortisol secretion followed the typical adult circadian change, seemingly unaltered by training. However, there was a significant decrease (P < 0.05) in the testosterone:cortisol ratio of the gymnasts when compared with controls from day 1 to day 3. After a rest on day 4 the testosterone: cortisol ratio of the gymnasts significantly increased (P < 0.05) but the ratio of the control group also increased indicating that there may have been some day-to-day change by factor(s) other than training. The most obvious factor which may have accounted for the unresponsiveness of serum cortisol concentration to the gymnastics training was that the exercise intensity was too low. However, several days of the training seemed to reduce the anabolic to catabolic balance but further experiments are needed to confirm this finding.

[Neurosurgical aspects of urologic metastases]

Metastases in the central nervous system (C.N.S.) from urological tumors can be spinal or craniocerebral. The experience of 30 patients with spinal and craniocerebral metastases from urological tumors admitted to Neurosurgical Clinic of the University of Milan, is reported. They were 7.5% of the all number of metastases admitted at the Neurosurgical Department, during the same period. The brain metastases constitute 10% of brain metastases diagnosed in this period. Only patients with solitary (to CT scan and NMR) metastasis, and with a general prognosis that allow to an adequate and useful period of survival, are submitted to surgical treatment. 23 patients (76.6%) are surgical treated. The mean survival from the discovery of the C.N.S. metastases was 9 months (9.4 months among surgically treated patients and 7.8 months among those were not operated). Surgical mortality was 13%. Out of patients with survival until 5 months, patients submitted to surgical treatment showed a better quality of life. Our results allow us to affirm that in selected patients surgical removal of solitary metastases, could improve the quality of survival, but is not able to prolong substantially the period of survival.

[A comparison between amiodarone and disopyramide in a delayed-release formulation in the prevention of recurrences of symptomatic atrial fibrillation]

In order to compare the efficacy in preventing recurrencies of symptomatic atrial fibrillation of amiodarone (A.) and slow release disopyramide (D.RET.), 76 consecutive patients with recent onset atrial fibrillation (1 to 24 hrs.) were enrolled. In 20 (26%) conversion to sinus rhythm was obtained by electrical cardioversion, and in 56 (74%) by oral quinidine loading. Forty-one patients (group A) were assigned at random to treatment with D.RET. (250 mg twice daily) and 35 patients (group B) to amiodarone treatment (1200 mg daily for 10 days, and subsequently 200 mg daily). The two groups were similar as to age, sex and cardiac pathology. Patients were followed as to clinical condition, standard and dynamic ECG after one and three months and every three months subsequently for an average of 13.2 months (group A) and 14.1 months (group B). Six group A patients (14%) were excluded from follow-up on account of side effects which arose during the first week of treatment. Crises of symptomatic atrial fibrillation occurred in 20 patients of group A (57%) and in 11 (32%) group patients; this difference is statistically significant (p less than 0.05). Four (10%) group A patients stopped taking the drug due to side effects of an anticholinergic type, and three (8.5%) patients developed hyperthyroidism during follow-up. The authors therefore come to the conclusion that amiodarone is more effective than slow-release disopyramide in preventing recurrencies of atrial fibrillation; besides untoward side effects are less frequent with amiodarone.

Posttraumatic diffuse cerebral lesions. Relationship between clinical course, CT findings and ICP

One hundred and fifty patients with posttraumatic diffuse cerebral lesions were reviewed. Criteria of inclusion were immediate coma and CT appearance of diffuse lesions, that were classified as follows: (a) Diffuse axonal injury (70 cases): patients with normal CT scan (50 cases) and patients with shearing injury (focal hemorrhages in corpus callosum, basal ganglia and brain stem; gliding contusions) (20 cases); (b) Diffuse brain swelling (80 cases): reduced or absent lateral ventricles, absence of 3rd ventricle and basal cisterns. Many of these patients had either subarachnoid haemorrhage or subdural blood effusion. Clinical course and mortality rate were in a ranking order in the considered groups. Patients with normal CT had a less severe coma and a better outcome than patients with shearing injury and diffuse brain swelling. There was evidence of high intracranial pressure in 75% of the patients with brain swelling, whereas no patient with normal CT had ICP elevation. Diffuse axonal injury represents a primary posttraumatic diffuse lesion. Secondary vascular involvement, due to hypoxia, shock and other unknown causes, is responsible for the appearance of vasoparesis, hyperemia and diffuse brain swelling.

Morphology and neurophysiology of focal axonal injury experimentally induced in the guinea pig optic nerve

A new model of focal axonal injury was reproduced by rapid and controlled elongation (uniaxial stretch) of the guinea pig optic nerve. Light microscopy study of optic nerve specimens after horseradish peroxidase injection into the vitreous of the animal's eye showed that axonal lesions were identical to those seen in human and primate post-traumatic diffuse axonal injury (DAI). The lesions were characterized by the formation of terminal clubs in severed axons and focal axonal enlargements in those axons that were lesioned-in-continuity. Visual-evoked potentials upon flash stimulation were recorded before and after injury. Mean amplitude and mean latency of occipital peaks were significantly elongated in the acute post-traumatic phase. Electron microscopy examination showed that the main axonal changes observed in this model were cytoskeleton disorganization, accumulation of axoplasm membrane-bound bodies at the site of terminal balls and dilatations-in-continuity and detachment of the axolemma from the myelin sheath. Such axonal alterations were similar to those found in many other biological models of central and peripheral axonal injuries in which the lesion was produced by invasive methods. This model is unique since it reproduces the same mechanism of injury and the identical lesions that have been demonstrated in humans and primates with post-traumatic (DAI).

[Anesthesia, awareness and wakefulness]

Drugs used in anesthesia do not always produce the expected neurophysiological results. By studying those cases in which the reappearance of intraoperative awareness is most common, an attempt was made to estimate how many and which levels of cerebral function could be identified. Four levels were recognised: awareness with or without memory, and wakefulness with or without dreams. These conditions are related to greater or lesser cortical activity. They can be identified using Tunstall's technique and by carefully interviewing the patient immediately after the operation.

Treatment of intracranial meningiomas in patients over 70 years old

The neurosurgeon often finds himself in the position to having to decide whether or not to operate on an elderly patient suffering from intracranial meningioma. The decision is rarely easy and the results often disappointing. We studied 46 cases of intracranial meningioma in patients over 70 years of age, 34 patients were operated on while 12 patients were not, although both groups were subjected to long term follow-up. The operative mortality rate was 12%, a rate which increased to 20% at 3 months follow-up. Various unfavourable prognostic factors were taken into consideration, the most significant of which were: poor overall clinical condition, peritumoral oedema, the presence of diabetes mellitus and the duration of surgery. A scored grading system was created to standardize surgical indications in elderly patients with cerebral meningioma. An analysis of the grading system, when applied to patients submitted to surgery, showed that the decreased patients within 3 months of surgery had a score which varied from 7 to 12, with a mean score of 10. The surviving patients had a score averaging from 10 to 16 with a mean of 13. The patients with the lowest scores (7-9) had a 100% mortality rate while those in the upper ranges (13-16) demonstrated a mortality rate of 0%. Among the conservatively treated patients the worst outcome was seen in patients with a grading equal to or less than 12.

Neuropsychological outcome of patients operated upon for an intracranial aneurysm: analysis of general prognostic factors and of the effects of the location of the aneurysm

One hundred and fourteen patients operated on for an intracranial aneurysm were followed up in order to investigate their neuropsychological outcome and to detect if there were any clinical features assessed around the time of operation that had prognostic significance. The neuropsychological examination evaluated language, apraxia, memory, intelligence and spatial ability. In the statistical analysis the overall severity of neuropsychological disorder was studied. "Late surgery timing" had a negative influence upon the neuropsychological outcome. There was not a difference between different aneurysm sites. Several patients with an apparently good clinical outcome showed neuropsychological deficits. Neuropsychological assessment is important in the evaluation of outcome after subarachnoid haemorrhage.

Primary intracranial rhabdomyosarcoma: report of two cases

Primary intracranial rhabdomyosarcoma (RMS) is a rare tumor in infancy and childhood that is found in various locations in the central nervous system. The clinical course worsens rapidly, and the final outcome is poor, with a median survival time of 8-10 months. Invasion of the meninges, spontaneous intratumoral bleeding, spinal leptomeningeal CSF spreading of tumor cells, and early recurrence of the mass are the distinctive features of RMS. Diagnosis of RMS may be missed: immunohistochemical staining using specific markers (myoglobin, myosin, desmin, vimentin, enolase), along with ultrastructural studies, provide the basis for making the final diagnosis. Treatment of RMS includes surgical excision, craniospinal radiation therapy, and chemotherapy. We report two cases of primary RMS in the CNS located in the posterior fossa and frontotemporal area. Both children underwent total surgical removal of the mass. Early recurrence of the tumor mass was noticed in both patients 2 months after surgery. Both children died shortly thereafter.

[Diffuse traumatic cerebral injuries in children]

A consecutive series of 41 patients aged less than 16 and admitted to the Department of Neurosurgery of the University of Milan in the period 1977-1978 following serious cranioencephalic trauma with Glasgow Coma Score (GCS) less than or equal to 7, duration of coma longer than 24 h and CT picture of diffuse lesion has been examined. These patients account for 5% of the paediatric cranial traumas observed in the same period and 66% of those in a state of coma. The CT picture made it possible to split patients into 3 groups: a) those without visible cerebral lesions and with subarachnoid and cisternal spaces present; b) those with small hyperdense lesions due to intraparenchymal or median/paramedian subcortical shearing lesions; c) those with marked constriction or absence of the 3rd ventricle and of the perimesencephalic cisterns. The first two pictures (a, b) were considered to be the expression of diffuse axonal damage, the last (c) of diffuse cerebral swelling. Intracranial pressure was monitored in about 50% of patients. The overall outcome of the series was favourable in more than 68% of cases with total mortality of 26.8%. Analysis of individual tomographic categories, however, showed that whereas the group of patients with diffuse axonal lesion presented nil mortality, those with diffuse cerebral swelling had 52% mortality owing to the onset of refractory intracranial hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

Monitoring of brain function by means of evoked potentials in cerebral aneurysm surgery

Deliberate arterial hypotension is currently used to operate upon cerebral aneurysms. However, it is not ascertained whether this practice is really safe for all patients, especially those presenting with preoperative vasospasm. 50 patients, requiring surgical treatment for cerebral aneurysm, have been submitted, during surgery, to the recording of Somatosensory Evoked Potentials (SEPs) on median nerve stimulation. This technique allows the functional evaluation of neural pathways mediating the somatosensory stimuli and of primary somatosensory cortex; it is known that a decrease of cerebral perfusion may affect the SEP waveforms in terms of reduced subcortical conduction velocity (i.e., increased central conduction time, CCT) and of reduced cortical response amplitude. These changes may be apparent before a permanent neurological damage is produced. Preoperative SEP recording demonstrated a prolonged CCT, possibly related to vasospasm, in 9 patients, a normal clinical evaluation notwithstanding (grade I and II). During intraoperative deliberate hypotension, a SEP change has always been produced. No postoperative damage has been observed, however, as long as the CCT did not exceed 9 msec for 10 minutes (maximum normal CCT value is 6.7 msec) and as the cortical response had been visible throughout the whole surgical procedure. The critical value of CCT has been reached at a mean arterial pressure (MAP) lower than 60 Torr in patients with a normal preoperative SEP recording; at the opposite, in patients presenting with a prolonged preoperative CCT, the value of 9 msec was arrived at with a MAP value that is generally accepted as safe for all patients (75 Torr).(ABSTRACT TRUNCATED AT 250 WORDS)

Pattern reversal visual evoked potentials in phenylketonuria

The pathogenesis of brain dysfunction in phenylketonuria (PKU) is still under investigation. Hyperphenylalaninaemia results in increased turnover of myelin. In order to demonstrate the derangement of myelinization in PKU we studied the visual evoked potentials (VEP) in 14 PKU patients and in 20 normal subjects. VEP findings were correlated with the metabolic control of the disease and with the electroencephalographic findings. VEP were more sensitive than the EEG in detecting a neurological dysfunction. VEP are influenced by dietary control and are normal only in children with good metabolic control.

Solitary plasmacytoma of the calvarium: two cases treated by operation alone

Two cases of solitary plasmacytoma of the calvarium operated on with radical removal are reported. The two patients were not submitted to postoperative radiotherapy, unlike other cases reported in the literature. The authors stress that solitary plasmacytoma of the calvarium may have a good prognosis if radically removed, and in these cases radiotherapy is not necessary.

Pattern-reversal visual evoked potentials in phenylketonuric children

Pattern-reversal visual evoked potentials (PR-VEPs) and EEG were recorded in 14 phenylketonuric (PKU) children on a low-phenylalanine (phe) diet; the data obtained were correlated with metabolic parameters, namely, the actual phe plasma level, the mean phe plasma level in the last year, an the beginning of the diet. PR-VEPs seem to be more sensitive than EEG in detecting neurophysiological derangements in these subjects; in fact PR-VEPs were pathological in six patients while EEG detected three; no significant alterations were found in the neurophysiological tests among the children with good metabolic control, and only one child was abnormal among the six on an early dietetic regimen; in contrast, six of the nine subjects presenting with high mean phe plasma levels (greater than 10 mg/100 ml) and five of the eight whose diet started after the 2nd month of life showed pathological PR-VEPs.

Acute spontaneous subdural hematomas

Fifteen cases of spontaneous subdural hematoma are presented. A review of the literature reveals the rarity of this pathology. Symptomatological onset cannot be distinguished from the other cerebrovascular lesions. High mortality is connected with patient's consciousness level. CT scan performed in all patients presenting symptoms of cerebral stroke permitted to demonstrate this clinical entity is not so rare as the literature asserted.

[Right cardiac echinococcosis with coronary compression. Description of a clinical case]

An outstanding case of cardiac echinococcosis is described. Clinical symptomatology was characterized by typical nitroglycerin-responsive crisis of angina pectoris associated to an electrocardiographic pattern of negative T wave on anterolateral and inferior leads. The diagnosis was suspected on the basis of thoracic computerized tomography and coronary arteriography. The anatomical localization was mainly pericardial but the right ventricle was involved too. Left anterior descending artery was dislocated and squeezed.

Acute bilateral epidural hematomas. Report of two cases and review of the literature

Two cases of acute postraumatic bilateral epidural hematomas with different clinical pictures are presented. In the review of the literature, acute, subacute and delayed bilateral epidural hematomas must be found. Clinical findings, results of CT scan and pathophysiology are discussed.

Evaluation of brainstem function, using acoustic evoked potentials, in 26 patients harbouring a CSF shunt for non-tumoral aqueductal stenosis hydrocephalus

26 patients harbouring a CSF shunt for non-tumoral aqueductal stenosis hydrocephalus underwent Brainstem Acoustic Evoked Potentials (BAEPs) recording, to evaluate brainstem function. Only 6 patients presented with normal responses both at standard and at sensitized tests. In the remaining 19 patients, BAEPs were abnormal, bilaterally in 10 cases, monolaterally in 9. Four out of the 6 normal responses belonged to the group recognized of congenital origin. As refers to ventricular size BAEPs were abnormal in 62% of patients with normal ventricle and in 92% of patients with enlarged ventricles. The most significant BAEPs abnormalities were found in patients with maximal ventricular dilation. It appears that BAEPs abnormalities are to the ascribed to both primary and secondary brainstem dysfunction: no reliable criterion to differentiate between these two possibilities is evident. In the individual patient, serial BAEPs recording may contribute to recognize the early phase of supratentorial hypertension due to shunt dysfunction.

Changes in visual evoked potentials in children on chronic dialysis treatment

Visual evoked potentials (VEP) were recorded in 20 children undergoing dialysis for chronic renal failure. VEP before treatment (72 h after last dialysis) were pathological in 17 patients (85%); responses obtained 3 h after treatment were abnormal in only 6 cases (30%). Furthermore, all patients improved after treatment, except two who were unchanged. However, VEP recorded immediately after dialysis were worse in 4 of 7 patients than before treatment, probably as an effect of the dysequilibrium syndrome; they improved spontaneously afterwards. The acute changes caused by dialysis seem to be more evident in children than in adults. No correlations have been found between blood chemistry indexes and VEP modifications. Finally, VEP have proved to be more sensitive than EEG in identifying a central nervous system (CNS) dysfunction in these uremic patients.