Recommendations for the management of biofilm: a consensus document.

The potential impact of biofilm on healing in acute and chronic wounds is one of the most controversial current issues in wound care. A significant amount of laboratory-based research has been carried out on this topic, however, in 2013 the European Wound Management Association (EWMA) pointed out the lack of guidance for managing biofilms in clinical practice and solicited the need for guidelines and further clinical research. In response to this challenge, the Italian Nursing Wound Healing Society (AISLeC) initiated a project which aimed to achieve consensus among a multidisciplinary and multiprofessional international panel of experts to identify what could be considered part of 'good clinical practice' with respect to the recognition and management of biofilms in acute and chronic wounds. The group followed a systematic approach, developed by the GRADE working group, to define relevant questions and clinical recommendations raised in clinical practice. An independent librarian retrieved and screened approximately 2000 pertinent published papers to produce tables of levels of evidence. After a smaller focus group had a multistep structured discussion, and a formal voting process had been completed, ten therapeutic interventions were identified as being strongly recommendable for clinical practice, while another four recommendations were graded as being 'weak'. The panel subsequently formulated a preliminary statement (although with a weak grade of agreement): 'provided that other causes that prevent optimal wound healing have been ruled out, chronic wounds are chronically infected'. All members of the panel agreed that there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence. In the meantime it was agreed that expert-based guidelines were needed to be developed for the recognition and management of biofilms in wounds and for the best design of future clinical trials. This is a fundamental and urgent task for both laboratory-based scientists and clinicians.

A bioinspired autonomous swimming robot as a tool for studying goal-directed locomotion.

The bioinspired approach has been key in combining the disciplines of robotics with neuroscience in an effective and promising fashion. Indeed, certain aspects in the field of neuroscience, such as goal-directed locomotion and behaviour selection, can be validated through robotic artefacts. In particular, swimming is a functionally important behaviour where neuromuscular structures, neural control architecture and operation can be replicated artificially following models from biology and neuroscience. In this article, we present a biomimetic system inspired by the lamprey, an early vertebrate that locomotes using anguilliform swimming. The artefact possesses extra- and proprioceptive sensory receptors, muscle-like actuation, distributed embedded control and a vision system. Experiments on optimised swimming and on goal-directed locomotion are reported, as well as the assessment of the performance of the system, which shows high energy efficiency and adaptive behaviour. While the focus is on providing a robotic platform for testing biological models, the reported system can also be of major relevance for the development of engineering system applications.

Duodenal levodopa infusion improves quality of life in advanced Parkinson's disease.

BACKGROUND: A significant percentage of patients with Parkinson's disease (PD) continue to experience motor fluctuations and dyskinesias despite the association of dopamine agonists and levodopa with COMT or MAO-B inhibitors. The use of apomorphine infusion is limited by compliance while deep brain stimulation is feasible only for a small number of patients mostly because of age constraints. OBJECTIVE: To assess prospectively the effectiveness of duodenal levodopa infusion on quality of life as well as motor features in patients with advanced PD. In all but 1 case levodopa infusion was stopped at nighttime. METHODS: We report the outcome of 22 PD patients, followed for up to 2 years, who were on continuous duodenal levodopa/carbidopa infusion through percutaneous endoscopic gastrostomy. RESULTS: We found a significant reduction in 'off' period duration as well as dyskinesia severity (Unified Parkinson's Disease Rating Scale part IV, items 33 and 39). There was significant improvement in the 39-item Parkinson's Disease Quality of Life Questionnaire as well as in the Unified Parkinson's Disease Rating Scale part II up to the 2-year follow-up. Five patients withdrew: 2 for poor compliance and 3 for adverse events (1 was related to percutaneous endoscopic gastrostomy). CONCLUSIONS: These results demonstrate significant clinical improvements in quality of life and activities of daily living consistent with the occurrence of a satisfactory therapeutic response and a reduction in dyskinesia severity.

Myostatin promotes distinct responses on protein metabolism of skeletal and cardiac muscle fibers of rodents.

Myostatin is a novel negative regulator of skeletal muscle mass. Myostatin expression is also found in heart in a much less extent, but it can be upregulated in pathological conditions, such as heart failure. Myostatin may be involved in inhibiting protein synthesis and/or increasing protein degradation in skeletal and cardiac muscles. Herein, we used cell cultures and isolated muscles from rats to determine protein degradation and synthesis. Muscles incubated with myostatin exhibited an increase in proteolysis with an increase of Atrogin-1, MuRF1 and LC3 genes. Extensor digitorum longus muscles and C2C12 myotubes exhibited a reduction in protein turnover. Cardiomyocytes showed an increase in proteolysis by activating autophagy and the ubiquitin proteasome system, and a decrease in protein synthesis by decreasing P70S6K. The effect of myostatin on protein metabolism is related to fiber type composition, which may be associated to the extent of atrophy mediated effect of myostatin on muscle.

Adrenodemedullation activates the Ca2+-dependent proteolysis in soleus muscles from rats exposed to cold.

Previous studies have shown that catecholamines in vivo and in vitro inhibit the activity of Ca2+-dependent proteolysis in skeletal muscles under basal conditions. In the present study we sought to investigate the role of catecholamines in regulating the Ca2+-dependent proteolysis in soleus and extensor digitorum longus (EDL) muscles from rats acutely exposed to cold. Overall proteolysis, the activity of proteolytic systems, protein levels and gene expression of different components of the calpain system were investigated in rats submitted to adrenodemedullation (ADMX) and exposed to cold for 24 h. ADMX drastically reduced plasma epinephrine and promoted an additional increase in the overall proteolysis, which was already increased by cold exposure. The rise in the rate of protein degradation in soleus muscles from adrenodemedullated cold-exposed rats was caused by the high activity of the Ca2+-dependent proteolysis, which was associated with the generation of a 145-kDa cleaved α-fodrin fragment, a typical calpain substrate, and lower protein levels and mRNA expression of calpastatin, the endogenous calpain inhibitor. Unlike that observed for soleus muscles, the cold-induced muscle proteolysis in EDL was not affected by ADMX. In isolated soleus muscle, clenbuterol, a selective ß2-adrenoceptor agonist, reduced the basal Ca2+-dependent proteolysis and completely abolished the activation of this pathway by the cholinergic agonist carbachol. These data suggest that catecholamines released from the adrenal medulla inhibit cold-induced protein breakdown in soleus, and this antiproteolytic effect on the Ca2+-dependent proteolytic system is apparently mediated through expression of calpastatin, which leads to suppression of calpain activation.NEW & NOTEWORTHY Although many effects of the sympathetic nervous system on muscle physiology are known, the role of catecholamines in skeletal muscle protein metabolism has been scarcely studied. We suggest that catecholamines released from adrenal medulla may be of particular importance for restraining the activation of the Ca2+-dependent proteolysis in soleus muscles during acute cold exposure. This finding helps us to understand the adaptive changes that occur in skeletal muscle protein metabolism during cold stress.

Pycnodysostosis presenting as atypical stridor.

OBJECTIVES: Pycnodysostosis is a rare genetic disorder caused by a mutation of the cathepsin K gene involved in bone turnover. It is responsible, in particular, for a combination of dwarfism and bone fragility. Upper airway obstruction may be observed, but associated stridor has never been previously described. MATERIALS AND METHODS: Single-centre retrospective study over a period of 15 years with review of the literature. RESULTS: Three children (aged 2-18 months) were managed for stridor and obstructive sleep apnoea syndrome confirmed by polysomnography. Physical examination of these children revealed stridor with laryngomalacia, characteristic dysmorphic features and failure to thrive. Patient 1 presented typical laryngomalacia treated by surgical section of the aryepiglottic folds. Patient 2 presented upper airway obstruction with a narrow nasopharynx and long soft palate, treated by surgery and noninvasive ventilation. Patient 3 presented moderate laryngomalacia and nasal obstruction, treated by surgery and noninvasive ventilation. CONCLUSION: The diagnosis of pycnodysostosis must be considered in the presence of atypical laryngomalacia associated with multifactorial upper airway obstruction, failure to thrive and dysmorphic syndrome. A genetics consultation is essential in these patients.

MRI deep white matter hyperintensity in a psychiatric population.

The authors evaluated magnetic resonance imaging (MRI) of deep white matter hyperintensity (DWMH) in 90 adult psychiatric inpatients in whom MRIs were clinically indicated and 25 age-matched, medically healthy controls. Forty-two percent of the psychiatric patients and 12% of the controls had evidence of DWMH on MRI. Both incidence and severity of DWMH were significantly correlated with age in both groups. Even after controlling for age in the psychiatric population, DWMH was significantly associated with hypertension, history of myocardial infarction or angina, abnormal electrocardiogram, and abnormal neurological examinations.

Increased cortical inhibition induced by apomorphine in patients with Parkinson's disease.

The electromyographic silent period following the motor potential evoked by cortical magnetic stimulation is decreased in parkinsonian patients. In this study we investigated whether the decrease in the silent period is connected only with parkinsonian symptoms. We evaluated the effect of apomorphine (a potent and rapid dopamine-agonist) on the changes in the peripheral and central silent period in 29 patients with Parkinson's disease and in two patients affected by multisystem atrophy (MSA). Apomorphine injection was found to induce a significant improvement in the central silent period in parkinsonian patients but not in the MSA patients, suggesting a relation between the clinical parkinsonian symptoms (akinesia and rigidity) and the silent period duration. The central silent period changes after apomorphine injection could be used as an adjunctive, safe and effective diagnostic tool to assess dopamine responsiveness of parkinsonian syndromes.

Cessation of cocaine use during pregnancy: a preliminary comparison.

This preliminary study examined differences between cocaine-dependent pregnant women who received "baseline" drug treatment (N = 13) and those requiring additional "intensive" treatment (N = 9). Baseline drug treatment consisted of weekly individual counseling sessions. Intensive treatment, in the form of contingency management procedures, was added for patients who showed no reduction in cocaine use during the first 4 weeks of treatment. There were no differences between the two groups in terms of demographic and pregnancy characteristics or history of cocaine use. Significantly more patients in the baseline treatment group were cocaine-free at intake and had a higher rate of compliance with scheduled prenatal clinical visits. These findings may indicate a decision to cease cocaine use prior to entering treatment, and a high degree of motivation to remain drug-free. Despite the small sample size, the finding that a substantial proportion of cocaine-dependent pregnant women remain cocaine-free during treatment is encouraging.

Combined use of interferon alpha-2, chlorambucil and prednisone in previously treated patients with low-grade non-Hodgkin's lymphomas. Results of a phase II study.

AIMS AND BACKGROUND: To investigate therapeutic activity and safety of alpha-interferon (alpha-IFN) in combination with chlorambucil (CLB) and prednisone (PDN), we treated 9 low-grade non-Hodgkin lymphoma patients with clinical evidence of relapsed (5 cases) or resistant (4 cases) disease with such an association. METHODS: In all instances, treatment consisted of alpha-2a IFN administered by subcutaneous route thrice weekly for 3 weeks, CLB, 5 mg/day for 21 days, and PDN, 30 mg three times a week for 3 weeks. Cycles were repeated every 28 days. RESULTS: A well-documented clinical response was observed in 6 (4 CRs+2 PRs) of 9 patients. Interestingly, 3 of 4 CRs were achieved in patients with histologically proven bone marrow involvement. Median duration of response was 18.5 months (range, 4-29 months). Myelosuppression was a common side effect. Two patients experienced grade 3 hematologic toxicity which did not preclude continuation of therapy. CONCLUSIONS: As new purine analogues are not currently available, the combination of alpha-IFN, CLB, and PDN may represent, in our opinion, a valid therapy for patients not eligible for aggressive therapy such as autologous bone marrow transplantation.

[Drug-resistant epilepsy treated with ketogenic diet]. / Epilessia farmaco-resistente trattata con dieta chetogenica.

A 4-year old girl affected by intractable seizures was treated with ketogenic diet. The diet was calculated to provide appropriate protein intake for growth (1.4 g/kg body weight) and adequate calories (1600 kcal) derived from 4 parts fat and 1 part protein + carbohydrates. The child remained on the diet for 8 months and had a decrease in seizure frequency of 90%. No serious side effects were reported and it was possible to discontinue or decrease antiepileptic drugs. Our results confirm the efficacy of ketogenic diet in the treatment of epilepsy. Since it is known that 20 to 30% of all patients with epilepsy do not have their seizures completely controlled with established antiepileptic drugs, it would be useful to increase the application of this dietetic treatment in selected patients in Italy as it already happens in other countries.

Prevalence and features of peripheral neuropathy in Parkinson's disease patients under different therapeutic regimens.

BACKGROUND: Recent reports suggest increased frequency of peripheral neuropathy (PN) in Parkinson's disease (PD) patients on levodopa compared with age-matched controls particularly during continuous levodopa delivery by intestinal infusion (CLDII). The aim of this study is to compare frequency, clinical features, and outcome of PN in PD patients undergoing different therapeutic regimens. METHODS: Three groups of consecutive PD patients, 50 on intestinal levodopa (CLDII), 50 on oral levodopa (O-LD) and 50 on other dopaminergic treatment (ODT), were enrolled in this study to assess frequency of PN using clinical and neurophysiological parameters. A biochemical study of all PN patients was performed. RESULTS: Frequency of PN of no evident cause was 28% in CLDII, 20% in O-LD, and 6% in ODT patients. Clinically, 71% of CLDII patients and all O-LD and ODT PN patients displayed a subacute sensory PN. In contrast, 29% of CLDII patients presented acute motor PN. Levodopa daily dose, vitamin B12 (VB12) and homocysteine (hcy) levels differed significantly in patients with PN compared to patients without PN. CONCLUSIONS: Our findings support the relationship between levodopa and PN and confirm that an imbalance in VB12/hcy may be a key pathogenic factor. We suggest two different, possibly overlapping mechanisms of PN in patients on CDLII: axonal degeneration due to vitamin deficiency and inflammatory damage. Whether inflammatory damage is triggered by vitamin deficiency and/or by modifications in the intestinal micro-environment should be further explored. Proper vitamin supplementation may prevent peripheral damage in most cases.

Effect of short-term cold exposure on skeletal muscle protein breakdown in rats.

Although it is well established that carbohydrate and lipid metabolism are profoundly altered by cold stress, the effects of short-term cold exposure on protein metabolism in skeletal muscle are still poorly understood. Because cold acclimation requires that an organism adjust its metabolic flux, and muscle amino acids may be an important energy source for heat production, we hypothesize that muscle proteolysis is increased and protein synthesis is decreased under such a stress condition. Herein, cold exposure for 24 h decreased rates of protein synthesis and increased overall proteolysis in both soleus and extensor digitorum longus (EDL) muscles, but it did not affect muscle weight. An increase in proteolysis was accompanied by hyperactivity of the ubiquitin-proteasome system (UPS) in both soleus and EDL, and Ca(2+)-dependent proteolysis in EDL. Furthermore, muscles of rats exposed to cold showed increased mRNA and protein levels of atrogin-1 and muscle RING finger enzyme-1 (MuRF1). Additionally, cold stress reduced phosphorylation of Akt and Forkhead box class O1 (FoxO1), a well-known effect that increases FoxO translocation to the nucleus and leads to activation of proteolysis. Plasma insulin levels were lower, whereas catecholamines, corticosterone, and thyroid hormones were higher in cold-exposed rats compared with control rats. The present data provide the first direct evidence that short-term cold exposure for 24 h decreases rates of protein synthesis and increases the UPS and Ca(2+)-dependent proteolytic processes, and increases expression of atrogin-1 and MuRF1 in skeletal muscles of young rats. The activation of atrophy induced by acute cold stress seems to be mediated at least in part through the inactivation of Akt/FoxO signaling and activation of AMP-activated protein kinase.

Behavioral demonstration of a somatosensory neuroprosthesis.

Tactile sensation is critical for effective object manipulation, but current prosthetic upper limbs make no provision for delivering somesthetic feedback to the user. For individuals who require use of prosthetic limbs, this lack of feedback transforms a mundane task into one that requires extreme concentration and effort. Although vibrotactile motors and sensory substitution devices can be used to convey gross sensations, a direct neural interface is required to provide detailed and intuitive sensory feedback. In light of this, we describe the implementation of a somatosensory prosthesis with which we elicit, through intracortical microstimulation (ICMS), percepts whose magnitude is graded according to the force exerted on the prosthetic finger. Specifically, the prosthesis consists of a sensorized finger, the force output of which is converted into a regime of ICMS delivered to primary somatosensory cortex through chronically implanted multi-electrode arrays. We show that the performance of animals (Rhesus macaques) on a tactile task is equivalent whether stimuli are delivered to the native finger or to the prosthetic finger.

A novel autonomous, bioinspired swimming robot developed by neuroscientists and bioengineers.

This paper describes the development of a new biorobotic platform inspired by the lamprey. Design, fabrication and implemented control are all based on biomechanical and neuroscientific findings on this eel-like fish. The lamprey model has been extensively studied and characterized in recent years because it possesses all basic functions and control mechanisms of higher vertebrates, while at the same time having fewer neurons and simplified neural structures. The untethered robot has a flexible body driven by compliant actuators with proprioceptive feedback. It also has binocular vision for vision-based navigation. The platform has been successfully and extensively experimentally tested in aquatic environments, has high energy efficiency and is ready to be used as investigation tool for high level motor tasks.