Psychopharmacological treatment in borderline personality disorder: A pilot observational study in a real-world setting.

Psychotherapy is the cornerstone of treatment for borderline personality disorder (BPD) while pharmacotherapy should be considered only as an adjunctive intervention. In clinical practice, however, most of BPD patients only receive medication. The aim of the study is to first describe pharmacological treatment in BPD patients in Italy and secondly to evaluate if comorbidity or illness severity are associated with the prescription of different class compounds. Data on pharmacological treatment and clinical evaluation of 75 BPD patients were collected in 5 clinical settings. The association between comorbidity and medication was assessed. Moreover, we evaluated the association between pharmacotherapy and severity, defined by a cluster analysis aimed at detecting different groups of patients. Most of the participants (82.7%) were characterized by polypharmacy, with a mean of 2.4 medications per person. Interestingly, the prescription didn't seem to depend on/be based on the severity of the disorder and was only partially determined by the presence of comorbidity. In conclusion, our findings are similar to what described in other clinical studies, supporting the idea that medication management for BPD is only partially coherent with international guidelines. This pilot study confirms the need for more rigorous studies to gain greater understanding of this topic and diminish the gap between guidelines and the real clinical world.

Parental evaluation of a telemonitoring service for children with Type 1 Diabetes.

Introduction In the past years, we developed a telemonitoring service for young patients affected by Type 1 Diabetes. The service provides data to the clinical staff and offers an important tool to the parents, that are able to oversee in real time their children. The aim of this work was to analyze the parents' perceived usefulness of the service. Methods The service was tested by the parents of 31 children enrolled in a seven-day clinical trial during a summer camp. To study the parents' perception we proposed and analyzed two questionnaires. A baseline questionnaire focused on the daily management and implications of their children's diabetes, while a post-study one measured the perceived benefits of telemonitoring. Questionnaires also included free text comment spaces. Results Analysis of the baseline questionnaires underlined the parents' suffering and fatigue: 51% of total responses showed a negative tendency and the mean value of the perceived quality of life was 64.13 in a 0-100 scale. In the post-study questionnaires about half of the parents believed in a possible improvement adopting telemonitoring. Moreover, the foreseen improvement in quality of life was significant, increasing from 64.13 to 78.39 ( p-value = 0.0001). The analysis of free text comments highlighted an improvement in mood, and parents' commitment was also proved by their willingness to pay for the service (median = 200 euro/year). Discussion A high number of parents appreciated the telemonitoring service and were confident that it could improve communication with physicians as well as the family's own peace of mind.

Psychological outcomes of evening and night closed-loop insulin delivery under free living conditions in people with Type 1 diabetes: a 2-month randomized crossover trial.

AIM: To assess the impact on fear of hypoglycaemia and treatment satisfaction with an artificial pancreas system used for 2 consecutive months, as well as participant acceptance of the artificial pancreas system. METHODS: In a randomized crossover trial patient-related outcomes associated with an evening-and-night artificial pancreas and sensor-augmented pump therapy were compared. Both intervention periods lasted 8 weeks. The artificial pancreas acceptance questionnaire (range 0-90, higher scores better), Hypoglycaemia Fear Survey II (range 0-72, higher scores worse) and Diabetes Treatment Satisfaction Questionnaire (range 0-36, higher scores better) were completed by 32 participants. Semi-structured interviews were conducted after study completion in a subset of six participants. Outcomes were compared using a repeated-measures anova model or paired t-test when appropriate. RESULTS: The total artificial pancreas acceptance questionnaire score at the end of the artificial pancreas period was 69.1 (sd 14.7; 95% CI 63.5, 74.7), indicating a positive attitude towards the artificial pancreas. No significant differences were found among the scores at baseline, end of sensor-augmented pump therapy period or end of the artificial pancreas period with regard to fear of hypoglycaemia [28.2 (sd 17.5), 23.5 (sd 16.6) and 23.5 (sd 16.7), respectively; P = 0.099] or diabetes treatment satisfaction [29.0 (sd 3.9), 28.2 (sd 5.2) and 28.0 (sd 7.1), respectively; P = 0.43]. Themes frequently mentioned in the interviews were 'positive effects at work', 'improved blood glucose', 'fewer worries about blood glucose', but also 'frequent alarms', 'technological issues' and 'demand for an all-in-one device'. CONCLUSIONS: The psychological outcomes of artificial pancreas and sensor-augmented pump therapy were similar. Current artificial pancreas technology is promising but user concerns should be taken into account to ensure utility of these systems.

Abnormalities in cortical gray matter density in borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a chronic condition with a strong impact on patients' affective, cognitive and social functioning. Neuroimaging techniques offer invaluable tools to understand the biological substrate of the disease. We aimed to investigate gray matter alterations over the whole cortex in a group of Borderline Personality Disorder (BPD) patients compared to healthy controls (HC). METHODS: Magnetic resonance-based cortical pattern matching was used to assess cortical gray matter density (GMD) in 26 BPD patients and in their age- and sex-matched HC (age: 38 ± 11; females: 16, 61%). RESULTS: BPD patients showed widespread lower cortical GMD compared to HC (4% difference) with peaks of lower density located in the dorsal frontal cortex, in the orbitofrontal cortex, the anterior and posterior cingulate, the right parietal lobe, the temporal lobe (medial temporal cortex and fusiform gyrus) and in the visual cortex (P<0.005). Our BPD subjects displayed a symmetric distribution of anomalies in the dorsal aspect of the cortical mantle, but a wider involvement of the left hemisphere in the mesial aspect in terms of lower density. A few restricted regions of higher density were detected in the right hemisphere. All regions remained significant after correction for multiple comparisons via permutation testing. CONCLUSIONS: BPD patients feature specific morphology of the cerebral structures involved in cognitive and emotional processing and social cognition/mentalization, consistent with clinical and functional data.

Multicenter outpatient dinner/overnight reduction of hypoglycemia and increased time of glucose in target with a wearable artificial pancreas using modular model predictive control in adults with type 1 diabetes.

AIMS: To test in an outpatient setting the safety and efficacy of continuous subcutaneous insulin infusion (CSII) driven by a modular model predictive control (MMPC) algorithm informed by continuous glucose monitoring (CGM) measurement. METHODS: 13 patients affected by type 1 diabetes participated to a non-randomized outpatient 42-h experiment that included two evening meals and overnight periods (in short, dinner & night periods). CSII was patient-driven during dinner & night period 1 and MMPC-driven during dinner&night period 2. The study was conducted in hotels, where patients could move around freely. A CGM system (G4 Platinum; Dexcom Inc., San Diego, CA, USA) and insulin pump (AccuChek Combo; Roche Diagnostics, Mannheim, Germany) were connected wirelessly to a smartphone-based platform (DiAs, Diabetes Assistant; University of Virginia, Charlottesville, VA, USA) during both periods. RESULTS: A significantly lower percentage of time spent with glucose levels <3.9 mmol/l was achieved in period 2 compared with period 1: 1.96 ± 4.56% vs 12.76 ± 15.84% (mean ± standard deviation, p < 0.01), together with a greater percentage of time spent in the 3.9-10 mmol/l target range: 83.56 ± 14.02% vs 62.43 ± 29.03% (p = 0.04). In addition, restricting the analysis to the overnight phases, a lower percentage of time spent with glucose levels <3.9 mmol/l (1.92 ± 4.89% vs 12.7 ± 19.75%; p = 0.03) was combined with a greater percentage of time spent in 3.9-10 mmol/l target range in period 2 compared with period 1 (92.16 ± 8.03% vs 63.97 ± 2.73%; p = 0.01). Average glucose levels were similar during both periods. CONCLUSIONS: The results suggest that MMPC managed by a wearable system is safe and effective during evening meal and overnight. Its sustained use during this period is currently being tested in an ongoing randomized 2-month study.

Risk of perioperative seizures in patients undergoing craniotomy with intraoperative brain mapping.

BACKGROUND: The identification of risk factors associated with perioperative seizures would be of great benefit to the anesthesiologist in managing brain tumor patients undergoing craniotomy with intraoperative brain mapping. METHODS: A series of 316 supratentorial craniotomies for tumor resection, in which intraoperative brain mapping was used, were analyzed. From January 2005 to December 2010 the occurrence of intraoperative and immediate postoperative clinical seizures was prospectively recorded into a database. Demographic data, tumor characteristics, preoperative seizure control, intraoperative events and anesthetic management were evaluated as risk factors for intraoperative clinical seizures. Additionally, the association between intraoperative clinical seizures and immediate postoperative seizures was evaluated. In order to determine the best predictors of intraoperative and immediate postoperative clinical seizures, a multivariable analysis by logistic regression was performed. RESULTS: Younger age, location of the tumor in the frontal and parietal lobe, brain mapping conducted under general anesthesia and non physiologic values of arterial carbon dioxide (PaCO2) during brain mapping were independent positive risk factors for the development of intraoperative clinical seizures. Location of tumor in the frontal lobe, antiepileptic polytherapy, intraoperative seizures requiring pharmacologic treatment during brain mapping, and blood on postoperative CT scan were independent positive risk factors for the development of immediate postoperative seizures. CONCLUSION: Clinical seizures are common intraoperative and postoperative complications of supratentorial craniotomies with intraoperative brain mapping. The identification of those patients at higher risk of seizures may guide intraoperative and postoperative medical management.

Drug dose as mediator of treatment effect in antidepressant drug trials: the case of fluoxetine.

OBJECTIVE: This study aimed at investigating whether dose is a mediator of treatment effect in fluoxetine-randomized trials. Specifically, we investigated whether dose was higher in trials in which the aim was to demonstrate fluoxetine efficacy in comparison with older antidepressants and lower in trials in which the aim was to demonstrate a new drug's efficacy against fluoxetine. METHOD: We applied the model developed by Baron and Kenny to investigate the mediational role of drug dose on treatment effect. We included all randomized controlled trials comparing fluoxetine with other antidepressants as monotherapy in the acute-phase treatment of unipolar major depression. RESULTS: A total of 173 studies were included. In 76 comparisons (44%), fluoxetine was the experimental antidepressant. A metaregression analysis indicated that after adjusting for possible confounders, studies where fluoxetine was the experimental agent were associated with a significant advantage for fluoxetine. However, the Baron and Kenny model revealed no mediational role of drug dose in influencing treatment effect. CONCLUSION: The outcome of fluoxetine-randomized trials changed according to whether this drug was used as a new compound or as a reference. This finding cannot be attributed to antidepressants dose, as dose failed to emerge as mediator of treatment effect in the Baron and Kenny approach.

Modular closed-loop control of diabetes.

Modularity plays a key role in many engineering systems, allowing for plug-and-play integration of components, enhancing flexibility and adaptability, and facilitating standardization. In the control of diabetes, i.e., the so-called "artificial pancreas," modularity allows for the step-wise introduction of (and regulatory approval for) algorithmic components, starting with subsystems for assured patient safety and followed by higher layer components that serve to modify the patient's basal rate in real time. In this paper, we introduce a three-layer modular architecture for the control of diabetes, consisting in a sensor/pump interface module (IM), a continuous safety module (CSM), and a real-time control module (RTCM), which separates the functions of insulin recommendation (postmeal insulin for mitigating hyperglycemia) and safety (prevention of hypoglycemia). In addition, we provide details of instances of all three layers of the architecture: the APS© serving as the IM, the safety supervision module (SSM) serving as the CSM, and the range correction module (RCM) serving as the RTCM. We evaluate the performance of the integrated system via in silico preclinical trials, demonstrating 1) the ability of the SSM to reduce the incidence of hypoglycemia under nonideal operating conditions and 2) the ability of the RCM to reduce glycemic variability.

Awake neurosurgery: an update.

Intraoperative brain mapping has the goal of aiding with maximal surgical resection of brain tumors while minimizing functional sequelae. Retrospective randomized studies on large populations have shown that this technique can optimize the surgical approach while reducing postoperative morbidity. During direct electrical stimulation of the language areas adjacent to the tumor, the patient should be collaborative and be able to speak to participate in language testing. Different anesthesiological protocols have been proposed to allow intraoperative brain mapping, which range from local anesthesia to conscious sedation or general anesthesia, with or without airway instrumentation. The most common intraoperative complications are seizure, respiratory depression, and patients' stress and discomfort. Since awake craniotomy carries both benefits and potential risks, the following factors are crucial in the management of patients: 1) careful selection of the patients and 2) communication between the anesthesiological and surgical teams. To date, there remains no consensus about the optimal anesthesiological regimen to use. Only prospective, multicentre randomized studies focused on evaluating the role of different anesthesiological techniques on intraoperative monitoring, postoperative deficits, and intraoperative complications can answer the question of which anesthesiological approach should be chosen when intraoperative brain mapping is requested.

[Multiple sclerosis and acute disseminated encephalomyelitis in children: a difficult diagnostic differentiation. Report of a young boy with early onset of the disease]. / Sclerosi multipla ed encefalomielite acuta disseminata: una diagnosi differenziale difficile. In merito ad un caso clinico con esordio molto precoce.

We report the case of an eight year old boy who developed suddenly acute left-sided hemiparesis syndrome. Brain magnetic resonance imaging (MRI) showed multiple white matter lesions. Therefore we considered in the differential diagnosis multiple sclerosis (MS) and acute disseminated encephalomyelitis (ADEM). The patient received intravenous immunoglobulin (IVIG), 1 g/kg/d over 2 days with complete regression of clinical symptoms. No relapses occurred within six months, although brain magnetic resonance imaging studies found new white matter lesions, suggesting multiple sclerosis with very early onset.

[Cystic dysplasia of the testis: report of a case and review of the literature]. / Displasia cistica del testicolo: descrizione di un caso e revisione della letteratura.

Cystic dysplasia of the testis (CDT) is a rare, benign and congenital lesion causing scrotal mass in pediatric population that can mimic testicular cancer. This lesion consists of cystic dilation of the rete testis and it is frequently associated with renal or genitourinary tract anomalies as renal agenesis and multicystic dysplasia of the kidney. This frequent presentation suggests that testicular cystic dysplasia is associated with a defect of the metamesonephric system in particular with a defect in the connection between the efferent ducts derived from the mesonephros and the rete testis tubules derived from the gonadoblastoma. The role of ultrasound is of primary importance for clinical diagnosis and follow-up of untreated forms. The sonographic appearance of CDT consists of multiple cysts in the mediastinum testis. The cysts range in size from microscopic to several millimetres and may involve the whole testicular parenchyma or have a focal aspect. If the cysts are tiny, the ultrasound must be able to distinguish between CDT and testicular microlithiasis, a potential premalignant condition. Today it is possible thanks to high frequency 7.5 to 10 mHz probes. In the past orchiectomy has been considered as the treatment of the choice for CDT. Today, non operative management of CDT represents an effective alternative option in these patients and the primary benefit of this approach is the preservation of endocrine function and spermiogenic activity. However, the natural history of untreated CDT and its effect on normal testicular tissue are still unknown, therefore long-term follow-up is recommended.

[Practice guidelines to manage children admitted in a general pediatric department with very mild or mild acute infective diarrhea]. / Linee comportamentali di fronte al bambino affetto da diarrea acuta infettiva di lieve o moderata gravità ricoverato in una Divisione di Pediatria.

A clinical-anamnestic card is proposed to gather the main minimal parameters which allow to monitor the course of children with severe or mild acute infective diarrhoea admitted to a pediatric department. This method has been verified through a back-evaluation of the data collected in our clinical-anamnestic cards throughout a period of seven months, and found it useful and appropriate. This case-record includes very mild or mild acute infective diarrhoea (corresponding to a loss lower than 10% of total body weight) in pediatric age children hospitalized in a general pediatric department. The clinical-anamnestic card is divided into five parts coinciding to five different clinical stages of the disease; during each stage, the essential anamnestic and/or clinical data necessary to a correct medical and nursing approach to the children affected with infective acute diarrhoea are recorded. The use of this card is also a good way to engage physicians, nurses and children's parents too, to pay attention to the substantial factors necessary for a correct management of the disease. The evaluation of these clinical-anamnestic cards led to the following general conclusions:--to keep body weight unmodified from the day of admission to the day of discharge--to use very seldom milk without lactose--to keep children on a very short term diet in order to quickly restore intestinal function, to increase body weight and to discharge children in few days.

[Screening of cholesterol levels in middle school students at the Community of Lainate (Milan)]. / Studio osservazionale sui livelli di colesterolo in alunni frequentanti le Scuole medie del Comune di Lainate (Milano).

An example of good integration of territorial sanitary services with hospital services. An observational study that pointed out cholesterol disorders in a pre-adolescent population of a little city next to Milan.

[The beta-hemolytic Streptococcus group A carrier state]. / Stato di portatore di Streptococco beta emolitico gruppo A.

In this study we describe the group A streptococcal upper respiratory tract carrier state, following a clinical method based on two main elements: the presence or the absence of symptoms and the result of throat swab. Through this method we are able to decide how to face each individual clinical case.

[Therapy of Helicobacter pylori infections in children]. / La terapia dell'infezione da Helicobacter pylori in età pediatrica.

We consider Helicobacter pylori treatment in children, giving some indications about the necessity of the treatment, the drugs to use, the duration and the results of therapy. We give importance to the choice of some specific drugs and to the follow-up.