The effect of tracheostomy on swallowing function in open partial horizontal laryngectomies: preliminary experience.

OBJECTIVE: Tracheostomy is required to ensure a safe airway in open partial horizontal laryngectomies. The presence of the tracheostomy tube can contribute to post-operative dysphagia. This study aimed to evaluate the effects of a circumferential tracheostomy technique on swallowing. METHODS: A retrospective study was conducted of patients who underwent open partial horizontal laryngectomies between April 2018 and June 2019. Patients were divided into two groups based on the tracheostomy technique: group 1 had two stitches from the inferior tracheal ring to the skin; group 2 had circumferential fixation of the trachea to the skin. Demographic information, surgical data, post-operative rehabilitation course and complication details were collected and analysed. RESULTS: Twenty-four patients were enrolled. Patients in group 2 had significant improvement in the initial phases of swallowing rehabilitation. CONCLUSION: Tracheostomy with anchorage of the trachea to the skin by circumferential stitches could allow early removal of the tracheal tube, with a better swallowing outcome.

A 1D CNN for high accuracy classification and transfer learning in motor imagery EEG-based brain-computer interface.

Objective.Brain-computer interface (BCI) aims to establish communication paths between the brain processes and external devices. Different methods have been used to extract human intentions from electroencephalography (EEG) recordings. Those based on motor imagery (MI) seem to have a great potential for future applications. These approaches rely on the extraction of EEG distinctive patterns during imagined movements. Techniques able to extract patterns from raw signals represent an important target for BCI as they do not need labor-intensive data pre-processing.Approach.We propose a new approach based on a 10-layer one-dimensional convolution neural network (1D-CNN) to classify five brain states (four MI classes plus a 'baseline' class) using a data augmentation algorithm and a limited number of EEG channels. In addition, we present a transfer learning method used to extract critical features from the EEG group dataset and then to customize the model to the single individual by training its late layers with only 12-min individual-related data.Main results.The model tested with the 'EEG Motor Movement/Imagery Dataset' outperforms the current state-of-the-art models by achieving a99.38%accuracy at the group level. In addition, the transfer learning approach we present achieves an average accuracy of99.46%.Significance.The proposed methods could foster the development of future BCI applications relying on few-channel portable recording devices and individual-based training.

Waveguide integrated hot electron bolometer for classical and quantum photonics.

The development of performant integrated detectors, which are sensitive to quantum fluctuations of coherent light, are strongly desired to realize a scalable and determinist photonic quantum processor based on continuous variables states of light. Here, we investigate the performance of hot electron bolometers (HEBs) fabricated on top of a silicon-on-insulator (SOI) photonic circuit showing responsivities up to 8600 V/W and a record noise equivalent temperature of 1.1 dB above the quantum limit. Thanks to a detailed analysis of the noise sources of the waveguide integrated HEB, we estimate 14.8 dBV clearance between the shot noise and electrical noise with just 1.1µW of local oscillator power. The full technology compatibility with superconducting nanowire single photon detectors (SNSPDs) opens the possibility of nonclassical state engineering and state tomography performed within the same platform, enabling a new class of optical quantum processors.

Single photon detection with superconducting nanowires on crystalline silicon carbide.

Silicon carbide (SiC) is among the most promising optical materials for the realization of classical and quantum photonics, due to the simultaneous presence of quantum emitters and a non-centrosymmetric crystal structure. In recent years, progress have been made in the development of SiC integrated optical components making this a mature platform for the implementation of quantum experiments on chip. Toward this scope, the fabrication of a single photon detector that can be implemented on top of a photonic circuit is essential to achieve a monolithic integration of all the fundamental building blocks required for photonic quantum technologies. Here we demonstrate for the first time single photon detection with superconducting nanowires on top of a bare 3C SiC layer using a novel approach for the fiber-to-detector coupling that allows the optical characterization of multiple detectors without the use of neither cryogenic positioners nor the micromachining of the substrate.

Approval rating and opinion of outpatients and general practitioners toward generic drugs: a questionnaire-based real-world study.

PURPOSE: Generic drugs use in the Liguria region is higher than the Italian average, but lower than in other European countries. No data exist about real-life prescription and level of awareness of generic drugs. In this study, we analyzed demographic, social, economic and cultural factors that may affect the level of awareness of generic drugs and their effective use. METHODS: We conducted a population survey using a structured questionnaire, administered to a sample of 8 outpatient clinics of general practitioners located in different districts of Genoa (Liguria, Italy). Multivariate logistic modeling was adopted to study the relationship between awareness/use of generic drugs and characteristics of subjects. RESULTS: Out of 2,000 outpatients surveyed, 95% were aware of generic drugs: these were mostly females (OR =2.2, 95% CI: 1.4-3.6), >35 years old (OR >6.0 vs 18-35 years), with a high level of education (OR >4.4 vs "elementary sch"), living in the west side of the city (OR =1.9 vs center); of these, only 59% declared that they effectively use generic drugs. Users were younger (OR =3.1, 18-35 years vs >65 years), with a high level of education (high school/university degree vs no title/elementary/secondary school OR =1.7), and were aware of the lower cost compared with branded drugs, and were mainly informed by pharmacists and physicians. CONCLUSIONS: Although subjects were substantially aware of the existence of generic drugs, ~40% still did not use them; doubts about their efficacy seem to be mainly driven by the idea that cheaper drugs lead to lower product quality, in terms of efficacy, safety and tolerability. New education policies on generic drugs are needed.

Intravesical Chemotherapy and Chemohyperthermia in Non-Muscle-Invasive Bladder Cancer; An Overview on Drug Administration Technologies and Pharmacokinetics.

BACKGROUND: Tumor recurrence is the most expected clinical event after the resection of non-muscle invasive bladder cancer, depending on histological findings of the initial lesion. In patients with low and intermediate risk of disease, the intravesical instillation of chemotherapy agents is recommended as a standard treatment to reduce recurrences. METHODS: A comprehensive review covering various aspects of different treatments with intravesical drugs is presented. RESULTS: Drugs may be instilled into the bladder starting with a single, 'early' postoperative administration or, after tumor resection with adjuvant intent or, before tumor resection under a neo-adjuvant regimen. Both latter protocols would consist of weekly treatments followed by monthly maintenance treatments. Different methods of administering drugs intravesically have been proposed to enhance the depth of drug penetration and its absorption into the bladder wall thus increasing the rate of drug-DNA reaction. These device-assisted therapies therefore have set a goal to potentiate the drug's effect and efficaciousness. The Radiofrequency-Induced Thermochemotherapeutic Effect (RITE) and the Electromotive-Drug Administration (EMDA) are the two most relevant modalities used to increase the activity of intravesical chemotherapy. Despite the widely adopted international guidelines' recommendations, and recent clinical trials of device-assisted chemotherapy instillations showing markedly enhanced recurrence-free survival compared even to the standard of care, clinicians and pharmacologists are not familiar with the in-depth physical aspects, pharmacokinetics and systemic absorption of chemotherapeutic drugs following their intravesical administration. CONCLUSION: Knowledge of drug diffusion mechanisms into the tissue and cellular cytoplasm following bladder instillation is a key to understand the safety profile and clinical activity of chemotherapy.

Clinical experience about an unexpected adverse event during nalmefene treatment in two patients with alcohol use disorder.

WHAT IS KNOWN AND OBJECTIVE: Nalmefene, a new opioid system regulator, has recently been approved for the treatment of alcohol dependence, primarily for reducing heavy drinking days. CASES DESCRIPTION: Two patients with a diagnosis of alcohol use disorder were treated with nalmefene. Both patients developed fatigue and deep sleepiness after 2 days of treatment. Only after 1 day of drug discontinuation, symptoms normalized. WHAT IS NEW AND CONCLUSION: We have analysed symptoms' development before and after treatment discontinuation and the possible association with nalmefene therapy. This case should pinpoint our attention on this adverse event for a careful choice of anticraving therapy in patients with severe alcohol use disorder.

Analysis of risk factors for pharyngocutaneous fistula after total laryngectomy with particular focus on nutritional status.

Pharyngocutaneous fistula (PCF) is the most common complication following total laryngectomy and the most difficult to manage. It often causes increased morbidity, delays starting adjuvant therapy, prolongs hospitalisation, increases treatment costs and reduces the quality of life (QoL). The objective of this study is to analyse the predisposing factors and the most important nutritional parameters related to the development of PCF in patients undergoing total laryngectomy and to suggest medical alternatives that might improve results. We performed a retrospective study of 69 patients who underwent either primary or salvage total laryngectomy in our department between January 2008 and January 2012. Risk factors for fistula formation were analysed including tumour characteristics (histology, grading, AJCC stage), treatment (primary or salvage surgery, extent of resection, flap reconstruction, preoperative radiotherapy), comorbidity and nutritional status (preoperative haemoglobin, albumin and prealbumin levels and their changes during hospitalisation). Twenty-four patients developed a PCF (overall incidence 34.8%). Fistula formation was significantly higher in patients with diabetes, preoperative malnutrition (identified from low preoperative albumin and prealbumin levels). After specific nutritional evaluation and support, no patient developed a PCF. Risk factors for PCF formation are extensively treated in the literature but identification of high-risk patients is still controversial. Our study demonstrates that nutritional status of the patient, assessed by preoperative albumin, is also an important risk factor for PCF formation in addition to classical factors. Maintenance of a normal perioperative nutritional status can be helpful to avoid this complication.

Results of Early Versus Intermediate or Delayed Voice Therapy in Patients With Unilateral Vocal Fold Paralysis: Our Experience in 171 Patients.

OBJECTIVES: Vocal fold paralysis can have an important impact on a patient's quality of life. The goal of this study was to compare, in terms of vocal improvement and motility recovery, the post-vocal treatment results of our patients with unilateral vocal fold paralysis (UVFP) when treatment was started early (within 4 weeks from injury) versus intermediate (from 4 to 8 weeks) or delayed (at least 8 weeks after injury) treatment. STUDY DESIGN: An 11-year retrospective study of patients with UVFP who underwent multidimensional diagnostic-therapeutic assessment. METHODS: In total, 171 patients with UVFP were included in our study, divided into three groups who underwent early (first group), intermediate (second group), or delayed (third group) voice treatment. All patients underwent voice therapy based on forcible exercises supplemented by manipulations and maneuvers. RESULTS: Of the 171 patients with UVFP, 106 (62%) recovered vocal fold motility. Of these 106 patients, 51/78 (65%) were in the first group, 30/49 (61%) in the second group, and 25/44 (56%) in the third group. A significant (P < 0.0001) reduction in fundamental frequency (Fo) was present in the first group with a manifest improvement in the mean values of Jitter (Jitt%; P = 0.001), Shimmer (Shim%; P < 0.0001), and noise-to-harmonic ratio (NHR; P < 0.0001). A significant (P < 0.0001) reduction in Fo was found in the second group with a manifest improvement in Jitt% (P < 0.001), Shim% (P < 0.0001), and NHR (P < 0.0001). For the third group, no values were statistically significant apart from the improvement in NHR (P < 0.001). CONCLUSIONS: This study confirms the importance of early rehabilitation underlining the non-functional vocal recovery in patients who started treatment later than 8 weeks after injury.

Paliperidone for the treatment of ketamine-induced psychosis: a case report.

Ketamine is an anaesthetic and analgesic drug synthesized in the 1960s from phencyclidine. The recreational use of ketamine increased among the dance culture of techno and house music, in particular in clubs, discotheques, and rave parties. The psychotropic effects of ketamine are now well known and they range from dissociation to positive, negative, and cognitive schizophrenia-like symptoms. We report a case of a chronic oral consumption of ketamine which induced agitation, behavioral abnormalities, and loss of contact with reality in a poly-drug abuser; these symptoms persisted more than two weeks after the drug consumption had stopped. Antipsychotic treatment with paliperidone led to a successful management of the psychosis, getting a complete resolution of the clinical picture. Paliperidone has proven to be very effective in the treatment of ketamine-induced disorders. Moreover, the pharmacological action and metabolism of paliperidone are poorly dependent from the activity of liver enzymes, so that it seems to be one of the best second generation antipsychotics for the treatment of smokers and alcohol abusers.

Experimental test of theories of the detection mechanism in a nanowire superconducting single photon detector.

We report an experimental test of the photodetection mechanism in a nanowire superconducting single photon detector. Detector tomography allows us to explore the 0.8-8 eV energy range via multiphoton excitations. High accuracy results enable a detailed comparison of the experimental data with theories for the mechanism of photon detection. We show that the temperature dependence of the efficiency of the superconducting single photon detector is determined not by the critical current but by the current associated with vortex unbinding. We find that both quasiparticle diffusion and vortices play a role in the detection event.

The Rao's Brief Repeatable Battery version B: normative values with age, education and gender corrections in an Italian population.

The Brief Repeatable Battery (BRB) of Neuropsychological Tests is one of the most widely used instruments to assess cognitive functioning in multiple sclerosis patients. However, to date, normative data for the Italian population are available only for the version A, which limits the use of the battery in longitudinal evaluations. We administered the BRB version B to 132 healthy subjects to obtain normative values taking into account the influences of demographic factors on the test scores and calculating corrections for these relevant factors (age, gender and education). Higher age and educational level were associated with better performance on all the tests. The World List Generation was also influenced by gender, since women performed better than men. Moreover, some tests of the version B seem to be easier than those of version A. Our data can improve the applicability of the BRB for both clinical and research purposes in longitudinal assessments.

Education protects against cognitive changes associated with multiple sclerosis.

PURPOSE: Although neuropsychological impairments are common in Multiple Sclerosis (MS), the manifestation of cognitive deficits may vary greatly across MS patients. Here, we explored the influence of cognitive reserve proxy indices (education and occupation) and perceived fatigue on cognitive performance. METHODS: Fifty relapsing-remitting MS patients were evaluated. Cognitive performance was measured using the Paced Auditory Serial Addition Test (PASAT), in which information processing speed can be manipulated by varying the presentation speed of stimuli. RESULTS: MS patients with low education performed worse than healthy controls at faster PASAT speeds. By contrast, no difference was observed between MS patients with high education and matched healthy controls, regardless of PASAT speed. Moreover, we found that neither occupational attainment nor perceived fatigue has an influence on MS patients' cognitive performance. CONCLUSION: These findings provide evidence that higher education could be protective against MS-associated cognitive deficits and that high speed PASAT versions are more suitable for identifying compensatory capacities compared to low speed PASAT versions.

Osmotic actuation modelling for innovative biorobotic solutions inspired by the plant kingdom.

Osmotic-driven plant movements are widely recognized as impressive examples of energy efficiency and low power consumption. These aspects motivate the interest in developing an original biomimetic concept of new actuators based on the osmotic principle exploited by plants. This study takes a preliminary step in this direction, by modelling the dynamic behaviour of two exemplificative yet relevant implementations of an osmotic actuator concept. In more detail, the considered implementations differ from each other in the way actuation energy storage is achieved (through a piston displacement in the former case, through membrane bulging in the latter). The dynamic problem is analytically solved for both cases; scaling laws for the actuation figures of merit (namely characteristic time, maximum force, maximum power, power density, cumulated work and energy density) as a function of model parameters are obtained for the bulging implementation. Starting from such performance indicators, a preliminary dimensioning of the envisaged osmotic actuator is exemplified, based on design targets/constraints (such as characteristic time and/or maximum force). Moreover, model assumptions and limitations are discussed towards effective prototypical development and experimental testing. Nonetheless, this study takes the first step towards the design of new actuators based on the natural osmotic principle, which holds potential for disruptive innovation in many fields, including biorobotics and ICT solutions.

A case report on escitalopram-induced hyperglycaemia in a diabetic patient.

The incidence of depression in diabetic patients is quite high; moreover, it has been suggested that the presence of depression itself may increase the risk of diabetes mellitus. Hence, it follows that the simultaneous use of antidiabetic and antidepressant drugs is common. Some clinical evidence indicates that selective serotonin re-uptake inhibitors (SSRIs) could be very useful in treating overweight patients, both with and without diabetes. However, recent deregulation of glucidic metabolism was tested in diabetic subjects treated with antidepressants. Several cases of hyperglycaemia and hypoglycaemia associated with other SSRIs have been published, whereas only one case of escitalopram inducing hyperglycaemia has been noted. The exact mechanism of glucose control impairment in patients taking SSRIs--escitalopram in particular--still remains unclear. We describe a diabetic 83-year-old woman with good glycaemic control (as evinced by glycaemic and glycosylated haemoglobin assay--HbA1c--values) before escitalopram initiation in response to therapy with glibenclamide. Escitalopram resulted in a significantly increased glycaemia values 5 days following administration. Glycaemia values returned to normality only after suspension of escitalopram, despite antidiabetic dosage increase. We report this case to draw attention to escitalopram as a possible cause of glycaemic control loss.

Heparin-induced acute adverse reaction--case report of a patient with acute trauma and a genetic predisposition to thrombotic events: a concurrence of events.

WHAT IS KNOWN AND OBJECTIVE: The most common complication of heparin therapy is bleeding. Allergic reactions to heparin are rare, and the mechanisms are poorly understood. We report on a case of acute systemic reaction after subcutaneous injections of a low-molecular-weight heparin (LMWH) in a patient with a genetic predisposition to thrombotic events and review the literature on heparin-induced acute adverse reaction. CASE SUMMARY: A 57-year-old diabetic, hypertriglyceridemic and hypercholesterolemic man was admitted with a fractured right malleolus sustained while driving. He was prescribed parnaparin sodium 4250 IU subcutaneously once a day. During the third injection, the patient developed widespread pain, sickness and facial rash, followed by a state of stupor (Glasgow Coma Scale 8) and was hospitalized in Neurological Unit. He was found to be a carrier of two genetic mutations (i.e. prothrombin G20210A and MTHFR mutation) associated with an increased risk of thrombotic events. Discontinuation of parnaparin and supportive care led to a sufficient recovery of the patient to be discharged 6 days after admission. WHAT IS NEW AND CONCLUSION: Treatment for heparin-related hypersensitivity reactions is largely supportive and symptomatic. Clinicians should be aware of these rare but potentially serious adverse events. Prothrombin gene mutations are quite common, and guidelines on anticoagulant therapy for affected patients are needed.

Modified detector tomography technique applied to a superconducting multiphoton nanodetector.

We present an experimental method to characterize multi-photon detectors with a small overall detection efficiency. We do this by separating the nonlinear action of the multiphoton detection event from linear losses in the detector. Such a characterization is a necessary step for quantum information protocols with single and multiphoton detectors and can provide quantitative information to understand the underlying physics of a given detector. This characterization is applied to a superconducting multiphoton nanodetector, consisting of an NbN nanowire with a bowtie-shaped subwavelength constriction. Depending on the bias current, this detector has regimes with single and multiphoton sensitivity. We present the first full experimental characterization of such a detector.

General intellectual impairment in chronic right hemisphere damaged patients with anosognosia: a group study.

The study evaluates the possible relations between cognitive impairment, persisting anosognosia for hemiplegia and peripersonal neglect. Thirty eight chronic right hemisphere stroke patients were divided in three age- and education-matched groups: A (n = 13) patients with left hemiparesis, peripersonal neglect, and anosognosia for hemiplegia; B (n = 12) patients with left hemiparesis and peripersonal neglect, and C (n = 13) patients with left hemiparesis only. We used MMSE and WAIS Verbal IQ and verbal subtests to assess cognitive impairment in patients, in order to avoid a bias due to visuospatial deficit, which is common in patients with neglect. VIQ, Information, Digit Span and Vocabulary WAIS subtests as well as MMSE were found to be significantly lower in group A versus group B. No difference was found in any test between groups B and C, indicating a general worse cognition in patients compared to those without anosognosia for hemiplegia. Patients with anosognosia for hemiplegia also showed larger brain lesions and, more frequently, frontal, parietal, temporal and basal ganglia involvement, particularly if they had low verbal IQ, indicating a relationship between cognitive impairment, persisting anosognosia for hemiplegia and large right hemisphere lesions.

Persistence of the effects of attention and executive functions intensive rehabilitation in relapsing remitting multiple sclerosis.

BACKGROUND: Neuropsychological rehabilitation efficacy in multiple sclerosis (MS) is a currently investigated issue. We reported, in a single blind controlled study, that an intensive short duration cognitive training of attention and executive functions significantly improves the treated functions and reduces depression in MS. The persistence of these effects over time are unknown. OBJECTIVE: To evaluate the persistence over time of neuropsychological improvement due to cognitive training nine months after rehabilitation onset. METHODS: This is a single blind randomized controlled study. 24 MS patients were randomly assigned to experimental group (n=13) and received PC assisted neuropsychological treatment for three months, or to control group (n=11), receiving no treatment. Patients were submitted to neuropsychological evaluation, depression and quality of life questionnaires at baseline, three months and nine months later. RESULTS: Nine months follow up compared to baseline evaluation shows a statistically significant improvement (p<0.05) in attention, information processing and executive functions tests (PASAT 3″, COWA/S, WCSTpe), in depression and quality of life questionnaires in rehabilitated patients only. reliable change index (RCI) and modified RCI confirmed the clinical significance of this improvement in rehabilitated patients. CONCLUSIONS: Three months intensive neuropsychological rehabilitation of attention, information processing and executive functions induces a long lasting and clinically relevant neuropsychological improvement over time and a persistent depression and quality of life amelioration in patients with RR MS.

Bronchial selective ventilation in a wide tracheocutaneous fistula.

We present the treatment and management of a wide tracheocutaneous fistula after tracheotomy correlated with excessive cuff pressure in a 36-year-old woman with cerebral palsy since infancy in which persistent type II respiratory failure required continuous ventilatory support. We discuss the surgical treatment adopted for the management of this particularly wide lesion. At the end of surgery, mechanical ventilation through a tracheal cannula was hindered by the reduced length of the residual trachea below the tracheotomy. The need to guarantee mechanical ventilation to the patient led to the implementation of a cuff securing system in the two main bronchi. We describe the approach that may be attempted under extreme conditions, when traditional ventilation methods cannot be applied for anatomical reasons.