Determinants of outcome of transsphenoidal surgery for Cushing disease in a single-centre series.

BACKGROUND: First-line therapy of Cushing disease (CD) is transsphenoidal surgery (TSS) aimed to obtain a complete removal of the pituitary adenoma and remission of disease. PURPOSE: To analyse the surgical outcome of patients with CD who underwent TSS in our Centre. METHODS: Retrospective analysis on patients with CD who underwent TSS between 1990 and 2016. RESULTS: We analysed 102 TSS that included: 84 first TSS and 18 second and third TSS. The overall remission rate after surgery was 76.5%, with a significant higher percentage of remitted patients after the first TSS compared to the subsequent TSS (82% vs 50%, p = 0.014). The remission after the first TSS was significantly higher when performed by a dedicated surgical team (DST) (89.8% vs 71% p = 0.04) and when the immunohistochemical examination confirmed the adrenocorticotropic adenoma (87% vs 55%, p = 0.04). Neuroradiological findings influenced the surgical outcome in a non-significant manner. Post-TSS complications were reported in 32 patients, with no significant variation when TSS was performed by DST. In case of reintervention, remission of disease was obtained in 72.7% of microadenoma, while no remitted patients were observed in case of macroadenomas. The DST did not significantly improve the outcome. CONCLUSION: Cushing disease is characterized by a broad spectrum of neuroradiological presentation. Despite the availability of a DST make the TSS a safe and effective first-line treatment among all these patients, a precise pre-treatment evaluation is needed in order to define the aim of neurosurgery and to schedule the management of recurrent disease.

The trans-sphenoidal resection of pituitary adenomas in elderly patients and surgical risk.

In western countries, the process of "ageing of the population" is increasingly forcing clinical medicine to find answers for pathologies affecting the elder segments of our community. In this respect, pituitary adenomas often raise difficult questions on surgical indications, since little is known about postoperative morbidity and mortality in elderly patients. The transsphenoidal endonasal approach (TNS), which is considered the gold standard for surgical resection of the majority of functioning and non-functioning pituitary adenomas, is supposed to be a low morbidity and mortality procedure in adult patients. However, only a few contradicting data are available in the literature about elderly patients. In this paper we retrospectively analyze a cohort of 43 consecutive patients aged more than 65 years, operated on for pituitary adenomas at our Institution in the years 1998-2007. These patients were treated by transsphenoidal endonasal approach (TNS) for resection of non-functioning pituitary adenomas (n = 31), GH-secreting adenomas (n = 4) and ACTH-secreting adenomas (n = 8). Clinical records reported a macroadenoma with tumour-related mass symptoms in about 80 % of patients; single or multiple pituitary deficits were present in 44 % of patients. Regarding comorbidities, cardiac disease was the most frequently observed (86 %); assessment of anaesthesiological risk indicated a moderate to severe ASA score in most patients, 11 % showing a 4-5 score. On the basis of current criteria, our retrospective analysis revealed that cure was achieved in 54 % of patients. The outcome was similar to that observed in the general population of patients undergoing transphenoidal surgery in our centre, without differences in the rate of surgical and endocrinological cure, minor and major surgical complications and hospitalization duration. In particular, no significant anaesthesiological complications were observed and no patient developed either permanent diabetes insipidus or cerebrospinal fluid rhinorrhea. In conclusion, in specialized centres the surgical treatment of pituitary adenomas via the transsphenoidal route can be a safe and effective procedure even in elderly patients.

Predictive value of inferior fronto-occipital fasciculus (IFO) DTI-fiber tracking for determining the extent of resection for surgery of frontal and temporal gliomas preoperatively.

AIM: This work reports the analysis of the relationship between inferior fronto-occipital fasciculus (IFO), neoplastic lesions and surgical resection, in patients operated for gliomas located in the frontal, temporal and insular lobes of the dominant hemisphere. Aim of the study is evaluating the predictive value of inferior fronto-occipital fasciculus DTI-fiber tracking (FT) for determining the extent of resection preoperatively. METHODS: We selected 38 cases affected by lesions located in the frontal, temporal and insular lobes of the dominant hemisphere, which were related to the trajectory of the IFO. For each patient preoperative and postoperative MR images and DTI-FT were loaded into the neuronavigation system and merged; volumetric scan analysis was used for establishing tumor location and topography, as well as the volume of the lesion and of the residual tumor. All preoperative fiber tracking datasets were evaluated and the position of the tract (IFO) compared to the tumor was recorded. Postoperative MR scans were then compared with DTI-FT, in order to evaluate the correspondence between the resection boundaries and the trajectory of the fiber tract. RESULTS: Amongst the cases in which the IFO was inside the lesion, we found only incomplete resections (5 subtotal and 6 partial resections), while considering the cases in which the IFO was located outside the tumor, it was possible to perform a relevant (total/subtotal) resection in 18 of them (78%). CONCLUSION: FT of the inferior frontal-occipital fasciculus predicts the possibility and the extent of the resection for a frontal, temporal and/or insular lesion of the dominant hemisphere.

A study of HLA class I and class II 4-digit allele level in Stevens-Johnson syndrome and toxic epidermal necrolysis.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are represented by rare but life-threatening cutaneous adverse reactions to different drugs. Previous studies have found that in a Han Chinese population from Taiwan and other Asian Countries, a strong genetic association between HLA-class I alleles (B*15:02, B*58:01) and SJS and TEN was induced by carbamazepine and allopurinol, respectively. To identify genetic markers that covered the MHC region, we carried out a case-control association enrolling 20 Caucasian patients with SJS/TEN. Our patient series included 10 cases related to paracetamol, 7 to allopurinol and 3 to different drugs (plaquenil, itraconazol, nabumetone). Healthy controls were represented by 115 Caucasian bone marrow or stem cell donors. The HLA-A*, B*, C*, DRB1*, DQB1*, DQA1* and DPB1* genotyping were determined. The frequencies of HLA-A*33:03 as well as C*03:02 and C*08:01 were significantly higher in SJS/TEN patient subgroup showing allopurinol drug-induced severe cutaneous adverse reactions (SCAR) as compared to controls (28.6% vs 0%, P=0.00002, Pc=0.0011; 28.6% vs 0%, P=0.00002, Pc=0.001; 28.6% vs 0%, P=0.00002, Pc=0.001, respectively). In the same subgroup the frequencies of B*58:01, DRB1*15:02 and DRB1*13:02 alleles, although considerably higher than in control group (42.8% vs 5.2%, P=0.003; 28.6% vs 1.7%, P=0.005; 28.6% vs 3.5%, P=0.037, respectively), appeared no more statistically different after P correction (Pc=0.248; Pc=0.29; Pc=1.00, respectively). In addition, in 10 of the 20 SJS/TEN patient subgroup with paracetamol-induced SCAR no statistically significant association with HLA alleles could be found. However, in the same SJS/TEN patient subgroup showing allopurinol drug-induced SCAR, haplotype analysis indicated that B*58:01, DRB1*13:02 and DRB1*15:02 alleles, that in a single allele analysis lost statistical significance after P correction, may still confer susceptibility, because the B*58:01-DRB1*13:02 and DRB1*15:02-DQB1*05:02 are positively associated with the disease (14.2% vs 0.43%, P= 0.00001, Pc=0.00028; 14.2% vs 0.43%, P=0.00001, Pc=0.00028, respectively). Our results show that in contrast to SCAR-related to paracetamol, where HLA alleles do not appear to be involved, HLA molecules behave as a strong risk factor for SCAR-related to allopurinol even when a limited number of patients are considered.

Combination of temozolomide with immunocytokine F16-IL2 for the treatment of glioblastoma.

BACKGROUND: Glioblastoma patients are still not cured by the treatments available at the moment. We investigated the therapeutic properties of temozolomide in combination with F16-IL2, a clinical-stage immunocytokine consisting of human interleukin (IL)-2 fused to the human antibody F16, specific to the A1 domain of tenascin-C. METHODS: We conducted three preclinical therapy studies, using subcutaneous and intracranial U87MG glioblastoma tumours xenografted in BALB/c nude mice. The same therapeutic schedule was used, consisting of five total administrations every third day, of 0.525 mg temozolomide, 20 microg F16-IL2, the combination, or the control solution. RESULTS: Immunohistochemical analysis of U87MG xenografts and of human glioblastoma specimens showed selective tumour staining of F16. A quantitative biodistribution confirmed the preferential tumour accumulation of radiolabelled F16-IL2. In the study with subcutaneous xenografts, the combination of F16-IL2 with temozolomide induced complete remission of the animals, which remained tumour free for over 160 days. The same treatment led to a consistent size reduction of intracranial xenografts and to a longer survival of animals. The immunocytokine promoted the recruitment of leukocytes into tumours of both models. CONCLUSION: The combined use of temozolomide with F16-IL2 deserves clinical investigations, which will be facilitated by the excellent safety profile in cynomolgus monkeys, and by the fact that F16-IL2 is in clinical trials in patients with cancer.

Bilateral intracavernous carotid artery aneurysms presenting as abducens nerve palsy: case report.

Bilateral intracavernous carotid artery aneurysms are very rare and can be usually observed in patients with multiple intracranial aneurysms. Here we present the case of a 73 year-old woman who experienced worsening diplopia due to progressive bilateral paresis of the lateral rectus muscles. Computed tomography (CT) and magnetic resonance imaging (MRI) examinations showed bilateral roundish parasellar and intracavernous masses, with homogeneous contrast-enhancement and absence of subarachnoid haemorrhage (SAH). Cerebral angiography revealed bilateral aneurysms of the intracavernous carotid artery. Once considered the age of the patient, the anatomical features of the aneurysms and the risks of traditional or endovascular surgery, we decided not to proceed to any treatment other than the orthoptic correction of the diplopia and the careful correction of arterial hypertension. We provide a brief review of the literature on bilateral intracavernous aneurysms and a discussion about their treatment.

Immunity repressor of bacteriophage P2. Identification and DNA-binding activity.

The product of gene C of the temperate bacteriophage P2, the immunity repressor, can be detected as a unique band eluting from phosphocellulose columns at 0.12 M-potassium phosphate when differentially labelled with a radioactive amino acid: the band is absent when phages that either have lost gene C through deletion or carry a suppressor-sensitive mutation in the gene are used. The repressor in its monomeric form is about 11,000 in molecular weight. At near physiological salt concentrations, the form predominantly recovered is the dimer. In filter-binding assays, the partially purified repressor binds wild-type P2 DNA strongly. It does not bind DNA of P2 vir94, a deletion that removes all the genetic elements involved in the regulation of lysogeny; it also does not bind, or binds inefficiently, DNA of P2 vir3, a mutation in the operator that controls the early replicative functions of P2. At the concentrations employed, the dimer is the active form in binding. The P2 repressor clearly differs in several features from the well-studied immunity repressor of bacteriophage lambda.

Prospective study of first-line vigabatrin monotherapy in childhood partial epilepsies.

This was a prospective open comparative pilot study to assess the efficacy and tolerability of first-line vigabatrin monotherapy in childhood partial epilepsies. Two groups of patients were recruited over the same period. The vigabatrin monotherapy group comprised 40 patients (18 male, 22 female; mean age at last visit 7.5 years); the comparative carbamazepine monotherapy group comprised 40 consecutive clinic patients (22 male, 18 female; mean age at last visit 7.8 years). Seizures disappeared in 82% of vigabatrin patients and in all carbamazepine patients with idiopathic partial epilepsy, and in 50% of vigabatrin patients and 55% of carbamazepine patients with symptomatic partial epilepsy. Interictal EEG abnormalities decreased in vigabatrin patients more than in carbamazepine patients (P < 0.05). Tolerability was good in vigabatrin patients, but four out of 37 showed mild irritability by the end of the trial. Persistent sedation was observed in eight of the 40 patients receiving carbamazepine. No patient had drug therapy discontinued because of side-effects. During vigabatrin long-term monotherapy, efficacy and good clinical tolerability were maintained. These results suggest that vigabatrin may be an alternative first-line treatment for childhood partial epilepsies. Further blinded comparative randomized trials are needed.

Gonadal sperm reserve in purebred Landrace and Large White boars of high average daily gain.

The present study investigated the effects of average growth rate (AGR) levels and age on the number of sperm cells per gram of testis parenchyma and on the gonadal reserve in Landrace (LD) and Large White (LW) boars. In Experiment 1, the effects of breed (LD, LW), level of AGR from birth up to 90 days of age (Level 1: 384 +/- 32 g/day; Level 2: 512 +/- 22 g/day; Level 3: 624 +/- 41 g/day), and age (13, 15, 17, 19 and 21 weeks) on testicular cell concentration were evaluated. Data were analyzed under a 2 x 3 x 4 factorial design. There were significant effects associated with breed (P < 0.001) and age (P < 0.001) but not with AGR (P > 0.05) on sperm cell number per gram of testicular parenchyma. The number of cells increased with age and was greater in LW than in LD young boars, mainly those up to 19 weeks of age. In Experiment 2, the effect of two AGR levels (Level 1: 649-694 g/day; Level 2: 813-885 g/day) from birth up to 100 kg body weight on the number of sperm cells per gram of testis parenchyma and on the gonadal reserve was investigated using 59 purebred LD and LW boars. The boars were castrated at 23, 25, 29 and 33 weeks of age. Age of boars significantly affected gonadal sperm reserve and the number of sperm cells per gram of testicular tissue (P < 0.001). Breed of boars and AGR Levels did not significantly affect number of sperm cells and gonadal sperm reserve (P > 0.05). It was concluded that the number of sperm cells in the testicular tissue of young boars is influenced by their breed and age, but not by the level of their AGR.

Effect of the time of artificial insemination with frozen-thawed or fresh semen on embryo viability and early pregnancy rate in gilts.

The aim of the present study was to evaluate the effect of artificial insemination time (before or after ovulation) using either fresh or frozen-thawed boar semen on embryo viability and early pregnancy rate. Seventy-seven prepubertal crossbred (Landrace x Large White x Duroc) gilts were inseminated in 4 treatments. Artificial inseminations were performed 6 h either after (A) or before (B) ovulation using frozenthawed (A-frozen, n = 19; B-frozen, n = 19) or fresh semen (A-fresh, n = 21; B-fresh, n = 18). The gilts were induced to puberty by administration of 400 IU of eCG and 200 IU hCG (sc) followed by 500 IU of hCG (sc) 72 h later. Ovulation was predicted to occur 42 h after the second injection. All animals were slaughtered 96 h after AI. Embryos were collected and classified as viable (5- to 8-cells, morulae, compacted morulae and early blastocysts) and nonviable (fragmented, degenerated and 1- to 4-cell embryos). The total embryo viability rate was: 64.3% (A-frozen), 54.2% (A-fresh), 76.0% (B-frozen), 91.9% (B-fresh); (A-fresh vs B-fresh, P = 0.018; A-frozen vs B-frozen, P = 0.094). It was observed that AI before ovulation resulted in a higher percentage of total viable embryos than AI after ovulation (P = 0.041). The early pregnancy rate, defined as presence of at least one viable embryo, was 78.9, 80.9, 84.2 and 94.4% for A-frozen, A-fresh, B-frozen, B-fresh, respectively. There was no significant difference in the early pregnancy rate among groups. In conclusion, there was a detrimental effect upon total embryo viability rate when AI was performed after ovulation with either frozen-thawed or fresh semen. The total embryo viability rate and the early pregancy rate were not affected by AI with either frozen-thawed or fresh semen regardless of the time of AI.

Evaluation of gene expression in pigs selected for enhanced reproduction using differential display PCR and human microarrays: I. Ovarian follicles.

Differential display PCR (ddPCR) and complementary DNA microarray analyses were used to evaluate gene expression differences in porcine ovarian follicles between a line of pigs selected for an index of ovulation rate and embryo survival (Line I) and its randomly selected control line (Line C). Follicles (4.0 to 7.0 mm) were dissected from ovaries of multiparous sows (n = 27) at either 2 or 4 d following PGF2alpha analog injection on d 12 to 14 of the estrous cycle. Using ddPCR, differentially expressed bands (n = 282) were excised from gels and 107 were sequenced, yielding 84 unique porcine follicle expressed sequence tags. Northern hybridization confirmed differential expression (between lines, days, or follicle sizes) for messenger RNA representing the calpain I light subunit, cytochrome C oxidase subunit III, cytochrome P450 aromatase, and cytochrome P450 side chain cleavage genes. For microarray analysis, two mRNA pools representing follicles (d 2; 4.50 to 4.75 mm) from Line I and Line C sows were hybridized to the Incyte UniGEM V1.0 human chip (approximately 7,000 gene probes). A second analysis was performed using mRNA from follicles (d 2; 4.50 to 5.00 mm) hybridized to the Incyte UniGEM V2.0 human chip (approximately 9,100 gene probes). A total of 33 and 21 genes were identified with significant expression differences using UniGEM V1.0 and V2.0, respectively (twofold or greater relative expression following adjustment for expression of control probes). However, there was little overlap between results of the two hybridizations. Expression differences between lines for two genes, follistatin and nuclear receptor subfamily 4, group A, member 1, were confirmed using Northern hybridization. These results demonstrate changes in follicular gene expression as the result of long-term selection for enhanced reproduction. These correlated responses may directly represent allelic variation utilized by selection (e.g., quantitative trait loci), or more likely, transcriptional changes in other genes that interact with reproductive QTL. This work represents one of the first applications of gene expression analysis to evaluate long-term selection response in livestock populations.

Evaluation of gene expression in pigs selected for enhanced reproduction using differential display PCR: II. Anterior pituitary.

The objective of this study was to identify differentially expressed genes in the anterior pituitary (AP) of sows selected for enhanced reproductive phenotypes. Selection in the Index (I) line was based on an index of ovulation rate and embryo survival, whereas random selection was used in the Control (C) line. Average numbers of fully formed piglets at birth were 12.5 +/- 1.5 and 9.9 +/- 2.0 for Line I and C sows used in this study, respectively. In order to induce luteolysis and synchronize follicle development, sows were injected (i.m.) with 2 mL of prostaglandin F2alpha analog between d 12 and 14 of the estrous cycle. Tissue was harvested 2 d (d2) or 4 d (d4) after injection, resulting in four experimental groups: Cd2 (n = 6), Cd4 (n = 4), Id2 (n = 6), and Id4 (n = 7). Differential display PCR (ddPCR) was used to search for transcriptional changes between selection lines in the AP, using samples within line but pooled across days. Northern hybridization was used to confirm ddPCR results. For ddPCR, two pools were used from each line (C and I). Three genes were confirmed to be differentially expressed between Lines I and C: G-beta like protein, ferritin heavy-chain, and follicle stimulating hormone beta subunit, whereas many other expressed sequence tags were observed to be differentially expressed but still require confirmation. Our findings indicate that long-term selection to increase ovulation rate and decrease embryo mortality has altered transcriptional patterns in the anterior pituitary, most likely as correlated responses.

[Remote results and critical review of the use of the Sparks-Mandril prosthesis]. / Risultati a distanza e revisione critica dell'uso della protesi di Sparks-Mandril.

Long-term clinical results and pathologic features, both macroscopic and microscopic, of 24 Sparks-Mandril grafts as femoro-popliteal substitutes are reviewed. High rate of complications and low percentage of patency are stressed. Further use of this graft is not recommended.

[Use of the human umbilical vein as a vascular prosthesis. Experimental study]. / Uso della vena ombelicale umana come protesi vascolare. Studio sperimentale.

The possible use of the human umbelical vein as a vascular transplant, following appropriate chemico-physical treatment is discussed. The properties of this new prosthesis have been studied on the basis, first, of physical and dynamic tests and, thereafter, following experimental intervention on 12 dogs in which a segment of the abdominal aorta was replaced. The animals were angiographed at varying times from the operation, up to a maximum of 8 months, and finally sacrificed for thorough histological study using various techniques.

Efficient assembly of full-length infectious clone of Brazilian IBDV isolate by homologous recombination in yeast.

The Infectious Bursal Disease Virus (IBDV) causes immunosuppression in young chickens. Advances in molecular virology and vaccines for IBDV have been achieved by viral reverse genetics (VRG). VRG for IBDV has undergone changes over time, however all strategies used to generate particles of IBDV involves multiple rounds of amplification and need of in vitro ligation and restriction sites. The aim of this research was to build the world's first VRG for IBDV by yeast-based homologous recombination; a more efficient, robust and simple process than cloning by in vitro ligation. The wild type IBDV (Wt-IBDV-Br) was isolated in Brazil and had its genome cloned in pJG-CMV-HDR vector by yeast-based homologous recombination. The clones were transfected into chicken embryo fibroblasts and the recovered virus (IC-IBDV-Br) showed genetic stability and similar phenotype to Wt-IBDV-Br, which were observed by nucleotide sequence, focus size/morphology and replication kinetics, respectively. Thus, IBDV reverse genetics by yeast-based homologous recombination provides tools to IBDV understanding and vaccines/viral vectors development.

Prognostic markers in AML: focus on CBFL.

Acute myeloid leukemia (AML) is a heterogeneous disease increasing in frequency owing to an aging population. Decisions on intensive induction treatments, intensification and allografting rely on the ability to divide an apparently homogeneous group according to risk. A wide range of clinical, cytogenetic and molecular variables may be used to inform this task; here we examine those variables useful in assessing prognosis for a patient with non-acute promyelocitic AML focusing on core binding factor leukemia. In clinical practice, when counseling an individual patient with AML, a range of well-known clinical variables (age, performance status and tumor burden) and genetic variables (cytogenetic and gene mutation) must be considered to better define the prognostic risk.