Monitoring of scoliosis surgery with epidurally recorded motor evoked potentials (D wave) revealed false results.

OBJECTIVE: To elucidate the mechanism behind D wave amplitude changes after surgical correction of scoliosis. METHODS: We collected D wave and muscle MEP data from 93 patients (78 female, 15 male, age range 4-19 years, mean age 15.9 years), who underwent surgical correction of scoliosis. D waves were recorded via a catheter electrode inserted epidurally through the flavectomy. Muscle MEPs from lower limb muscles were also recorded. Muscle MEPs/D wave were elicited by short trains/single transcranial electrical stimuli. SEPs were elicited through bilateral percutaneous stimulation of the tibial nerves at the ankle and an averaged response from 100 to 200 single sweeps were recorded over the scalp at Cz'/Fz. In addition, we analyzed intraoperatively obtained X-ray images of the spine in 9 patients and preoperative spinal MRI in two of those nine. RESULTS: After surgical correction of scoliosis in 25 of 93 (27%) patients, the D wave amplitude changed by more than 20% of its baseline value. A decremental change occurred in 21 (84%) and an incremental change in 4 (16%) patients. D wave decrements of more than 50% were observed in 5 patients without significant SEP changes in any of these cases. In 9 patients, intraoperatively obtained X-rays of the spine (before and after correction of spine curvature) showed no catheter displacement. Muscle MEPs did not change and postoperative sensory-motor status was normal. In 2 patients, preoperative MRI revealed displacement of the spinal cord towards the concave side of the scoliotic curvature. CONCLUSIONS: During scoliosis surgery, D wave amplitude changes should be interpreted cautiously until the definitive cause(s) of these changes are found. One possible mechanism to explain D wave changes during scoliosis correction could involve rotation of the spinal cord within the spinal canal, and the relative position of the epidural recording catheter (ERC). Rotation of the spinal cord after correction of scoliosis could introduce a new relationship between the ERC and the corticospinal tracts (CTs). Due to high incidence of false D wave amplitude changes we suggest that this methodology should not be used to assess the functional integrity of the CTs during scoliosis surgery. SIGNIFICANCE: This study provides new insight into the methodology of D wave monitoring as well as strong evidence of a high incidence of false positive results using D wave monitoring during surgical correction of scoliosis.

Time to discontinuation of the first highly active antiretroviral therapy regimen: a comparison between protease inhibitor- and non-nucleoside reverse transcriptase inhibitor-containing regimens.

Data from a cohort of HIV-positive individuals who were antiretroviral naive at enrollment were analysed to estimate the probability of discontinuing the first highly active antiretroviral therapy (HAART) regimen, comparing protease inhibitor- and non-nucleoside reverse transcriptase-containing regimens. Of the 2002 individuals who began HAART, 857 (42.8%) discontinued their first regimen. No statistically significant difference was found in the time to discontinuation by specific type of regimen, either when considered overall or by specific reason.

Neurophysiological evaluation of areflexia in Holmes-Adie syndrome.

PURPOSE: To evaluate ankle areflexia in Holmes-Adie syndrome (HAS). PATIENTS AND METHODS: Hoffmann (H) and Tendon (T) soleus reflexes, tonic vibration reflex (TVR), and polysynaptic extension reflex of soleus muscle (PERS) were evaluated in eight patients with idiopathic HAS. Motor (MNCV) and sensory (SNCV) nerve conduction velocities, compound motor-action potential (CMAP), and sensory action potential (SAP) were also determined in upper and lower limbs. RESULTS: Soleus T reflex was obtained in one out of eight patients, and H-reflex was found in none of the patients. TVR was recorded in four out of eight patients, and PERS in all of the patients. MNCV, SNCV, CMAP and SAP showed normal values in all patients. In six out of the eight patients a late response following the tibial nerve stimulation showed constant latency, amplitude and morphology, with no recovery cycle or vibration inhibition. CONCLUSION: In this study, the neurophysiological spinal reflex circuitry evaluations support the view that HAS ankles areflexia is due to a selective impairement of monosynaptic connections of Ia afferents. A normal nuclear excitability is suggested by polysynaptic activation of the soleus motor nucleus.

[Tonic pupil and tendon areflexia: the Holmes-Adie's syndrome]. / Pupilla tonica e areflessia tendinea: la sindrome di Holmes-Adie.

The Holmes-Adie syndrome (HAS) is characterised by initially monolateral, then bilateral enlargement of the pupil with delayed responses to near vision and subsequent redilation, and absent tendon reflexes. The diameter of the affected pupil is oval or irregular, sometimes with spontaneous movements of the pupillary sphincter muscle. Reaction to light may require several minutes' exposure to bright light, as it does redilation after a prolonged stay in a dark room. The reaction to near vision is tonic and delayed, as the subsequent redilation. In 10% of cases there is a permanent failure of the pupil to react either to light or to near vision. Absence of deep tendon reflexes is acquired and permanent, most frequently involving the Achilles' tendon reflex. Loss of different degrees of ciliary and spinal ganglia neurons, without evidence of inflammatory findings, are the neuropathological data accounting for the clinical signs of HAS. Polyneuropathies of different origin can be complicated by a symptomatic form of HAS.

[Auditory abilities in children with cleft lip and/or palate according to Fisher's]. / Habilidades auditivas de niños con hendidura labial y/o palatina según el cuestionario Fisher.

AIM: Patients with cleft palate and/or lip have similar behaviors to those with auditory processing disorders (APD), then the aim of this study was to investigate auditory abilities in the population with cleft lip/palate. MATERIAL AND METHODS: 100 children between 7 and 12 years old with cleft and 65 between 6 and 10 years old without it. Conventional audiological evaluations such as pure tone, word discrimination audiometry and acoustic immittance measures. A questionnaire (Fisher) was given to parents, with 25 items about behaviors found in children with APD. RESULTS: 100% of children with cleft lip/palate showed some indicative behaviors of APD. CONCLUSION: There was significant occurrence of suggestive behaviors of APD, what points out the importance of inclusion of auditory processing tests in evaluation of children with cleft lip/palate.

Preoperative evaluation in infants and children: recommendations of the Italian Society of Pediatric and Neonatal Anesthesia and Intensive Care (SARNePI).

BACKGROUND: The preoperative assessment involves the process of evaluating the patient's clinical condition, which is intended to define the physical status classification, eligibility for anesthesia and the risks associated with it, thus providing elements to select the most appropriate and individualized anesthetic plan. The aim of this recommendation was provide a framework reference for the preoperative evaluation assessment of pediatric patients undergoing elective surgery or diagnostic/therapeutic procedures. METHODS: We obtained evidence concerning pediatric preoperative evaluation from a systematic search of the electronic databases MEDLINE and Embase between January 1998 and February 2012. We used the format developed by the Italian Center for Evaluation of the Effectiveness of Health Care's scoring system for assessing the level of evidence and strength of recommendations. RESULTS: We produce a set of consensus guidelines on the preoperative assessment and on the request for preoperative tests. A review of the existing literature supporting these recommendations is provided. In reaching consensus, emphasis was placed on the level of evidence, clinical relevance and the risk/benefit ratio. CONCLUSION: Preoperative evaluation is mandatory before any diagnostic or therapeutic procedure that requires the use of anesthesia or sedation. The systematic prescription of complementary tests in children should be abandoned, and replaced by a selective and rational prescription, based on the patient history and clinical examination performed during the preoperative evaluation.

Extraction, identification, and quantification of flavonoids and phenolic acids in electron beam-irradiated almond skin powder.

The effect of electron beam irradiation doses from 0 to 30 kGy on extraction yield and phenolic compounds was evaluated in almond skin phenolic extracts (ASPE). Total soluble phenols and distribution of phenolic compounds from acidified methanol ASPE and 52% methanol ASPE were quantified using Folin-Ciocalteau method, liquid chromatography with diode array and fluorescence detection, and negative ion electrospray-mass spectrometry. Electron beam irradiation increased extraction yield by as much as 23%, with the greatest increase observed in the acidified methanol ASPE. Irradiated samples extracted with acidified methanol also exhibited an increase in extractable phenols (Folin-Ciocalteau) and total HPLC-resolved phenolics at all irradiation doses. Samples extracted with 52% methanol exhibited an increase at 10 and 20 kGy, but a 31% decrease at 30 kGy. An increase in aglycones respective to their glycosides was not observed with irradiation. Therefore, the increase in phenolics was attributed to release of phenolics from their cellular matrix.

A novel multifunctional metabolic pathway in a marine mollusc leads to unprecedented prostaglandin derivatives (prostaglandin 1,15-lactones).

The discovery of high levels of prostaglandin (PG) 1,15-lactones of both the E and F series and their co-existence with PGs has been recently described in the opisthobranch mollusc Tethys fimbria. The present study was undertaken in order to investigate the biosynthesis of these novel natural PG derivatives in vivo using radiolabelled precursors, and to gain a preliminary understanding of their biological role. PGE2 1,15-lactone was shown to be produced from both PGE2 and PGF2 alpha in the mollusc mantle and appeared to be quickly transferred to the mollusc dorsal appendices (cerata). The detachment of the latter during the typical defence behaviour of T. fimbria was accompanied by the conversion of PGE2 and PGE3 1,15-lactones back to the corresponding PGs. Both PGE2 and PGE2 1,15-lactone were also shown to be biosynthesized from arachidonic acid. Lactones of the F series were present as 11-acetyl derivatives in T. fimbria mantle and as 9- and 11-fatty acyl esters in the mollusc egg-mass and reproductive gland, and their biosynthesis from PGF2 alpha was demonstrated in all of these tissues. A multiple biological role of PG 1,15-lactones in T. fimbria defensive behaviour, smooth muscle contraction and egg production/fertilization control is hypothesized. The high amounts of PG derivatives found in T. fimbria and the biosynthetic studies described herein indicate that this marine mollusc may be a useful model for future studies on PG biosynthesis.

Neuromyotonia, peripheral neuropathy and myasthenia gravis.

A patient with neuromyotonia, peripheral neuropathy and myasthenia gravis (MG) is described. Neurophysiological studies, at rest, showed continuous muscle discharges of motor unit action potentials (MUAPs) in duplets and triplets. Motor (MNCV) and sensory (SNCV) nerve conduction studies revealed mild axonal and demyelinating peripheral neuropathy. Plasma exchange was followed by disappearance of clinical and electrophysiological signs of neuromyotonia and MG, as well as peripheral neuropathy.