Vestibular failure managed with osteopathic manipulative treatment: A report of two cases.

INTRODUCTION: Vestibular failure or hypofunction can be generated by pathologies such as vestibular neuritis (VN), causing the onset of rotatory vertigo and the vestibulo-ocular reflex (VOR) hyporeaction. VN is a post-viral inflammation-producing vestibular nerve-axon impairment, which reaches compensation in 70% of cases. Here, we present two cases of vestibular failure that did not respond to pharmacological therapy, but did show modulated vestibular response after an osteopathic manipulative treatment. Dizziness handicap inventory (DHI) was used to assess disability, while VOR was examined by means of video head impulse test (v-HIT). Case 1 showed bilateral VOR areflexia with severe related disability due to chronic vertigo, while case 2 showed sub-acute VN complicated by intense vomiting. After treatment, both cases had a complete remission of symptoms, with a reduction in DHI score of 60 and 70 points respectively, as well as a normalization of the v-HIT exam. CONCLUSION: OMT might work to modulate VOR, through osteopathic manipulation of the fascial-system and interaction with proprioceptive inputs. Further clinical trials should be performed to investigate the OMT clinical efficacy in uncompensated vestibular neuritis.

Efficacy of Osteopathic Manipulative Treatment on postural control in Parkinsonian patients with Pisa syndrome: A pilot randomized placebo-controlled trial.

BACKGROUND: Pisa syndrome (PS) is a clinical condition frequently associated with Parkinson's disease (PD). It is characterized by a trunk lateral flexion higher than 10 degrees and reversible when lying. One pathophysiological hypothesis is the altered verticality perception, due to a somatosensory impairment. Osteopathic Manipulative Treatment (OMT) manages fascial-system alterations, linked to somatic dysfunctions. Fascial system showed to be implicated in proprioceptive sensibility. OBJECTIVE: The aim of the study was to assess OMT efficacy on postural control in PD-PS patients by stabilometry. METHODS: In this single-blinded trial we studied 24 PD-PS patients, 12 of whom were randomly assigned to receive a multidisciplinary physical therapy protocol (MIRT) and sham OMT, while the other 12 received four OMT plus MIRT, for one month. The primary endpoint was the eye closed sway area assessment after the intervention. Evaluation of trunk lateral flexion (TLF) with DIERS formetrics was also performed. RESULTS: At one month, the sway area of the OMT group significantly decreased compared to placebo (mean delta OMT - 326.00±491.24 mm2, p = 0.01). In the experimental group TLF showed a mean inclination reduction of 3.33 degrees after treatment (p = 0.044, mean d = 0.54). Moreover, a significant positive association between delta ECSA and delta TLF was observed (p = 0.04, r = 0.46). DISCUSSION: Among PD-PS patients, MIRT plus OMT showed preliminary evidence of postural control and TLF improvement, compared to the control group.

Osteopathic manipulative treatment in pudendal neuralgia: A case report.

Pudendal neuralgia is characterised by pain in the pudendal dermatome. It could be due to a stenosis of the pudendal canal, a compression along its pathway, or a pelvic trauma. Pudendal nerve entrapment (PNE) syndrome is frequently involved in pudendal neuralgia onset. This case report describes the osteopathic manipulative treatment (OMT) of a patient with functional PNE. A 40-year-old female presented with a 12-month history of intense pelvic pain resistant to 3 months of pharmacologic treatment that arose after three proctological surgeries. A perineal retracted painful scar was visible upon examination. PNE syndrome diagnosis was based on Nantes criteria. The electromyogram of the nerve showed an increased motor response latency of the left pudendal nerve. Visual analogue scale (VAS), female National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), Oswestry Disability Index (ODI) and Tampa scale of kinesiophobia (TSK) were used to assess patient's symptoms at baseline (T0), after pharmacologic treatment (T1), after OMT (T2), and at 6-month follow-up. Five treatments, including direct and indirect techniques, were performed over 1 month. OMT reduced pelvic neuralgia and disability indexes without any complications, maintaining a positive outcome at 6-month follow-up (VAS: T0 = 10, T1 = 10, T2 = 1.8, T3 = 1.5), (NIH-CPSI: T0 = 34, T1 = 30, T2 = 7, T3 = 6), (ODI: T0 = 48, T1 = 29, T2 = 9, T3 = 5) and (TSK: T0 = 51, T1 = 41, T2 = 20, T3 = 17). This is the first report of a patient diagnosed with functional PNE managed with OMT. A link between PNE, scar and pelvic somatic dysfunctions could suggest double crush syndrome.

Timing of oral feeding changes in premature infants who underwent osteopathic manipulative treatment.

BACKGROUND: The delayed transition from gavage-to-nipple feeding is one of the most significant factors that may prolong hospital length of stay (LOS). Osteopathic manipulative treatment (OMT) has been demonstrated to be effective regarding LOS reduction, but no investigations have documented its clinical validity for attaining oral feeding. OBJECTIVES: To assess OMT utility regarding the timing of oral feeding in healthy preterm infants. DESIGN: Preliminary propensity score-matched retrospective cohort study. SETTING: Data were extrapolated from the neonatal intensive care unit (NICU) of Del Ponte Hospital in Varese, Italy, during the period between March 2012 and December 2013. INTERVENTIONS: Two propensity score-matched groups of healthy preterm infants aged 28+0 to 33+6 were compared, observing those supported with OMT until hospital discharge and control subjects. MAIN OUTCOME MEASURES: Days from birth to the attainment of oral feeding was the primary endpoint. Body weight, body length, head circumference and LOS were considered as secondary endpoints. RESULTS: Seventy premature infants were included in the study as the control group (n = 35; body weight (BW) = 1457.9 ± 316.2 g; gestational age (GA) = 31.5 ± 1.73 wk) and the osteopathic group (n = 35; BW = 1509.6 ± 250.8 g; GA = 31.8 ± 1.64 wk). The two groups had analogous characteristics at study entry. In this cohort, we observed a significant reduction in TOF (-5.00 days; p = 0.042) in the osteopathic group with a greater effect in very low birth weight infants. CONCLUSIONS: These data demonstrate the utility and potential efficacy of OMT for the attainment of oral feeding. Further adequately powered clinical trials are recommended.

Osteopathic manipulative treatment in chronic coccydynia: A case series.

BACKGROUND: Coccydynia is a disorder associated with pain/discomfort at the base of the spine. The role of osteopathic manipulative treatment (OMT) in chronic coccydynia as well as for low back pain (LBP) and radicular pain (RP) associated with coccydynia, has not previously been investigated. This study seeks to analyse the effects of OMT on chronic coccydynia compared to physical therapy and pharmacological treatment (PTPT). The secondary objective is to analyse the effect of OMT on LBP and RP associated with coccydynia. METHODS: Clinical records of 50 patients were examined. These patients (aged 39.94 ± 15.34 years, BMI 21.22 ± 3.15) who complained of chronic coccydynia were assessed 3 times: before any treatment (t0), after PTPT (t1) and after OMT (t2). Patients were treated with PTPT during the first 3 months and then referred by physicians to osteopaths to receive 3 sessions of OMT over a period of 5 weeks. The outcome measurements were made by a visual analogue scale (VAS 0-10 cm) and the Oswestry Low Back Pain Disability Questionnaire. RESULTS: Before starting OMT treatment, patients showed a stable condition of coccydynia (mean VAS values from 7.1 to 6.5 p = 0.065) and a slight but significant reduction in disability (mean OD values from 17.7 to 14.5 p = 0.017) after PTPT. After the 3 sessions of OMT, all subjects gained a successful reduction in pain (mean VAS values from 6.5 to 1.2, p ≤ 0.001) and demonstrated a higher significant reduction in disability (mean Oswestry scale values from 14.5 to 2.5, p < 0.001). CONCLUSIONS: This case series shows that OMT elicits a positive benefit for pain relief and reduction in disability in patients complaining of coccydynia (with or without LBP and RP associated with coccydynia). Therefore, OMT could be considered as a valid therapeutic approach for treating chronic coccydynia. Nevertheless, further research is required to test the hypothesis and to better determine the benefits of OMT.

The possible role of glutathione-S-transferase activity in diabetic nephropathy.

The most common cause of end stage renal disease is diabetic nephropathy. An early diagnosis may allow an intervention to slow down disease progression. Recently, it has been hypothesized that glutathione-S-transferase (GST) activity may be a marker of severity of chronic kidney disease. In particular, a lower GST activity is present in healthy subjects compared to patients with nephropathy. In the present review we illustrate the scientific evidence underlying the possible role of GST activity in the development of diabetic nephropathy and we analyze its usefulness as a possible early biomarker of this diabetic complication.

Vasospasm and cerebral infarction from pituitary apoplexy. A case report.

Pituitary apoplexy is a potentially life-threatening acute or subacute clinical syndrome occurring from enlargement of the pituitary gland, and pituitary insufficiency, from hemorrhage or ischemia from an unknown pituitary lesion, most frequently being a non-functioning macroadenoma. A close, and multidisciplinary management is required. The purpose of this case report is to increase awareness to pituitary apoplexy presentation and management by reporting clinical features and neuroradiological findings observed in a 70-year-old patient with an unknown pituitary lesion. He presented with pituitary apoplexy and brain ischemia at magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. MR angiography (MRA) showed diffuse vasospasm of anterior and posterior circulation. Both MRI and cytochemical examination of the cerebrospinal fluid ruled out subarachnoid hemorrhage. Due to concomitant diseases, and absence of visual deficit, the management was conservative by medical and substitutive therapy, without surgery. Clinical follow-up showed clearcut improvement, and this was consistent with MRI and MRA evidence of vasospasm regression, and clearcut pituitary lesion shrinkage. Pituitary lesions with hemorrhagic infarction presenting with pituitary apoplexy may be associated with vasospasm and brain ischemia at diagnosis, also in the absence of subarachnoid hemorrhage. A correct MR evaluation of patients with PA should include DWI, ADC maps, and MRA. Notably, early diagnosis of PA-associated vasospasm and cerebral ischemia avoids the possibility of their detection only after neurosurgery.

Cortical activity and connectivity of human brain during the prisoner's dilemma: an EEG hyperscanning study.

A major limitation of the approaches used in most of the studies performed so far for the characterization of the brain responses during social interaction is that only one of the participating brains is measured each time. The "interaction" between cooperating, competing or communicating brains is thus not measured directly, but inferred by independent observations aggregated by cognitive models and assumptions that link behavior and neural activation. In this paper, we use the simultaneous neuroelectric recording of several subjects engaged in cooperative games (EEG hyperscanning). This EEG hyperscanning allow us to observe and model directly the neural signature of human interactions in order to understand the cerebral processes generating and generated by social cooperation or competition. We used a paradigm called Prisoner's dilemma derived from the game theory. Results collected in a population of 22 subjects suggested that the most consistently activated structure in social interaction paradigms is the medial prefrontal cortex, which is found to be active in all the conflict situations analyzed. The role of the anterior cingulated cortex (ACC) assumes a main character being a discriminant factor for the "defect" attitude of the entire population examined. This observation is compatible with the role that the Theory of Mind assigns to the ACC.

Hepatitis C virus infection and rituximab therapy after renal transplantation.

BACKGROUND: Rituximab, a chimeric monoclonal antibody, has been successfully given in various diseases including HCV-associated mixed cryoglobulinemia. However, only preliminary data exists on its efficacy and safety after renal transplantation. METHODS: We report on a renal transplant recipient with chronic hepatitis C who received rituximab therapy for gastric cancer. Four rituximab infusions of 375 mg/m(2) were given. RESULTS: Rituximab therapy was complicated by cholestatic hepatitis C with very high HCV RNA levels; liver insufficiency occurred. The patient developed bacterial pneumoniae and respiratory insufficiency was the cause of death. Although other mechanisms cannot be excluded, we found that rituximab therapy was implicated in the pathogenesis of cholestatic hepatitis C in our patient. CONCLUSIONS: We suggest that rituximab therapy may be associated with significant side effects. More experience has to be accumulated before any conclusions on efficacy and safety of rituximab therapy after RT can be drawn.

The value of fat saturation sequences and contrast medium administration in MRI of degenerative disease of the posterior/perispinal elements of the lumbosacral spine.

Degenerative-inflammatory lumbar spinal pathology is one of the most common reasons why individuals seek medical care, and low back pain is the main symptom among those most commonly associated with this pathologic condition. Pain is commonly attributed to degenerative disc disease, particularly herniated discs, but many different spinal and perispinal structures may undergo degenerative-inflammatory phenomena and produce pain: discs, bone, facet joints, ligaments and muscles. In particular, in patients with non-radicular low back pain, this syndrome may arise from changes of the posterior elements/perispinal tissues of the lumbar spine (i.e., the "posterior vertebral compartment"). They include: facet joint pathology (e.g., osteoarthritis, joint effusion, synovitis and synovial cysts), spondylolysis, spinal/perispinal ligamentous degenerative-inflammatory changes and perispinal muscular changes. It is well known that magnetic resonance is the most sensitive imaging method for the evaluation of spinal degenerative pathology, even in the initial stages of the disease. T2-weighted sequences with fat saturation, and when indicated the use of contrast-enhanced T1-weighted images with fat saturation, permit the visualization of degenerative-inflammatory changes of the posterior elements of the lumbar spine that in most cases would have been overlooked with conventional non-fat suppressed imaging.

Dialysis and kidney transplantation: similarities and differences in the psychological aspects of noncompliance.

BACKGROUND: Dialysis and kidney transplantation represent two effective strategies in treating chronic uremia, albeit with different results. Our study compared the psychological aspects of two categories of patients: patients who faced kidney transplantation and have been on dialysis, and noncompliant patients treated with these therapies. MATERIALS AND METHODS: On 170 patients (120 hemodialysis and 50 peritoneal dialysis) we used a personality analysis (MMPI2) and the COPE, which assessed the ability of patients to cope under certain conditions that can be perceived as stressful or, in any case, unusual. The screening succeeded in 11 cases among the first group and 9 in the second. Three of the 20 patients were considered to be partially noncompliant: 1 on peritoneal and the other 2 on hemodialysis. We also tested a control group of 300 people of different ages, sexes, social and cultural status, dates and kinds of transplantation (cadaveric or living donors). Of the 36 feedbacks received, only 30 were considered valuable. RESULTS: The results of the research showed that patients with less than 2 years of dialysis treatment and patients with more than 2 years survival after transplantation time were inclined to deny their disease and the possible emotions about their clinical status, drawing an inadequate attention to the difficulties. This behavior was clearer among noncompliant patients. Family problems and couple malaise in everyday life can push more and more of these patients to be noncompliant with therapeutic prescriptions, as they do not feel adequate support. The result is an excessive foreboding, poor disposition, and nervousness. CONCLUSIONS: Screening of patients' social and psychological status is useful as is psychological intervention for those who miss emotional support from the family. This psychological support is advisable for uremics who have to enter a waiting list and for those who are subject to postoperative treatment in order to promote compliant behavior.

Fat saturation technique and gadolinium in MRI of lumbar spinal degenerative disease.

We evaluated the potential of MR sequences with Fat Saturation and gadolinium in patients with degenerative disease of the lumbar spine and low back pain, by studying both anterior and posterior elements of the lumbar spine. We examined 3323 patients (age range 15-78 years) presenting low back pain. We used T2-weighted sequences with Fat Saturation and in some selected cases (1063 patients, 32%) administered gadolinium using T1-weighted sequences with Fat Saturation. In particular we used gadolinium in the following cases: 1) presence of hyperintense areas on T2 weighted images with Fat Saturation in the osteo-articular and muscular-ligamentous structures of the lumbar spine; 2) Clinical-radiological discrepancy in patients without disc-root conflict and clinical suspicion of posterior vertebral compartment syndrome. We found degenerative-inflammatory changes in osteo-articular, ligamentous and muscular structures in 1063 patients: osteochondrosis, "aseptic discitis", facet joint effusion and synovitis, osteoarthritis, synovial cysts, spondylolysis, degenerative-inflammatory changes of the posterior ligaments (flava, interspinous and supraspinous ligaments) and posterior perispinal muscles. To improve diagnostic accuracy and allow correct therapeutic guidance, MR examination in patients with low back pain must evaluate both anterior and posterior elements of the lumbar spine. Our study indicates that T2 sequences with Fat Saturation and, in selected cases, gadolinium administration, better visualize or disclose degenerative-inflammatory changes in the lumbar spine, showing the active-inflammatory phase and extension of these processes which may not be depicted during a standard MR examination.

[Non compliance predictive factors in renal transplantation]. / fattori predittivi di non compliance nel trapianto renale.

Currently many authors report a kidney graft survival of 90-95% at one years post-transplantation. The patients' adherence to the immunosuppressive therapy is an important condition for maintaining graft functioning. A review of the medical literature shows that graft survival is significantly worse in non-compliance patients. As a matter of fact, 267 non compliance patients lost their graft of 7206 renal graft recipients. There are usually three different non-compliance profiles in transplantation : 1) 'Accidental non compliers' (47%) identifies those patients who sometimes forget to take the therapy. 2) 'Invulnerables' (28%) are those patients who believe that they do not need to take their immunosuppressive drugs regularly; 3) 'Decisive non compliers' (25%) are those patients who decide what therapy they should take. Many predictive factors have been associated with non compliance: 1) Demographic variables 2) Psychological variables 3) Psychiatric disorders 4) Poor social support 5) Pretransplantation compliance 6) Substance abuse We therefore think that it is particularly useful to identify non compliers before transplantation through psychological screening, in order to increase their compliance by supportive psychological assistance. Unfortunately, these patients tend to avoid specialists' intervention so it is very useful to provide the medical teams with the necessary training to cope with the psychological problems of their patients.

From cyclosporine to the future.

Most of the experience acquired in our unit with cyclosporine (CsA) comes from randomized trials. A first trial demonstrated that CsA-treated patients had a better 10-year graft survival than azathioprine-treated patients. A second trial showed equivalence between double therapy with CsA plus steroids and triple therapy with CsA, steroids, and azatioprine. A third trial showed similar 2-year graft survival with CsA monotherapy and triple therapy. A larger multicenter study that compared three different CsA-based regimens showed similar long-term graft survival with monotherapy, double therapy, and triple therapy. However, patients given monotherapy had less frequent steroid-related side-effects. Finally a more recent multicenter international trial showed that the rate of acute rejection can be reduced without increasing side effects by adding the monoclonal antibody basiliximab to the triple therapy. By reviewing our cumulative experience with CsA we found a mean graft half-life of 18.7 years for cadaver renal transplant recipients and 31.9 for the living transplant recipients. No significant attrition of graft function was found for patients with grafts functioning at 15 years. Two important issues with the present immunosuppression concern the long-term nephrotoxicity of calcineurin inhibitors and the cardiovascular disease, which is at least in part related to the use of steroids. To face these problems, we are currently involved in two multicenter trials, one comparing sirolimus plus mycophenolate mofetil to sirolimus plus low-dose CsA, while the other trial compares certican plus CsA to certican plus CsA plus corticosteroids.

Necrotizing glomerulonephritis in a living donor kidney transplant recipient.

The occurrence of a rapidly progressive necrotizing glomerulonephritis after kidney transplantation is exceptional and usually leads to graft failure. We describe a case of necrotizing glomerulonephritis that developed 5 months after renal transplantation in a patient suffering from prolonged bowel paralysis and sepsis. After reinforcement of corticosteroid therapy and introduction of cyclophosphamide, glomerulonephritis recovered. Cyclophosphamide was stopped after 2 months and replaced by azatioprine while prednisone was progressively reduced. Three years after transplantation the patient has a stable serum creatinine of 1.7 mg/dL and mild proteinuria. To the best of our knowledge this is the first case of recovery from a necrotizing glomerulonephritis in a renal transplant recipient.

Design of a trial comparing sirolimus plus mycophenolate mofetil versus sirolimus plus cyclosporine.

We present the study design of a prospective, multicenter, randomized trial aimed at comparing the effects of two different combinations of sirolimus. Renal transplant recipients will be allocated to receive either sirolimus and mycophenolate mofetil (group A) or sirolimus and cyclosporine (group B). The primary endpoint will be the graft function at 3, 6, 12, 24, 36, 48, and 60 months. A number of secondary endpoints will also be considered. To obtain a significant difference in the primary endpoint 180 patients will be enrolled.

[Living-donor kidney transplantation in the cyclosporine era]. / Il trapianto di rene da donatore vivente nell'era della ciclosporina.

BACKGROUND: Renal transplantation is the best possibile form of treatment for chronic renal failure. It offers the patient a longer life expectancy when compared to dialysis. Aim of the study was to evaluate our results with live donor transplantation and the variables that influenced the long-term patient and graft survival. METHODS: 190 patients received a live donor kidney transplantation in our Hospital between 1984 and 2000. Thirty-eight of them received a graft from an HLA identical donor, 130 from an HLA haploidentical donor, 22 from a living unrelated donor (spouse). Fourteen patients underwent a pre-emptive transplantation. Aim of the study was to evaluate which variables could influence the long-term patient and graft survival. RESULTS: The median follow-up of recipients was 69.5 months. The 10-year patient and graft survival were 94.7% and 73.4% respectively. Graft half-life was 29.6 years. Six patients died. Twelve patients lost their graft because of vascular thrombosis and five patients because of rejection within the first six months. After the first year, 11 patients lost their graft because of chronic rejection and 4 after recurrence of the original disease. One hundred and forty-four patients are still under observation, and at the last examination their mean plasma creatinine was 2.0+/-1.1 mg/dl. At univariate statistical analysis the absence of locus DR incompatibility was associated with a trend toward a better long-term survival of both patient and graft (P=0.05), while less than one year of dialysis showed a significantly better survival rate (P < 0.01). CONCLUSIONS: Living-donor transplantation offers an excellent long-term patient and graft survival.