Clinical perspectives on treatment of rifampicin-resistant/multidrug-resistant TB.

Rapid diagnostics, newer drugs, repurposed medications, and shorter regimens have radically altered the landscape for treating rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB). There are multiple ongoing clinical trials aiming to build a robust evidence base to guide RR/MDR-TB treatment, and both observational studies and programmatic data have contributed to advancing the treatment field. In December 2019, the WHO issued their second 'Rapid Communication´ related to RR-TB management. This reiterated their prior recommendation that a majority of people with RR/MDR-TB receive all-oral treatment regimens, and now allow for specific shorter duration regimens to be used programmatically as well. Many TB programs need clinical advice as they seek to roll out such regimens in their specific setting. In this Perspective, we highlight our early experiences and lessons learned from working with National TB Programs, adult and pediatric clinicians and civil society, in optimizing treatment of RR/MDR-TB, using shorter, highly-effective, oral regimens for the majority of people with RR/MDR-TB.

The moderating effect of gender role on the relationships between gender and attitudes about body and eating in a sample of Italian adolescents.

PURPOSE: The differential prevalence of eating disorders in males and females can be explained by the impact of gender-role orientations. Inside the Italian socio-cultural context, gender socialization can be influenced by stereotypical gender beliefs, and this may contribute to the psychological distress of individuals who identify with discrepant gender roles from their biological sex. Our study explored, within the Italian context, the potential moderating effect of masculinity and femininity on the relationships between gender and attitudes about body and eating. METHODS: Nine hundred and twenty Italian male and female adolescents (M = 427, F = 493; age 14-21 years) completed the Eating Disorder Inventory-2 (EDI-2) and the Bem Sex-Role Inventory (BSRI). RESULTS: A moderating effect of gender role on the relationship between gender and bulimia, and drive of thinness emerged. Girls with higher levels of masculinity scored higher on bulimia than did their counterparts with lower levels, and boys with higher levels of femininity scored higher on bulimia and on drive for thinness than did their counterparts with lower levels. Data did not reveal a moderating effect of gender role on the relationship between gender and body satisfaction. CONCLUSIONS: Our data suggest that adolescents who endorsed a gender role that is socially considered discrepant from their biological sex (girls with higher levels of masculinity and boys with higher levels of femininity) are more likely to show higher level of bulimia and drive of thinness. This suggests the need for prevention and treatment programmes for eating disorders that take into account individuals' gender-role orientation and the influence that culturally dominant gender beliefs can exert on it.

QTc and anti-tuberculosis drugs: a perfect storm or a tempest in a teacup? Review of evidence and a risk assessment.

Multicentre registry of brain-injured patients with disorder of consciousness: rationale and preliminary data.

Diagnostic accuracy and reliable estimation of clinical evolution are challenging issues in the management of patients with disorders of consciousness (DoC). Longitudinal systematic investigations conducted in large cohorts of patients with DoC could make it possible to identify reliable diagnostic and prognostic markers. On the basis of this consideration, we devised a multicentre prospective registry for patients with DoC admitted to ten intensive rehabilitation units. The registry collects homogeneous and detailed data on patients' demographic and clinical features, neurophysiological and neuroimaging findings, and medical and surgical complications. Here we present the rationale and the design of the registry and the preliminary results obtained in 53 patients with DoC (vegetative state or minimally conscious state) enrolled during the first seven months of the study. Data at 6-month post-injury follow-up were available for 46 of them. This registry could be an important tool for collecting high-quality data through the application of rigorous methods, and it could be used in the routine management of patients with DoC admitted to rehabilitation settings.

High-fat meal, systemic inflammation and glucose homeostasis in obese children and adolescents.

We aimed to assess in obese youths the relationships between interleukin-6 (IL-6), fat meal-induced endotoxemia and glucose homeostasis. Twenty obese children/adolescents (9-17 years old, 11 boys) underwent a standard oral glucose tolerance test and, 7-14 days later, a 5-h fat meal test (fat=69% of energy, saturated/monounsaturated/polyunsaturated fatty acids=31.5%/35%/33.5%), with serial measures of IL-6 and two markers of lipopolysaccharide (LPS) exposure and translocation, LPS-binding protein (LBP) and soluble CD14 (sCD14). IL-6 correlated not only with basal (homeostatic model assessment-insulin resistance) but also with post-prandial (Matsuda index) insulin sensitivity (r=0.61 (0.24-0.82), P=0.005, r=-0.53 (0.12-0.78), P=0.03, respectively). IL-6 did not change after the meal whereas LBP and sCD14 decreased significantly, indicating LPS translocation. Neither basal sCD14 and LBP nor their incremental concentrations correlated with IL-6 or glucose homeostasis. In our sample, IL-6 was associated with insulin sensitivity but not with LPS exposure, suggesting that meals with a balanced content of saturated/monounsaturated/polyunsaturated fatty acids may not be associated with LPS-induced inflammation and metabolic impairment.

Fluid intake and hydration status in obese vs normal weight children.

BACKGROUND/OBJECTIVES: Little is known on the relationship between obesity and hydration levels in children. This study assessed whether and by which mechanisms hydration status differs between obese and non-obese children. SUBJECTS/METHODS: Hydration levels of 86 obese and 89 normal weight children (age: 7-11 years) were compared. Hydration was measured as the average free water reserve (FWR=urine output/24 h minus the obligatory urine output [total 24 h excreted solutes/97th percentile of urine osmolality of children with adequate water intake, that is, 830 mOsm/kg]) over 2 days. Three days of weighed dietary and fluid intakes were recorded. Non-parametric tests were used to compare variables that were skewed and to assess which variables correlated with hydration. Variables mediating the different hydration levels of obese and normal weight children were assessed by co-variance analysis. RESULTS: Obese children were less hydrated than normal weight peers [FWR=median (IQR): 0.80 (-0.80-2.80) hg/day vs 2.10 (0.10-4.45) hg/day, P<0.02; 32% of obese children vs 20% of non-obese peers had negative FWR, P<0.001]. Body mass index (BMI) z-score (z-BMI) and water intake from fluids correlated with FWR (ρ=-0.18 and 0.45, respectively, both P<0.05). Water intake from fluids completely explained the different hydration between obese and normal weight children [FWR adjusted for water from fluids and z-BMI=2.44 (0.44) hg vs 2.10 (0.50) hg, P=NS; B coefficient of co-variation between FWR (hg/day) and water intake from fluids (hg/day)=0.47, P<0.001]. CONCLUSIONS: Obese children were less hydrated than normal weight ones because, taking into account their z-BMI, they drank less. Future prospective studies are needed to explore possible causal relationships between hydration and obesity.

Metabolic and hormonal consequences of two different meals after a moderate intensity exercise bout in obese prepubertal children.

BACKGROUND/OBJECTIVES: To investigate the relationship between postprandial nutrient balance, satiety and hormone changes induced by two different meals taken after a moderate intensity exercise bout. SUBJECTS/METHODS: Ten prepubertal obese children participated in the study. The experiment was designed as a cross-over study for repeated measures. Each test period lasted five consecutive hours during which the children were under medical supervision. The effects of two isocaloric meals were compared after a moderate intensity exercise (4 multiples of resting metabolic rate, 30 min, cycling): a low-fat/high-carbohydrate meal (meal A) and a high-fat/low-carbohydrate meal (meal B). Pre and postprandial (3 h) substrate oxidation, biochemical parameters, gastrointestinal hormone concentrations and appetite were measured. RESULTS: The main results were: (i) higher fat balance (5.1±5.0 vs -5.0±6.6 g, P=0.001) and lower carbohydrate balance after meal B than A (-9.7±13.3 vs 11.3±18.3 g, P<0.01); (ii) higher energy balance after meal B than after meal A (5.9±21.5 vs -13.9±20.2 kcal, P<0.05); (iii) higher plasma triglyceride concentrations (area under the curve) after meal B than after meal A (2962.5±2095.8 mg*180 min/dl vs -169.5±1633.7 mg*180 min/dl, P<0.01); (iv) higher serum glucagon-like peptide-1 concentrations after meal B than after meal A (1101.5±873.0 pmol*180 min/l vs 478.8±638.3 pmol*180 min/l, P<0.05). CONCLUSIONS: After a bout of moderate intensity exercise, a meal with a high-fat/low-carbohydrate ratio had a less favorable metabolic impact than an isoenergetic, isoproteic low-fat/high-carbohydrate meal.

Diet macronutrient composition reported before treatment predicts BMI change in obese children: the role of lipids.

In this study, we tested the hypothesis that diet composition reported by children before the beginning of an obesity treatment program could be a predicting factor of the clinical outcome. A sample of 138 obese 6-16-year-old children and adolescents were recruited. Anthropometry and dietary habits were recorded. Each patient participated in a multidimensional treatment program in an outpatient obesity public service clinic. Therapy was based on a 6-month educational program on nutrition, lifestyle and physical activity. Children with a lipid intake above 34.7% of total energy had a 2.5 times higher chance of reducing at least 1.5 units of BMI with treatment than children with lower lipid intake. These results suggest that the assessment of habitual diet, in particular diet composition before starting treatment, may help to identify obese children who are more sensitive to intervention and those who need more specific nutritional assistance.

Breakfast skipping in prepubertal obese children: hormonal, metabolic and cognitive consequences.

BACKGROUND AND AIMS: Skipping breakfast influences cognitive performance. The aim of our study was to investigate the relationship between the variation of hormonal and metabolic postprandial parameters induced by breakfast consumption or fasting and cognitive performance in obese children. METHODS: Cross-sectional study for repeated measures. Memory and attention assessment tests, hormones and nutrient oxidation were measured before and after consuming breakfast vs fasting in 10 prepubertal obese children. RESULTS: Fasting induced a significant (P<0.05) increase of the Overall Index of the Continuous Performance Test II (a global index of inattention) and the Test of Memory and Learning Word Selective Reminding (a test of verbal memory), whereas no changes were found after breakfast. Fasting was associated with a reduction of insulin and an increase in glucagon, with no changes in glucose. The increase in inattention was associated with a reduction of carbohydrate oxidation (ρ=-0.66, P<0.05). We found no difference in the area under the curve of peptide YY and glucagon-like peptide-1 after breakfast or fasting, whereas Ghrelin was significantly lower. No association between postprandial hormone variation and cognitive performance was found. CONCLUSIONS: Attention and visual memory performance in the morning were reduced when the children skipped breakfast. No association was found with hormones or metabolic changes, but we did find an association with a reduction of carbohydrate oxidation. Nevertheless, these preliminary findings need confirmation in larger sample size.

Epstein-Barr virus is associated with grey matter atrophy in multiple sclerosis.

OBJECTIVE: The aim of the study was to determine whether the presence of anti-Epstein-Barr virus (EBV) antibodies is associated with MRI measures of brain injury and neurodegeneration in patients with multiple sclerosis (MS). METHODS: 135 patients with MS (86 women, 49 men) underwent brain MRI and testing for antibodies against EBV. MRI measurements included gadolinium enhancing lesion volume, T1 and T2 lesion volumes and fractions of whole brain parenchyma (BPF), white matter and grey matter (GMF). The anti-EBV panel included anti-EBV early antigen IgG, anti-EBV nuclear antigen IgG and anti-EBV viral capsid antigen (VCA) IgG levels. The relationships between antibody levels and MRI measurements were assessed in regression analysis. Repeat measurements of anti-EBV VCA IgG and MRI measures were available for a subset of 50 patients after a mean follow-up of 3.1 years. RESULTS: GMF (R(2) = 0.24 for overall model, p = 0.002) and BPF (R(2) = 0.39 for overall model, p<0.001) showed negative associations with anti-EBV-VCA IgG levels. A greater decline in BPF over 3 years was significantly associated with increased 3 years prior time point anti-EBV VCA IgG levels (p<0.001). CONCLUSIONS: The results suggest that the presence of anti-EBV antibodies is associated with MRI markers of GM atrophy in MS and with increased loss of brain volume over 3 years.

Relationships between platelet counts, platelet volumes and reticulated platelets in patients with ITP: evidence for significant platelet count inaccuracies with conventional instrument methods.

The platelet count has a primary role in the diagnosis and treatment of idiopathic thrombocytopenic purpura (ITP). This study analysed the accuracy of ITP patient platelet counts determined by Abbott CD-Sapphire (impedance/optical) and Bayer Advia 120 (optical) analyses, compared with a reference immunoplatelet method. Instrument platelet estimates showed broad equivalence in the higher range of observed values, but significant discrepancies against the immunoplatelet count were seen when platelet counts were <10 x 10(9)/l. CD-Sapphire mean platelet volume (MPV) results revealed increased (>12 fl) platelet volumes in eight of eight ITP patients with counts of <20 x 10(9)/l compared with 6/6 and 5/13 patients with platelet counts of 20-50 and >50 x 10(9)/l. In contrast, Bayer Advia MPV values showed no relationship with the platelet count. Increased reticulated platelets were associated with an increasing CD-Sapphire MPV (R(2) = 0.61) and a decreasing platelet count. High (>40%) reticulated platelet values were seen in 9/9 patients with immunoplatelet counts of <20 x 10(9)/l compared with 0/19 patients with platelet counts above 20 x 10(9)/l. There may be a need for caution in the interpretation of platelet counts in ITP patients obtained with conventional instrument methods, and therapeutic decisions should ideally be validated by reference immunoplatelet procedures.

Time course of serum collagen types I and III metabolism products after reperfused acute myocardial infarction in patients with and without systemic hypertension.

We examined 55 consecutive patients successfully treated with primary percutaneous coronary intervention (PCI) for a first acute myocardial infarction with left ventricular (LV) systolic dysfunction. In all patients we performed echocardiographic examination, dosage of plasma brain natriuretic peptide, serum carboxy-terminal propeptide and telopeptide of procollagen type I and amino-terminal propeptide of procollagen type III at days 1 and 3, and at 1 and 6 months after index infarction. The hypertensive patients (group 1; n=30) differed for higher baseline blood pressure (133+/-4 mm Hg vs 118+/-4 mm Hg; P=0.03), greater LV mass index (108+/-5 vs 94+/-4 g m(-2), P=0.03) and lower mitral E/A wave peak (0.8+/-0.06 vs 1.1+/-0.12, P=0.02) with respect to non-hypertensive patients (group 2; n=25). From day 1 to month 6 carboxy-terminal propeptide of procollagen type I and amino-terminal propeptide of procollagen type III increased (P<0.005 and P<0.05, respectively) in both groups, whereas carboxy-terminal telopeptide of procollagen type I increased from day 1 to day 3 (P<0.01 in both groups, respectively) and then decreased from day 3 to month 6 (P<0.01 and P<0.05 in both groups, respectively). From day 1, brain natriuretic peptide decreased in both groups (P<0.005). There was no significant difference between the two groups in values of procollagens and natriuretic peptide. Finally, LV diastolic volume and function at 6 months were similar in the two groups. Thus, in patients with reperfused acute myocardial infarction and LV dysfunction, antecedent hypertension was not associated with a different pattern of serum procollagen release and ventricular remodelling at 6 months of follow-up.

[Mesothelioma of the pleura in the Province of Trieste]. / Mesotelioma della pleura nella Provincia di Trieste.

BACKGROUND: The Province of Trieste, north-eastern Italy (population about 240,000), has been identified as an area with a high incidence of pleural mesothelioma. OBJECTIVES: (i) To obtain preliminary data on the trend of the mesothelioma epidemic in the Province of Trieste during the last six years; (ii) to define the cases in terms of asbestos exposure. METHODS: Pleural mesotheliomas diagnosed at the Department of Surgery, Thoracic Surgery Unit, Trieste University, in the period January 2001-May 2006 were reviewed. The histological diagnosis was generally based on material obtained at thoracoscopy, pleurectomy, or pleuropneumonectomy. In three cases the pathological diagnosis was made by biopsy of the thoracic wall, and in a further three cases by cytological examination ofpleuralfluid. Detailed occupational histories were obtained from the patients themselves at the time of first admission. RESULTS: The group included 99 people resident in the Province of Trieste (89 men and 10 women, aged between 43 and 89 years). On the basis of the occupational history, 95 cases were defined as asbestos-related. A majority ofpatients had been employed in marine work, including shipbuilding (46 cases), port activity (13 cases), and maritime trades (8 cases). Thirteen patients had worked in other industries (iron industry, petrochemical, etc.). Fourteen people had been employed in a variety of occupations (fire-fighter, lift mechanic, cinema projectionist, pastry worker, telephone technician, etc.). Five women had histories of exposure to asbestos at home. About 70% of the patients had their first exposure to asbestos before 1960. Two-thirds of the cases were exposed to asbestos for 20 years or more. Latency periods (time intervals elapsed between first exposure to asbestos and diagnosis of mesothelioma) rangedfrom 25 to 71 years (mean 49.3, median 49.0). One patient had a history ofprior thoracic irradiationfor Hodgkin's disease. CONCLUSIONS: In the Province of Trieste the mesothelioma epidemic does not show any signs of abatement. Besides marine work, a variety of other occupations appear to be associated with the tumour in this area.

Characterization of the functional and growth properties of long-term cell cultures established from a human somatostatinoma.

In somatostatinoma, a rare malignant somatostatin (SST)-secreting neoplasia, tumour regression is rarely observed, implying the need for novel antiproliferative strategies. Here, we characterized a long-term culture (SST-secreting cancer (SS-C cells)) established from a human somatostatinoma. High concentrations of SST and chromogranin A were released by SS-C cells and SST release was stimulated by depolarizing stimuli and inhibited by the SST analogue, octreotide. SS-C cells expressed mRNA for SST receptor (SSTR) subtypes 1, 2 and 4, being also able to bind native SST. Moreover, SS-C cells were positively stained with an antibody to SSTR2. SS-C cells also expressed interferon-gamma (IFN-gamma) receptor mRNA and measurable telomerase activity. Our findings indicate that in vitro exposure of SS-C cells to native SST-28, to octreotide, to IFN-gamma, or to 3'-azido-3'deoxythymidine (AZT), a telomerase inhibitor, results in inhibition of SS-C cell proliferation. Concomitant with growth inhibition, apoptosis was detected in SST-, octreotide-, IFN-gamma- or AZT-treated SS-C cell cultures. Taken together our results characterized native SST, SST analogues, IFN-gamma and a telomerase inhibitor as growth-inhibiting and proapoptotic stimuli in cultured human somatostatinoma cells. Based on these findings, the potential of SST analogues, IFN-gamma and AZT, alone or in combination, should be further explored in the medical treatment of somatostatinoma.

Long-term effects of intravenous high dose methylprednisolone pulses on bone mineral density in patients with multiple sclerosis.

To determine the effects of high dose methylprednisolone (HDMP) pulses on bone mineral density (BMD) in patients with multiple sclerosis (MS), we studied 25 MS patients who received regular pulses of HDMP as well as pulses of HDMP for relapses, 18 MS patients who received HDMP at the same dose schedule only for relapses, and 61 healthy controls. We measured BMDs at lumbar spine and femoral neck and we assessed biochemical markers of bone metabolism and turnover. The average lifetime dosage of MP was 75.4 (SD 11.9) g in the pulsed HDMP group and 28.6 (SD 18.3) g in the HDMP for relapses group (P < 0.0001). Two MS patients (4.7%) and four controls (6.6%) had osteoporosis (P = NS), whereas 25 patients with MS (58.1%) and 21 controls (34.4%) had osteopenia (P = 0.016). BMDs measured at lumbar spine and femoral neck and biochemical indices of bone metabolism did not differ in MS patients and controls. BMD measures were not associated with lifetime methylprednisolone dosage. In partial correlation analysis, controlling for age, gender and menopausal status there was a significant inverse correlation between BMD at femoral neck and Expanded Disability Status Scale (EDSS) score (r = -0.31, P = 0.05). In conclusion, treatment with repeated HDMP pulses was not associated with osteoporosis in patients with MS who participated in a trial of methylprednisolone. However, osteopenia was observed more frequently in MS patients than healthy controls. Our data are reassuring, as them suggest that repeated pulses of methylprednisolone do not result in substantially increased risk of osteoporosis in MS patients. Moreover, osteopenia was found only in patients treated for relapses, who had a significantly higher EDSS score than patients in the HDMP group, suggesting that decreased mobility may contribute to bone loss more than corticosteroid use. BMD should be monitored in patients with MS, regardless of the use of methylprednisolone.

Risk factors of multiple sclerosis: a case-control study.

We assessed the risk of multiple sclerosis (MS) associated with a series of putative risk factors. We studied 140 patients (90 women) with MS (mean age, 42.1 years; SD= 10.2 years; disease duration, 10.9 years, SD= 7.5 years) and 131 sex-and age-matched controls. Using a structured questionnaire, we collected information related to demographic data, socio-economic status, education, ethnicity, changes of domiciles, migration, occupation, environmental, nutritional and hormonal factors, exposure to various bacterial and viral agents, vaccinations, and family history of diseases. In multiple logistic regression analysis, we found independent risk factors of MS to be: familiarity for MS (OR= 12.1; 95% CI, 1.3-110.7), autoimmune diseases (OR= 3.8; 95% CI, 2.0-7.1) and migraine (OR= 8.7; 95% CI, 1.0-75.4); comorbidity with autoimmune disease (OR= 6.8; 95% CI, 1.4-32.0) and migraine (OR= 13.5; 95% CI, 1.5-116.6); and vaccination against measles (OR= 92.2; 95%, 12.1-700.2). Familial susceptibility to MS, autoimmune diseases and migraine, and vaccination to measles are associated with an increased risk of MS. The data collected in this study are confirmatory and support the hypothesis that etiology of MS constitutes the effect of interplay between genetic and environmental risk factors. However, the relatively small number of cases and controls prevents firm conclusions.

Correlation of sexual dysfunction and brain magnetic resonance imaging in multiple sclerosis.

Sixty-two patients (40 women and 22 men) with multiple sclerosis (MS) were examined with 1.5 tesla magnetic resonance imaging (MRI) of the brain. Information on sexual and sphincteric disturbances has been collected, and data on disability, independence, cognitive performances and psychological functioning have been assessed. Calculations of T1- and T2-lesion load (LL) of total brain, frontal lobes and pons have been performed using a reproducible semiautomated technique. Whole brain, frontal and pontine atrophies were estimated using a normalized measure, the brain parenchymal fraction (BPF), obtained with a computerized interactive program. When comparing patients with and without sexual dysfunction (SD), there were no differences in total brain, frontal and pontine T1- and T2-LL, as well as in measures of whole brain and frontal atrophy. The only significant difference was in the pontine BPF (P = 0.026). In linear multiple regression analysis, SD was associated with depression (R = 0.56, P < 0.001) and, after adjusting for depression and anxiety, with bladder dysfunction (R = 0.43, P = 0.003) and pontine BPF (R = 0.56, P < 0.001). No association between SD and any of the measures of T1- and T2-LL was found. The findings showed a relationship between SD and pontine atrophy, confirmed the correlation of SD with bladder dysfunction and highlighted the role of psychological factors in determining SD.

Depressive symptoms and MRI changes in multiple sclerosis.

To determine whether changes in specific regions of the brain can contribute to the development of depression in patients with multiple sclerosis (MS). We prospectively studied 90 patients with clinically definite MS. Disability, independence, cognitive performances, and depressive and anxiety symptoms have been assessed at baseline and 2 years later. At these two time-points, patients underwent a 1.5-T magnetic resonance examination of the brain including T1- and T2-weighted images. Calculation of regional and total lesion loads (LL) have been performed by a semiautomatic technique; total and regional brain volumes have been calculated by a fully automatic highly reproducible computerized interactive program. Measurements of LL did not show any significant difference between depressed and non-depressed patients. Brain atrophy was significantly more conspicuous in the left frontal lobe (P=0.039), in both frontal lobes (P=0.046) and showed a trend towards a difference in the right frontal lobe (P=0.056), in the right temporal lobe (P=0.057) and in both temporal lobes (P=0.072) of depressed patients. Disability, independence and cognitive performances were similar in depressed and non-depressed patients (P=NS). Spearman correlation analysis and multiple-regression analysis demonstrated that the severity of the depressive symptoms score was associated both with the disability score and the right temporal brain volume. Destructive lesions in the right temporal lobe can contribute to the severity of depression in patients with MS but the influence of the severity of neurological impairment should be taken into account.

[Anesthesia for carotid paraganglioma exeresis. Report of 3 cases]. / Implicaciones anestesiológicas de la exéresis de paragangliomas carotídeos. A propósito de tres casos clínicos.

This report of carotid paraganglioma excision in three patients discusses differential diagnosis, preoperative assessment, preoperative embolization of the tumor, monitoring of anesthesia including cerebral oximetry, and postoperative complications. We consider cerebral protection to be essential during carotid paraganglioma surgery. Such protection may be provided by drugs such as sodium thiopental and by temporarily shunting the internal carotid artery. Preoperative angiography is also important for evaluating retrograde circulation through Willis's polygon and to examine the arteries irrigating the tumor. Information thus obtained helps establish the need for presurgical embolization of the tumor, thereby possibly reducing the risks, such as obstructive hematoma that are inherent to the procedure. Finally, in our opinion, full monitoring should include cerebral oximetry so that possible complications can be detected and resolved.