A safe immunosuppressive protocol in adult-to-adult living related liver transplantation.

BACKGROUND: In this series of 32 adult-to-adult living related liver transplantations, we assessed the efficacy and safety of basiliximab in combination with a tacrolimus-based regimen. Basiliximab, a chimeric monoclonal antibody directed against the alpha chain of the interleukin-2 (IL-2) receptor (CD25), has been extensively evaluated as induction therapy for cadaveric liver transplant recipients. PATIENTS AND METHODS: Thirty-two adult-to-adult living related liver transplantations were performed in the last 3 years. All patients received two 20 mg doses of basiliximab (days 0 and 4 posttransplantation) followed by tacrolimus (0.15 mg/kg/d; 10-15 ng/mL target trough levels) and steroids (starting with 20 mg IV switched to PO as soon as the patient was able to eat and weaned within 1-2 months). The average follow-up was 395 days after transplantation. RESULTS: Of the patients, 93.75% remained rejection-free during follow-up with an actuarial rejection-free probability of 92.59% within 3 months. Two patients (6%) had one episode of biopsy-proven acute cellular rejection (ACR). Actuarial patient and graft survival rates at 3 years were 86.85% and 81.25%. One patient (3%) experienced one episode of sepsis. There was no evidence of cytomegalovirus infections or side effects related to the basiliximab. We found zero de novo malignancy but we observed two patients with metastatic spread of their primary malignancy during the follow-up. CONCLUSION: Basiliximab in association with tacrolimus and steroids is effective as prophylaxis of ACR among adult living related liver transplant recipients.

Reduced habituation to experimental pain in migraine patients: a CO(2) laser evoked potential study.

The habituation to sensory stimuli of different modalities is reduced in migraine patients. However, the habituation to pain has never been evaluated. Our aim was to assess the nociceptive pathway function and the habituation to experimental pain in patients with migraine. Scalp potentials were evoked by CO(2) laser stimulation (laser evoked potentials, LEPs) of the hand and facial skin in 24 patients with migraine without aura (MO), 19 patients with chronic tension-type headache (CTTH), and 28 control subjects (CS). The habituation was studied by measuring the changes of LEP amplitudes across three consecutive repetitions of 30 trials each (the repetitions lasted 5 min and were separated by 5-min intervals). The slope of the regression line between LEP amplitude and number of repetitions was taken as an index of habituation. The LEPs consisted of middle-latency, low-amplitude responses (N1, contralateral temporal region, and P1, frontal region) followed by a late, high-amplitude, negative-positive complex (N2/P2, vertex). The latency and amplitude of these responses were similar in both patients and controls. While CS and CTTH patients showed a significant habituation of the N2/P2 response, in MO patients this LEP component did not develop any habituation at all after face stimulation and showed a significantly lower habituation than in CS after hand stimulation. The habituation index of the vertex N2/P2 complex exceeded the normal limits in 13 out of the 24 MO patients and in none of the 19 CTTH patients (P<0.0001; Fisher's exact test). Moreover, while the N1-P1 amplitude showed a significant habituation in CS after hand stimulation, it did not change across repetitions in MO patients. In conclusion, no functional impairment of the nociceptive pathways, including the trigeminal pathways, was found in either MO or CTTH patients. But patients with migraine had a reduced habituation, which probably reflects an abnormal excitability of the cortical areas involved in pain processing.

Peripheral neuropathy with hypomyelinating features in adult-onset Krabbe's disease.

We describe three brothers suffering from Krabbe's disease with onset in the fifth decade. The proband showed a complete deficiency of leukocyte enzyme galactocerebrosidase and was found to be heterozygous for two previously described mutations: G > A809 and 502T/del consisting of a 30 kb deletion. In all three brothers the neurological examination showed features of asymmetrical peripheral neuropathy associated with pyramidal signs and the electrophysiological examination showed a generalized slowing of nerve conduction velocities. Two patients died at 59 and 61 years of age due to respiratory failure. Both the proband and his brother underwent a sural nerve biopsy. In the former the most striking finding was the presence of uniformly thin myelin sheaths without evidence of demyelination; a complete absence of fibers was found in the latter. Our findings confirm that peripheral neuropathy may be the presenting feature of late-onset Krabbe's disease. Hypomyelination rather than demyelination may represent the distinguishing pathological finding of this condition.

Immunocytochemical localization of thioredoxin in human trophoblast and decidua.

An immunocytochemical investigation into the expression of thioredoxin in human reproductive tissues was performed using monoclonal antibodies produced against recombinant human thioredoxin. First trimester and term human placental villi, decidua and term fetal membranes were examined for thioredoxin content and cellular localization. In first trimester tissue strong thioredoxin staining was observed in the underlying cytotrophoblast cells and in the stromal cells present in the decidua, but not in the syncytiotrophoblast surrounding the chorionic villi. In term placental villi very little thioredoxin was observed. Term fetal membranes proved to be a rich source of thioredoxin, the most intense staining was seen in the cytotrophoblast cells in the chorionic membrane, with the amnion and decidua also showing positive immunoreactivity. The potential role/s that thioredoxin may play within the placental bed is considered.

Immunosuppressive effect of early pregnancy factor on early expression of cell surface membrane IgG.

We have adopted a new assay to investigate the influence of early pregnancy factor (EPF) on the modulation of lymphocyte activity. Lymphocytes were attached to the plastic surfaces of microplates in serum-free medium in the presence of Sepharose-Con A. After 2-3 days incubation with EPF, and ELISA assay was used to detect the expression of surface membrane IgG (smIgG); this was done in the same microplates used for the culture, thus avoiding cell manipulation. Using only a few picograms of EPF a significant inhibition (in the range 26-40%) was obtained. The variation in the inhibition observed was mainly due to the different sources of lymphocytes used. Unrelated proteins and hormones, tested at the same concentration as EPF, did not show any inhibitory activity. Using the F(ab)2 fragment of anti-human IgG instead of the whole molecule the same levels of inhibition were obtained, suggesting that the observed inhibition by EPF was not due to a non-specific interaction between the anti-human IgG and the Fc receptors on the cell. Such inhibitory activity detected in vitro by this method provides additional support for a suppressive role for EPF during pregnancy.

Identification of a histamine-releasing factor secreted by human pre-implantation embryos grown in vitro.

Human pre-implantation stage embryos cultured in vitro spontaneously secreted a factor capable of inducing histamine-release from human blood basophils. The embryo-derived histamine-releasing factor (EHRF) has been isolated from the culture medium by means of heparin-Sepharose affinity chromatography. The factor bound to the column and was then eluted by increasing the buffer molarity to 1.5 M NaCl. EHRF was detected using an enzymatic-isotopic microassay and sensitized basophils known to undergo release with anti-IgE. The EHRF-induced histamine-release was calcium and temperature dependent and the relatively slow kinetics (10 min) were similar to those obtained with anti-IgE. EHRF caused the release of a substantial amount of histamine (48%, n = 18) in a dose-dependent manner. The equivalent fraction isolated from medium containing unfertilized oocytes gave less than 10% of histamine-release using the same source of basophils, suggesting that EHRF was secreted after fertilization. EHRF was very stable since it was resistant to boiling, lyophilization, and to several freeze and thaw treatments. The histamine-releasing activity induced by EHRF was measured in vitro also by means of purified leukocytes containing sensitized basophils. EHRF could represent a message sent by the embryo to the mother to induce histamine release at the time of implantation.

Dispersal of rat uterine mast cells and their functional response to an embryo-derived histamine releasing factor: a possible model for embryo implantation.

Rat uterine tissue was dissociated by enzymatic digestion with collagenase and viable mast cells were obtained. Their viability was assessed by the ability to exclude trypan blue dye and to respond functionally to different stimuli. Challenge with anti-IgE gave a calcium-dependent histamine release of 49%, whilst the undigested uterine fragments gave 23%. Moreover, they were capable of releasing histamine on challenge with the compound 48/80, suggesting a similarity with connective tissue mast cells. This similarity was further supported by their insensitivity to aldehyde blocking of dye binding. The final dispersed cell preparation contained 3 X 10(5) mast cells/g of uterine tissue, representing about 2% of total nucleated cells. The total histamine content of the undigested uterus was 2.5 micrograms/g of tissue, whilst after digestion the histamine determined was 1.2 pg per mast cell with a yield of 14%. The total histamine content of the uterus changed throughout the reproductive cycle, increasing before ovulation, reaching a maximum during ovulation and then decreasing after embryo implantation. This suggests that the implanting embryo, interacting with the uterus, may be capable of inducing the release of histamine. The embryo-derived histamine releasing factor (EHRF) that we have described previously is capable of inducing 22% histamine-release on uterine mast cells, thus supporting this hypothesis.

On the white matter lesions of the Creutzfeldt-Jakob disease. Can a new subentity be recognized in man?

One case of CJD with severe involvement of the white matter is discussed. The patient was admitted after a 3-month clinical course with rapidly increasing mental deterioration, coma vigil-like state, myoclonic twitching of the limbs and of the facial muscles. The EEG showed the typical features of CJD. The first CT scan, performed 3 months after onset, revealed only a mild cortical and subcortical atrophy of the brain. The second CT scan, 12 months later, showed a considerable cortical and subcortical atrophy of the brain. The patient died 18 months after onset. Neuropathological examination showed a severe degeneration in the gray matter, with spongiosis, loss of neurones and hypertrophic glial reaction. The white matter was also involved with severe spongiosis, demyelination and hypertrophic glial proliferation. The case is discussed in relation to the data in the literature. It is argued that cases of CJD with severe involvement of the white matter should be classified as a new neuropathological subentity of CJD.

Anatomo-clinical correlations in normotensive hydrocephalus. Reports on three cases.

The brains of 3 adult subjects suffering from normotensive hydrocephalus have been examined pathologically. The diagnosis of normotensive hydrocephalus was based on clinical symptoms, pneumoencephalography and isotope cisternography, in 1 case integrated with the results of the constant-infusion manometric test. Part of the neuropathological findings were common to the 3 patients: leptomeningeal non-obstructive fibrosis, ventricular ependymal disruption, subependymal glial reaction, periventricular demyelination and spongiosis. Other neuropathological abnormalities were peculiar to each patient: leptomeningeal signs of previous subarachnoid haemorrhage; arteriosclerosis and multiple brain cystic infarcts; Alzheimer's plaques in the gray matter. The possible pathogenetic significance of the neuropathological findings summarized above in relation to the development of normotensive hydrocephalus is discussed.

Experimental acute hypoxia. Brain preservation by phenobarbital pretreatment. Histological study in guinea pigs.

Acute hypoxia was induced by keeping guinea pigs in an atmosphere of 5% O2/95% N2 for 20 min. Four groups of 10 guinea pigs each were used: (A) control; (B) after 20 min of hypoxia; (C) after 20 min of hypoxia and 20 min of oxygen therapy (100%); (D) pretreatment with phenobarbital (100 mg/kg body wt) and 20 min of hypoxia, followed by 20 min of oxygen therapy. The histological study did not show significant differences between barbiturate-treated and untreated hypoxic brains. In fact, the severity of ischemic-hypoxic damage as well as its distribution were similar in all the experimental groups of animals. Lesions predominated in the regions which are known to be more sensitive to hypoxia (3rd and 4th layers of parieto-occipital cortex, Sommer's fields, cerebellum). It is considered that in the experimental conditions barbiturates did not act as a protective agent--at least as assessed morphologically.

Guinea pig serum L-asparaginase: purification, and immunological relationship to liver L-asparaginase and serum L-asparaginases in other mammals.

L-asparaginase, an enzyme used in the treatment of acute lymphocytic leukemia, is found in the serum of only a few mammalian groups, including the guinea pig and its close relatives in the superfamily Cavioidea. This report describes the purification and characterization of L-asparaginase from guinea pig serum. Antiserum against the purified enzyme cross-reacted with sera from other Cavioidean species but not with mouse serum. Relatively weak cross-reaction with unpurified L-asparaginase in guinea pig liver indicates a significant degree of evolutionary divergence.

Myasthenia gravis and thymic Hodgkin's disease associated in one patient with familial lymphoproliferative disorders.

A 38-year-old man affected with generalized myasthenia gravis (MG) was submitted to thymectomy. At surgery thymic Hodgkin's disease (granulomatous thymoma) and an area of thymic hyperplasia were found. Subsequently, after treatment with anticholinesterase and corticosteroids, the patient achieved clinical remission. The development of MG in this patient could be related to the presence of thymic hyperplasia, rather than to the granulomatous thymoma. Family history revealed that a brother of the patient was affected by non-Hodgkin T-cell lymphoma. Human leukocyte antigens (HLA) were identical in the two affected siblings. The present report suggests a possible link between MG and lymphoproliferative disorders whose mechanism still needs to be clarified.

Gliomatosis cerebri: report of an atypical case.

Gliomatosis cerebri (GC) is a rare, diffusely infiltrating tumor of neuroepithelial origin. The clinical diagnosis is difficult since GC is a diffuse and progressive disease of the central nervous system (CNS). Non-specific findings can be detected by computed tomography (CT) whereas, according to some authors, the extent of this tumor can be accurately depicted by magnetic resonance imaging (MRI). In this paper the neuroradiologic, neuropathologic and immunohistochemical features in a further case of GC are reported.

Morphological studies of sural nerve biopsies in the pseudopolyneuropathic form of amyotrophic lateral sclerosis.

The aim of this work was to study the neuropathological picture of the sural nerve in the pseudopolyneuropathic form of amyotrophic lateral sclerosis (ALS). Five patients were considered: in all cases the clinical and electromyographic follow-up excluded other diseases. EMG-studies were repeatedly performed: they showed the progressive evolution of the spinal anterior horn cell pathology from lower spinal to cervical levels. The sural nerve was removed and immediately fixed in phosphate-buffered 2.5% glutaraldehyde and processed according to the procedure used in our laboratory for light and ultrastructural microscopy. Quantitative analysis of myelinated fiber density was carried out on photographic enlargements of 1 micron semithin sections and recorded on histograms. The light and ultrastructural findings revealed a severe loss of myelinated fibers, the decrease affecting all types of fibers, but predominantly the largest ones. In the teased fibers, Wallerian-like degeneration was observed. In the axons there was an increase of mitochondria, dilatation of the small vesicles, and an increase in the number of neurofilaments. It can be assumed from the histopathologic data that the neuropathologic pattern in the pseudopolyneuropathic form of ALS shows an axonal degeneration. It is our opinion that the histopathologic data obtained in the sural nerve biopsy in this form of ALS reveals a clear involvement of the sensory neurons of the spinal ganglia, and the results can be useful for the study of precocious lesions in ALS.

Multiple sclerosis associated with peripheral demyelinating neuropathy.

We report clinical, electrophysiological, magnetic resonance imaging, and nerve biopsy findings of 2 patients with definite multiple sclerosis and peripheral demyelinating disease. Although it is not easy to assess the real incidence of peripheral neuropathy in patients with multiple sclerosis, this association seems to be rare. The combination of central and peripheral demyelination may be a fortuitous coincidence, but it appears improbable. Alternatively, these patients may represent a specific subpopulation and common immunopathogenetic mechanisms (such as immunological factors, endothelial alterations, and abnormal expression of adhesion molecules) may underly both central and peripheral myelin involvement. The study of these cases might clarify specific mechanisms of pathogenetic significance in demyelinating diseases.

Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS).

We report the clinical, pathological, and genetic findings of a case of MELAS syndrome. This was a man who died for metabolic failure at the age of 27 years. His familiar history was positive for hypoacusia and stroke. He was of short stature and presented mild mental retardation. Since the age of 21 he suffered from recurrent brain-ischemic lesions mainly in the occipital lobes, documented by repeated CT scans. The laboratory data and muscle biopsy disclosed lactic acidosis with ragged red fibres. Neurophysiological data and peripheral nerve biopsy showed an axonal neuropathy. A point mutation in the tRNALeu(UUR) gene of mitochondrial DNA was detected in 5 post-mortem tissues and in muscle biopsy. No defects of mitochondrial respiratory chain were detected. The histological and ultrastructural studies of the brain showed multiple and heterogeneous ischemic lesions with no obvious alterations of cerebral blood vessels. These lesions do not correspond to the vascular territories of main cerebral arteries. Our observations support the hypothesis that local metabolic alterations would play a crucial role in the pathogenesis of cerebral ischemic lesions in MELAS. The correlation between genetic, biochemical, and pathological data are discussed.

Light and ultrastructural studies in sural biopsies of the pseudopolyneuropathic form of ALS.

The aim of this work was to study the neuropathological picture of the sural nerve in the pseudopolineuropathic form of A.L.S. Five patients were considered: in all cases the clinical and electromyographic follow-up excluded other diseases. EMG-studies were repeatedly performed: they showed the progressive evolution of the spinal anterior horn cell pathology from lower spinal to cervical levels. The sural nerve was processed according to the procedure used in our laboratory for light and ultrastructural examination. Quantitative analysis of myelinated fiber density was carried out on photographic enlargement and reported on histograms. The light and ultrastructural examination showed a severe loss of myelinated fibers; the decrease affected all types of fibers, but predominated in the largest ones. In the axons there was an increase of mitochondria, dilation of the small vesicles and increase in the number of neurofilaments. It is our opinion that all histopathologic data obtained in the sural nerve biopsy in this form of A.L.S. reveal a clear involvement of the sensory neurons of the spinal ganglia and the results can be useful for the study of precocius lesions in the A.L.S.

[Citicoline in the treatment of cognitive and behavioral disorders in pathologic senile decline]. / La citicolina nel trattamento dei disturbi cognitivi e comportamentali del decadimento senile patologico.

A three months study was performed on 150 aging patients with primary memory deficits in order to verify the effectiveness of CDP-Choline, administered in repeated cycles of four weeks, with an interval of one week between cycles, in improving patients' cognitive and behavioral efficiency and in stabilizing their cognitive decline. Objective measures of memory and attention, and a behavioral rating scale were used to assess treatment effects. CDP-Choline treatment demonstrated both symptomatic efficacy and a long lasting effect on cognition and behavior of these patients. Level of activation and attention responsiveness improved during treatment cycles and no further changes were identified of these variables in the follow-up period. Measures related to specific memory functioning showed, besides improvements during treatment, after-effects still active in the follow-up period, suggesting a long lasting change of the cognitive decline trend characteristic of these patients.

Gabapentin in the prophylaxis of migraine: a double-blind randomized placebo-controlled study.

OBJECTIVE: Gabapentin is an antiepileptic drug of new generation that increases brain GABA levels. We report the results of a three-month randomised double-blind placebo-controlled study on the effects of gabapentin in the prophylaxis of patients with migraine meeting the IHS criteria. PATIENTS AND METHODS: We treated 63 patients suffering from migraine with or without aura. Patients treated their attack at home using symptomatic drugs and clinical assessment was recorded on a diary. After a washout of 8 week from any other prophylactic treatment, all patients were treated with 1200 mg/day of gabapentin; this is our therapeutic plan: 400 mg/day from 1st to 3rd day, 800 mg/day from 4th to 6th day and 1200 mg/day from 7th day. RESULTS: No patients withdrew, gabapentin was well tolerated; adverse events (somnolence, dizziness, tremor, fatigue and ataxia) generally were transient and mild to moderate in severity and in 13 patients (27%) only occurred. At the end of treatment, in such case, we reported a significative reduction of frequency and intensity of migraine in 30 patients treated with gabapentin. DISCUSSION: Our observations indicate that gabapentin is well tolerated by patients and that reduces headache frequency and use of symptomatic drugs in both groups. Gabapentin shows to have an effective therapeutic action in the prophylactic treatment of migraine.

Antiepileptic drugs in migraine prophylaxis: state of the art.

Antiepileptic drugs have proven their efficacy in the prophylactic treatment of migraine. Our study comprises a clinical trial that examines the efficacy of gabapentin and topiramate and a description of the pharmacologic characteristics and the efficacy of tiagabine, lamotrigine, levetiracetam and zonisamide. Antiepileptic drugs have multiple modes of action which can explain their efficacy in reducing neuronal excitability which is proven in epilepsy and postulated in migraine. The relationship between epilepsy and migraine has, in fact, been much debated but never convincingly proven. Antiepileptic drugs could be useful in migraine prophylaxis as some of these have determined a reduction in the monthly frequency and intensity of crises in subjects suffering from migraine with and without aura. These are the aims that have been proposed by the U.S. Headache Consortium Evidence-Based Guidelines. Further double-blind placebo-controlled studies are necessary in order to assess their safety and efficacy.