Original technique for preoperative preparation of patients and intraoperative localization of parathyroid adenomas.

Surgical approach of single parathyroid adenoma treatment is turning to a less invasive surgery, allowing us to obtain better aesthetic results, reduction of duration of surgical operation, reduction of post-operative morbidity and hospital stay. Tc99m-sestaMIBI scintigraphy is mainly performed for preoperative localization of parathyroid adenomas. Our technique is instead based on the possibility to inhibit the interference of Tc99m-sestaMIBI uptake of the thyroid gland by means of the administration of Lugol's solution. Indeed, to confirm the identification and removal of the hyperfunctional parathyroid, it is accepted as adequate an ex vivo radioactivity count of the adenoma 20% or 40% greater than the value of the post-excisional background radioactivity, in association or not with intraoperative measurement of PTH. This method allows us to perform surgery with no timetable restriction, and to clearly distinguish the radioactivity of parathyroid adenoma from that of the surrounding tissues and thyroid gland.

Functional connectivity changes within specific networks parallel the clinical evolution of multiple sclerosis.

BACKGROUND: In multiple sclerosis (MS), the location of focal lesions does not always correlate with clinical symptoms, suggesting disconnection as a major pathophysiological mechanism. Resting-state (RS) functional magnetic resonance imaging (fMRI) is believed to reflect brain functional connectivity (FC) within specific neuronal networks. OBJECTIVE: RS-fMRI was used to investigate changes in FC within two critical networks for the understanding of MS disabilities, namely, the sensory-motor network (SMN) and the default-mode network (DMN), respectively, implicated in sensory-motor and cognitive functions. METHODS: Thirty-four relapsing-remitting (RR), 14 secondary progressive (SP) MS patients and 25 healthy controls underwent MRI at 3T, including conventional images, T1-weighted volumes, and RS-fMRI sequences. Independent component analysis (ICA) was employed to extract maps of the relevant RS networks for every participant. Group analyses were performed to assess changes in FC within the SMN and DMN in the two MS phenotypes. RESULTS: Increased FC was found in both networks of MS patients. Interestingly, specific changes in either direction were observed also between RR and SP MS groups. CONCLUSIONS: FC changes seem to parallel patients' clinical state and capability of compensating for the severity of clinical/cognitive disabilities.

Effect of glatiramer acetate on disease reactivation in MS patients discontinuing natalizumab.

BACKGROUND AND PURPOSE: Multiple sclerosis (MS) patients discontinuing natalizumab are at risk of rebound of disease activity. METHODS: In the present multi-center, open-label, non-randomized, prospective, pilot study, we tested whether treatment with glatiramer acetate (GA) is safe and effective after natalizumab in MS patients. The study was performed at academic tertiary medical centers. Forty active relapsing-remitting MS patients who never failed GA therapy and who discontinued natalizumab after 12-18 months of therapy were enrolled. GA was initiated 4 weeks after the last dose of natalizumab. RESULTS: 62.5% of patients were relapse-free 12 months after GA initiation. Annualized relapse rate and time to relapse were significantly lower than before natalizumab. Notably, the frequency of relapses was significantly lower amongst those patients who had experienced ≤2 relapses the year before initiation of natalizumab therapy, compared with patients who had had three or more relapses. No evidence of rebound was observed in magnetic resonance imaging scans. Furthermore, Expanded Disability Status Scale and Multiple Sclerosis Functional Composite were stable in our patients, again suggesting that 12 months of post-natalizumab-GA therapy is not associated with clinical deterioration. CONCLUSIONS: Following discontinuation of natalizumab, 12 months of therapy with GA is safe and well tolerated in MS patients. GA can reduce the risk of early reactivation/rebound of disease activity in this setting.

Effects of intermittent theta burst stimulation on spasticity in patients with multiple sclerosis.

BACKGROUND AND PURPOSE: Spasticity is a common disorder and a major cause of long-term disability in patients with multiple sclerosis (MS). Our aim was to evaluate whether a recently developed repetitive transcranial magnetic stimulation protocol, the intermittent theta burst stimulation (iTBS) is effective in modulating lower limb spasticity in MS patients. METHODS: Twenty MS patients were pseudorandomized to undergo a 2-week daily sessions of real or sham iTBS protocol. The H/M amplitude ratio of the Soleus H reflex, a reliable neurophysiological index of spinal excitability and the Modified Ashworth Scale (MAS) for spasticity were evaluated by blinded raters before and after the stimulation protocols. RESULTS: Patients receiving real iTBS showed a significant reduction of H/M amplitude ratio and MAS scores 1 week after the stimulation and persisting up to 2 weeks after the end of stimulation protocol. There were no significant effects for sham stimulation. CONCLUSIONS: These results show that iTBS, a safe, non-invasive, well-tolerated and feasible protocol, is a promising tool for the treatment of spasticity in MS.

Technetium-99m tetrofosmin single photon emission computed tomography in the evaluation of suspected lung cancer.

Technetium-99m-tetrofosmin is a radiopharmaceutical employed for myocardial imaging, which has recently emerged as useful in the visualization of tumors. In this study technetium-99m-tetrofosmin was evaluated for its accuracy in differentiating malignant from benign pulmonary lesions, and in detecting mediastinal node metastasis due to lung cancer. Eighty-one patients with a solitary lung lesion on the chest radiograph and/or CT scan were submitted to chest single photon emission computed tomography after technetium-99m-tetrofosmin injection (740 MBq i.v.). The scintigraphic findings were correlated to the final histopathological diagnosis, demonstrating abnormal tracer accumulation in 51 of 54 malignant lesions (sensitivity 94%) and in 4 out of 27 benign conditions (specificity 85%), yielding an accuracy of 91%. Mediastinal lymph-node involvement was evaluated in 35 patients with non small cell lung cancer who underwent mediastinoscopy and/or surgery. Tetrofosmin accuracy (89%) was significantly higher than that of CT (69%, p < 0.05); the false negative scintigraphic results were in nodes sized less than 1 cm. In conclusion, technetium-99m-tetrofosmin imaging is useful in distinguishing malignant from benign pulmonary lesions, and in non-invasively assessing mediastinal node metastases from non small cell lung cancer, especially in patients with enlarged nodes by CT scan.

Concurrent right atrial myxoma and malignant lymphoma.

Atrial myxomas are the most common primary tumor of the heart. We report an unusual case where an incidentally found right atrial myxoma was associated with a malignant lymphoma. Surgical management of the concurrent problems is discussed as well as a review of pertinent literature and efficacy of diagnostic modalities.

Technetium-99m tetrofosmin imaging in malignant lymphomas.

AIMS: To assess the utility of 99mTc tetrofosmin (TF) scintigraphy as a diagnostic modality in lymphomas. METHODS: Seventeen patients (14 with Hodgkin's disease and three with non-Hodgkin's lymphomas; age range, 10-59 years) were investigated. Planar and SPECT images of the supradiaphragmatic region (including neck and chest) were obtained. All patients were untreated at the time of the first scintigraphy. Follow-up scans after therapy were acquired in six patients (in five twice), so a total of 28 scintigraphic studies were performed. Mediastinal, pulmonary, cervical, supraclavicular and axillary activity was evaluated and results were compared in a blinded fashion with those of CT. RESULTS: TF imaging demonstrated pathological focal uptake at 38 sites (16 in the mediastinum, eight in the lungs, four in the axillae, eight in the supraclavicular region and two in the cervical region) in 16 of 17 untreated patients. CT identified 24 lesions (16 in the mediastinum, two in the lungs, two in the axillae, two in the supraclavicular and two in the cervical region) in 17 patients. Scintigraphy detected 22 of the 24 lesions demonstrated by CT and revealed 16 unknown tumor sites in 10 patients. The only negative pre-treatment scintigraphy result was found in a patient with axillary lymph node involvement. On the first post-treatment scintigrams there was a reduction in the number of visualized pathological sites (seven vs 16) in five of the six patients examined. The second follow-up study demonstrated only two lesions in two of the five patients examined. CONCLUSIONS: Our preliminary results indicate that TF imaging is effective in depicting supradiaphragmatic lymphoma lesions in untreated patients and suggest that serial scintigraphic studies may be suitable for monitoring response to treatment. However, larger series are needed to better define the possible role of TF scintigraphy in the follow-up of the response to therapy.

Adrenal ablation.

Of 135 patients who had bilateral adrenalectomies for metastatic breast cancer, 110 could be evaluated and 63 patients (57.3%) responded (43 objective, 20 subjective responders). Patients aged 31 to 45 years had a 56% response rate; 58% of patients aged 46 to 70 responded. Oophorectomy responders benefited from adrenalectomy 62% of the time and oophorectomy failures reponded in 38% of the cases. Patients with a disease-free interval of zero to 2.5 years responded to adrenalectomy at a rate of 46%, whereas patients with a free interval greater than 2.5 years responded at a rate of 73%. The median survival rate of 63 adrenalectomy responders was 28 months; it was ten months for 47 nonresponders.

[Study of the effect of Stressen on homocysteine blood levels in patients affected by vascular disease]. / Studio dell'effetto della specialità medicinale "Stressen" sui livelli ematici di omocisteina in pazienti con patologia vascolare.

OBJECTIVE: This study was carried out to confirm the results obtained in a previous trial, where Stressen had reduced homocysteinemia in patients with elevated concentrations of this amino acid and affected by vascular disease. MATERIALS AND METHODS: 50 patients were enrolled and they received Stressen twice daily for 30 days. Basal levels of homocysteinemia were determined and, after the treatment, evaluation of this parameter was repeated. RESULTS: At enrollment homocysteinemia was 23.44 +/- 7.24 micromol/l; at the end of the treatment with Stressen it was reduced to 10.22 +/- 3.41 micromol/l, corresponding to a decrease of 56.4% (p<0.0001). No significant difference between sexes was noted. CONCLUSIONS: The results of this study confirm the efficacy of Stressen on homocysteine plasma levels and agree with literature about the relationship among vitamin B12, folate and homocysteine; the activity of the drug was therefore predictable considering its composition, constituted of cobamamide, calcium folinate and arginine glutamate.

[Controlled study of the effect of Stressen on homocysteine blood levels in patients with vascular disease]. / Studio controllato dell'effetto della specialità medicinale "Stressen" sui livelli ematici di omocisteina in pazienti con patologia vascolare.

OBJECTIVE: Plasma levels of folate and vitamin B12 are inversely related to homocysteinemia and nowadays a further supplement of these vitamins, other than diet, is considered useful for lowering homocysteine blood levels. Stressen possesses the requirements for the control of this biochemical parameter; this study had the purpose to verify the activity of the product in patients affected by vascular disease. MATERIALS AND METHODS: 40 patients have taken a bottle of Stressen twice daily for 30 days and 20 subjects, suffering from the same pathology and non treated with the drug, have been considered as controls. Homocysteinemia was evaluated at the beginning and at the end of the treatment. RESULTS: Stressen determined a statistical reduction of 51.1% of basal concentration (p<0.0001), while levels of controls remained unchanged after the 30 days period. CONCLUSIONS: Supplement of vitamin B12 and folate, consisting in Stressen administration, normalized homocysteinemia. Furthermore, arginine glutamate, in the composition of the product, represents substrate for NO synthase and could be particularly useful for the treatment of vascular disease, improving endothelial-dependent dilation.

Association of CNR1 and FAAH endocannabinoid gene polymorphisms with anorexia nervosa and bulimia nervosa: evidence for synergistic effects.

Endocannabinoids modulate eating behavior; hence, endocannabinoid genes may contribute to the biological vulnerability to eating disorders. The rs1049353 (1359 G/A) single nucleotide polymorphism (SNP) of the gene coding the endocannabinoid CB1 receptor (CNR1) and the rs324420 (cDNA 385C to A) SNP of the gene coding fatty acid amide hydrolase (FAAH), the major degrading enzyme of endocannabinoids, have been suggested to have functional effects on mature proteins. Therefore, we explored the possibility that those SNPs were associated to anorexia nervosa and/or bulimia nervosa. The distributions of the CNR1 1359 G/A SNP and of the FAAH cDNA 385C to A SNP were investigated in 134 patients with anorexia nervosa, 180 patients with bulimia nervosa and 148 normal weight healthy controls. Additive effects of the two SNPs in the genetic susceptibility to anorexia nervosa and bulimia nervosa were also tested. As compared to healthy controls, anorexic and bulimic patients showed significantly higher frequencies of the AG genotype and the A allele of the CNR1 1359 G/A SNP. Similarly, the AC genotype and the A allele of the FAAH cDNA 385C to A SNP were significantly more frequent in anorexic and bulimic individuals. A synergistic effect of the two SNPs was evident in anorexia nervosa but not in bulimia nervosa. Present findings show for the first time that the CNR1 1359 G/A SNP and the FAAH cDNA 385C to A SNP are significantly associated to anorexia nervosa and bulimia nervosa, and demonstrate a synergistic effect of the two SNPs in anorexia nervosa.

Improvement of hand dexterity following motor cortex rTMS in multiple sclerosis patients with cerebellar impairment.

We tested the effects of 5-Hz repetitive transcranial magnetic stimulation (rTMS) over the motor cortex in multiple sclerosis (MS) subjects with cerebellar symptoms. rTMS improved hand dexterity in cerebellar patients (n=8) but not in healthy subjects (n=7), as detected by a significant transient reduction of the time required to complete the nine-hole pegboard task. rTMS of the motor cortex may be a useful approach to treat cerebellar impairment in MS patients.

Splenic injury as a complication of colonoscopy and polypectomy. Report of a case and review of the literature.

Injury to the spleen is a rare complication of colonoscopy and polypectomy. The danger of this unusual complication is real and its early recognition and proper management are essential to a favorable outcome. A case of injury to the spleen requiring splenectomy following colonoscopy and polypectomy is reported and discussed. Review of the literature by the authors revealed only six similar cases.

Familial hemiplegic migraine in developmental age: report of two cases.

The authors report two cases of a particular type of migraine with aura, known as familial hemiplegic migraine (FHM). According to the International Headache Society (IHS) diagnostic criteria, the FHM can be diagnosed with the exception of organic causes, in a patient with migraine with aura including emiparesis of anything severity and with an end occurring a member of the family with similarity in the attach pattern. The two clinical cases reported clearly show these features and they can be considered exemplary for this type of pathology. This rare type of migraine has an unknown etiology, it seems to depend on a decreases of cerebral blood flow originative on the occipital lobe, over the subsequentially spreading anteriory region temporal and parietal lobe. The hypoperfusion with the next following neural ischemia is related to the variation of blood flow and/or "the spreading depression" supported by Leao and Olesen recently. We wanted to show these two cases so that the psychiatrist, the pediatrician, and the neurologist can be able to refer parents to the right approach, considering possibility of a pathology rare but benign; this is the FHM.

[Behavior of blood ferritin in acute myocardial infarct]. / Comportamento della ferritinemia nell'infarto miocardico acuto.

Ferritin (F) is an iron-protein (molecular weight 445.000) present in various organs including the heart. Using the immunoenzymatic method (Ferrizyme Abbott), ferritinemia (Fe) was determined daily in 28 patients with acute myocardial infarction (AMI). A significant rise was revealed, already evident in the first few days 8-9 after with Fe gradually returns to baseline levels. The results have shown that this pattern is not evident in patients with angina, heart failure, valve defects, pericarditis or cor pulmonale and may thus be considered a reliable, if not early, marker of myocardial cytolysis. In those cases studied no correlations were observed between CPK and Fe peak or between these and clinical intensity of AMI.

Splenic vein aneurysm: is it a surgical indication?

Splenic vein aneurysms are rare and are usually caused by portal hypertension. Symptoms are unusual, but may include rupture or abdominal pain. Diagnosis can usually be made either by means of duplex ultrasonography or computed tomography scanning. Treatment varies from noninvasive follow-up to aneurysm excision. We report an expanding splenic vein aneurysm in a young woman with abdominal and back pain and no history of portal hypertension. She was treated with aneurysm excision and splenectomy.

Uremic autonomic neuropathy studied by spectral analysis of heart rate.

BACKGROUND: There is good evidence that power spectral analysis (PSA) of heart rate variability may provide an insight into the understanding of autonomic disorders. METHODS: We investigated 30 chronic uremic patients who were on periodic bicarbonate hemodialysis by a battery of six cardiovascular autonomic tests (beat-to-beat variations during quiet breathing and deep breathing, heart rate responses to the Valsalva maneuver and standing, blood pressure responses to standing and sustained handgrip) and PSA of heart rate variations. RESULTS: Eleven patients (37%) had an abnormal response to only one parasympathetic test. Twelve patients (40%) had a definite parasympathetic damage, as indicated by at least two abnormal heart rate tests, whereas four (13%) had combined parasympathetic and sympathetic damage. Multivariate analysis of the cardiovascular tests revealed that 19 patients (63%) had moderate-to-severe autonomic neuropathy (AN), and 11 patients exhibited normal autonomic function. Among the symptoms suggestive of autonomic dysfunction, only impotence in males was significantly associated with test-proven AN. The PSA of the heart rate variability demonstrated a good discrimination of low-frequency (LF) and high-frequency (HF) bands (LF, 0.03 to 0.15 Hz; HF, 0.15 to 0.33 Hz) among controls, uremic patients without test-proven AN, and uremic patients with test-proven AN. A significant reduction of the LF value on supine uremic patients without AN suggests that an early sympathetic involvement exists that traditional autonomic tests were unable to detect. CONCLUSIONS: Our study indicates that the current opinion of a major parasympathetic damage in chronic uremic patients on hemodialysis has to be modified in favor of a more widespread autonomic dysfunction involving both the sympathetic and parasympathetic pathways.